Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
Home » VTE Diagnostic Test

Release Notes:
Data Element
Version 2020B

Name:VTE Diagnostic Test
Collected For: VTE-6
Definition:Documentation that a diagnostic test was performed during the hospitalization.
Question:Is there documentation that a diagnostic test was performed on the day of arrival or anytime during the hospitalization?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)      There is documentation that a diagnostic test was performed on the day of arrival or anytime during the hospitalization.

N (No)     There is no documentation that a diagnostic test was performed on the day of arrival or anytime during the hospitalization, or unable to determine from medical record documentation.
Notes for Abstraction:
  • The time frame for this data element includes patients who had one of the acceptable diagnostic tests performed on arrival or anytime during hospitalization.
    Acceptable Examples:
    • Patient arrives on 01/01/20XX and documentation indicates a CT of chest with contrast was performed earlier that same day.
    • Patient arrived on 01/01/20XX and documentation indicates that the patient was admitted on 01/02/20XX. A VQ scan was performed on 01/04/20XX.
      Unacceptable Example:
    • Patient transferred on 01/05/20XX with documentation from a transferring hospital indicating vascular ultrasound was performed on 01/02/20XX.”
  • If a diagnostic test was performed that is not on the inclusion list, select “No.”
    Example:
    Patient admitted on 01/01/20XX. 2D Echo done on 01/05/20XX. Physician notes indicate that the test confirmed a PE, select “No.”
Documentation in sources other than radiology reports:
  • Documentation other than radiology reports must confirm one of the acceptable tests was performed.
    Examples:
    • Physician Notes: Venous Doppler positive for DVT left popliteal, select “Yes.”
    • Emergency Notes: Patient to CT without contrast, select “No.”
  • The physician/APN/PA documentation must reflect the time frame from arrival to hospital discharge.
Suggested Data Sources:
  • Admission notes
  • Consult notes
  • Discharge summary
  • Emergency Department record
  • History and physical
  • Physician notes
  • Radiology report
Additional Notes: Diagnostic testing includes the following:
THIS LIST IS ALL INCLUSIVE
  • Compression Ultrasound of lower extremities
  • Venous Ultrasound of lower extremities
  • Duplex Ultrasound (DUS) of lower extremities
  • Venous Doppler of lower extremities
  • Vascular vein mapping of the lower extremities
  • Computed tomography angiography (CTA) / Angiogram of Chest
  • Computed tomography angiography (CTA) / Pulmonary Angiogram of Chest
  • Computed tomography (CT) of thorax (chest) with IV contrast
  • Computed tomography angiography (CTA) / Angiogram of the abdomen
  • Computed tomography (CT) of the abdomen/abdominal aorta with IV contrast
  • Computed tomography (CT) of the pelvis with IV contrast
  • Computed tomography angiography (CTA) / Angiogram of the pelvis
  • Computed tomography (CT) of the lower extremity leg veins with IV contrast
  • CT pulmonary angiogram (CTPA) / CTPA Scan / CT pulmonary embolism (CTPE)
  • Magnetic resonance imaging (MRI or MRV) of the thorax (chest, cardiac)
  • Magnetic resonance imaging (MRI or MRV) of the abdomen
  • Magnetic resonance imaging (MRI or MRV) of the pelvis
  • Magnetic resonance imaging (MRI or MRV) of the lower extremity leg veins
  • Nuclear Medicine Pulmonary Scan/ventilation/perfusion (V/Q) lung scan
  • Pulmonary arteriography/angiography/angiogram
  • Cavagram/cavogram
  • Inferior venocavagram
  • Venography/Venogram of pelvis using IV contrast material
  • Venography/Venogram of femoral using IV contrast material
  • Venography/Venogram of other lower extremity veins using IV contrast material
Guidelines for Abstraction:
Inclusion Exclusion

  • Patients with VTE confirmation by only D-dimer tests
  • Patients with VTE diagnosed by tests not listed

VTE Diagnostic Test
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Specifications Manual for Joint Commission National Quality Measures (v2020B)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

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