Measure Information Form
Version 2020A2
Venous Thromboembolism (VTE)
Set Measures
| Set Measure ID | Measure Short Name |
|---|---|
| VTE-6 | Hospital Acquired Potentially-Preventable Venous Thromboembolism |
General Data Elements
| Element Name | Collected For |
|---|---|
| Admission Date | All Records, |
| Birthdate | All Records, |
| Discharge Date | All Records, Not collected for HBIPS-2 and HBIPS-3 |
| Hispanic Ethnicity | All Records, |
| ICD-10-CM Other Diagnosis Codes | All Records, Optional for HBIPS-2, HBIPS-3 |
| ICD-10-CM Principal Diagnosis Code | All Records, Optional for HBIPS-2, HBIPS-3 |
| ICD-10-PCS Other Procedure Codes | All Records, Optional for All HBIPS Records |
| ICD-10-PCS Other Procedure Dates | All Records, Optional for All HBIPS Records |
| ICD-10-PCS Principal Procedure Code | All Records, Optional for All HBIPS Records |
| ICD-10-PCS Principal Procedure Date | All Records, Optional for All HBIPS Records |
| Measure Category Assignment | All Records, Calculation, Transmission, Hospital Clinical Data File, Used in calculation of the Joint Commission's aggregate data and in the transmission of the Hospital Clinical Data file. |
| Payment Source | All Records, Optional for HBIPS-2 and HBIPS-3 |
| Race | All Records, |
| Sex | All Records, |
Algorithm Output Data Elements
| Element Name | Collected For |
|---|---|
| Measure Category Assignment | All Records, Calculation, Transmission, Hospital Clinical Data File |
Measure Set Specific Data Elements
Related Materials
Venous Thromboembolism (VTE) Initial Patient Population
The VTE measure set is unique in that there is only one sub-population within the measure set.
Initial Patient Population Definitions Table| Measures | Initial Patient Population definition |
|---|---|
| VTE-6 | The count of all patients in sub-population 3 |
The VTE sub-population utilizes four data elements:
• Admission Date• Birthdate
• Discharge Date
• ICD-10-CM Other Diagnosis Code Patients admitted to the hospital for inpatient acute care are included in the VTE ICD sub-populations if they have:
1 – No VTE sub-population – is retired.
2 – Principal VTE sub-population – is retired.
3 - Other VTE Only sub-population – Patients with an ICD-10-CM Other Diagnosis Code as defined in Appendix A, Tables 7.03 and 7.04, a Patient Age (Admission Date minus Birthdate) greater than or equal to 18 years, and a Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days. The patients cannot have an ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Tables 7.03 and 7.04.
Initial Patient Population Algorithm
Sample Size Requirements
Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may choose to use a larger sample size than is required. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter/month for the sub-population cannot sample that sub-population. Hospitals that have five or fewer discharges for the VTE sub-population (both Medicare and non-Medicare combined) are not required to submit VTE patient level data to the Joint Commission’s Data Warehouse.
Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Due to exclusions and contraindications, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size.
For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual.
Quarterly SamplingSampling for VTE Sub-population 3 – The Other VTE Only sub-population is not eligible for sampling and will use the entire Initial Patient Population for reporting.
To determine if a hospital may choose to not submit VTE patient level data to the Joint Commission’s Data Warehouse, the count of discharges, for the quarter, for the Other VTE Only sub-population must be five or less.
Monthly SamplingSampling for VTE Sub-population 3 – The Other VTE Only sub-population is not eligible for sampling and will use the entire Initial Patient Sub-Population for reporting.
CPT® only copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.
U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.
Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.
This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.