Specifications Manual for Joint Commission National Quality Measures (v2022B)

Posted: 2/1/2022

Release Notes:
Release Notes
Version 2022B

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Release Notes for the TJC2022B Manual

Measure Information Forms

Section	Rationale	Description
ACHF-01	Updated left ventricular ejection fraction (LVEF) to ≤40% to align with the AHA / ACC heart failure guidelines.	Updated Measure Description Change From: Description: Beta-blocker therapy (i.e., bisoprolol, carvedilol, or sustained-release metoprolol succinate) is prescribed for heart failure patients with LVSD at discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction. Change To: Description: Beta-blocker therapy (i.e., bisoprolol, carvedilol, or sustained-release metoprolol succinate) is prescribed for heart failure patients with LVSD at discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) ≤40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction. Denominator Statement Change From: Denominator Statement: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) < 40%. Change To: Denominator Statement: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) ≤40%. Denominator Included Populations Change From: Discharges with ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and Documentation of LVSD < 40% Change To: Discharges with ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and Documentation of LVSD ≤40%. Algorithm change LVSD=3 exit from "B" to "D".
ACHFOP-01	Rationale: Update left ventricular systolic function (LVSF) to align with AHA/ACC heart failure guidelines.	Description Change From: Beta-blocker therapy (i.e., bisoprolol, carvedilol, or sustained-release metoprolol succinate) is prescribed for heart failure patients with LVSD. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction. Change To: Beta-blocker therapy (i.e., bisoprolol, carvedilol, or sustained-release metoprolol succinate) is prescribed for heart failure patients with LVSD. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) ≤40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction. Denominator Statement Change From: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) < 40%. Change To: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) ≤40%. Denominator Included Populations Change From: E/M Code for hospital outpatient encounter as defined in Appendix A, Table 2.0 An ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and Documentation of LVSD < 40% Change To: E/M Code for hospital outpatient encounter as defined in Appendix A, Table 2.0 An ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and Documentation of LVSD ≤40%. Algorithm change LVSD=3 exit from "B" to "D".
ACHFOP-02	Updated left ventricular ejection fraction (LVEF) to ≤40% to align with the AHA / ACC heart failure guidelines.	Change from: Description: Heart failure patients with left ventricular systolic dysfunction (LVSD) who are prescribed an ACEI or ARB in the outpatient setting. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction. Change to: Description: Heart failure patients with left ventricular systolic dysfunction (LVSD) who are prescribed an ACEI or ARB in the outpatient setting. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) ≤ 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction. Denominator Statement Change from: Denominator: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) < 40%. Change to: Denominator: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) ≤ 40%. Denominator Included Population Change from: Included population: E/M Code for hospital outpatient encounter as defined in Appendix A, Table 2.0 An ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and Documentation of LVSD < 40% Change to: Included population: E/M Code for hospital outpatient encounter as defined in Appendix A, Table 2.0 An ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and Documentation of LVSD ≤ 40% Algorithm change LVSD=3 exit from "B" to "D".
CSTK-02	The notice was updated to reflect changes to the performance measure requirements for thrombectomy-capable stroke centers.	Special Notice Change from: SUSPENDED for Comprehensive Stroke Centers, Effective January 1, 2018 To: SUSPENDED for Thrombectomy-Capable Stroke Centers, Effective July 1, 2022
PC-01	Updated Reference.	Selected References Remove: * American College of Obstetricians and Gynecologists. (November 1996). ACOG Educational Bulletin. Add: Kilpatrick, S. J., Papile, L.-A., & Macones, G. A. (Eds.). (2017). Guidelines for perinatal care (8th ed.). American Academy of Pediatrics.
PC-02	Clarify direction of improvement.	Improvement Noted As Change From: Decrease in the rate Change To: Within Optimal Range Measure Analysis Suggestions Change From: In order to identify areas for improvement, hospitals may want to review results based on specific ICD-10 codes or patient populations. Data could then be analyzed further determine specific patterns or trends to help reduce cesarean births. Change To: The Joint Commission does not want to encourage inappropriately low Cesarean rates that may be unsafe to patients. Acceptable PC-02 rates are 30% or lower, however there is not an established threshold for what rate may be too low. PC-06 serves as a balancing measure for PC-02 to guard against any unanticipated or unintended consequences and to identify unforeseen complications that might arise as a result of quality improvement activities and efforts for this measure. In order to identify areas for improvement, hospitals may want to review results based on specific ICD-10 codes or patient populations. Data could then be analyzed further determine specific patterns or trends to help reduce cesarean births.
STK-2	The Measure Information Form was updated to add the 2021 AHA Guideline for secondary stroke prevention.	Selected References Add: Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia J., Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC Jr., Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke In Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2021 July;52(7):e364-e467.
STK-3	The Measure Information Form was updated to add the 2021 AHA Guideline for secondary stroke prevention.	Selected References Add: Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia J., Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC Jr., Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke In Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2021 July;52(7):e364-e467.
STK-6	The Measure Information Form was updated to add the 2021 AHA Guideline for secondary stroke prevention.	Selected References Add: Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia J., Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC Jr., Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke In Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2021 July;52(7):e364-e467.
STK-VOL-1	A new measure and measure set ID were developed to capture mechanical thrombectomy procedure volume at primary stroke centers. There is only one measure in this measure set.	Measure Information Form Add MIF and algorithm.
THKR-IP-5	Update algorithm to match guidance that patients may complete the assessments at 90 days (plus or minus 60 days, ≥ 30 days after surgery and ≤ 150 days after surgery).	Algorithm change for the "Post Assessment Day" data element exit condition. If "Post Assessment Day" <30 days or >150 days then it goes to "D". If "Post Assessment Day">=30days and <=150 days then it goes to "E".
THKR-OP-5	Update algorithm to match guidance that patients may complete the assessments at 90 days (plus or minus 60 days, ≥ 30 days after surgery and ≤ 150 days after surgery).	Algorithm change for the "Post Assessment Day" data element exit condition. If "Post Assessment Day" <30 days or >150 days then it goes to "D". If "Post Assessment Day">=30days and <=150 days then it goes to "E".

Data Elements

Section	Rationale	Description
LVSD	Update left ventricular systolic function (LVSF) to align with AHA/ACC heart failure guidelines.	Updated measure question Change From: Is the left ventricular systolic function (LVSF) documented as an ejection fraction (EF) of <40% or ≤35% or a narrative description consistent with moderate or severe systolic dysfunction? Change To: Is the left ventricular systolic function (LVSF) documented as an ejection fraction (EF) of ≤40% or ≤35% or a narrative description consistent with moderate or severe systolic dysfunction? Allowable Values Change From: 1 LVSF is documented as an EF ≤35%. 2 LVSF is documented as an EF equal to 36-39%. 3 LVSF is documented as an EF equal to 40%. 4 Documentation of a narrative description consistent with moderate or severe systolic dysfunction. 5 EF or a narrative description consistent with moderate or severe systolic dysfunction is not documented, or EF ≥ 41% or unable to determine from medical record documentation. Change To: 1 LVSF is documented as an EF ≤35%. 2 LVSF is documented as an EF equal to 36-39%. 3 LVSF is documented as an EF of ≤40%. 4 Documentation of a narrative description consistent with moderate or severe systolic dysfunction. 5 EF or a narrative description consistent with moderate or severe systolic dysfunction is not documented, or EF ≥ 41% or unable to determine from medical record documentation.
Prior Uterine Surgery	Updated Notes for Abstraction to align with previously updated bullet in guidelines for abstraction inclusion: * Documentation of prior uterine incision with descriptors including "high" or "vertical" or "mid" or "active segment" or "classical".	Notes for Abstraction: Change From: In order to select “yes”, the current episode of care must contain documentation of one of the included surgeries below. An inverted T or J incision would be acceptable only if there is also documentation that the incision extended into the upper uterine segment. Change To: In order to select “yes”, the current episode of care must contain documentation of one of the included surgeries below. An inverted T or J incision would be acceptable only if there is also documentation that the incision extended into the upper uterine segment or includes descriptors "high" or "vertical" or "mid" or "active segment" or "classical".
Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate Prescribed for LVSD at Discharge	Rationale: Update left ventricular systolic function (LVSF) to align with AHA/ACC heart failure guidelines.	Notes for Abstraction Change From: If there is documentation in the medical record of LVSD greater than or equal to 40%, this data element is not required. Change To: If there is documentation in the medical record of LVSD greater than or equal to 41%, this data element is not required.

Section

Rationale

Description

LVSD

Update left ventricular systolic function (LVSF) to align with AHA/ACC heart failure guidelines.

Updated measure question

Change From: Is the left ventricular systolic function (LVSF) documented as an ejection fraction (EF) of <40% or ≤35% or a narrative description consistent with moderate or severe systolic dysfunction?

Change To: Is the left ventricular systolic function (LVSF) documented as an ejection fraction (EF) of ≤40% or ≤35% or a narrative description consistent with moderate or severe systolic dysfunction?

Allowable Values

Change From: 1 LVSF is documented as an EF ≤35%. 2 LVSF is documented as an EF equal to 36-39%. 3 LVSF is documented as an EF equal to 40%. 4 Documentation of a narrative description consistent with moderate or severe systolic dysfunction. 5 EF or a narrative description consistent with moderate or severe systolic dysfunction is not documented, or EF ≥ 41% or unable to determine from medical record documentation.

Change To: 1 LVSF is documented as an EF ≤35%. 2 LVSF is documented as an EF equal to 36-39%. 3 LVSF is documented as an EF of ≤40%. 4 Documentation of a narrative description consistent with moderate or severe systolic dysfunction. 5 EF or a narrative description consistent with moderate or severe systolic dysfunction is not documented, or EF ≥ 41% or unable to determine from medical record documentation.

Prior Uterine Surgery

Updated Notes for Abstraction to align with previously updated bullet in guidelines for abstraction inclusion: * Documentation of prior uterine incision with descriptors including "high" or "vertical" or "mid" or "active segment" or "classical".

Notes for Abstraction:

Change From: In order to select “yes”, the current episode of care must contain documentation of one of the included surgeries below. An inverted T or J incision would be acceptable only if there is also documentation that the incision extended into the upper uterine segment.

Change To: In order to select “yes”, the current episode of care must contain documentation of one of the included surgeries below. An inverted T or J incision would be acceptable only if there is also documentation that the incision extended into the upper uterine segment or includes descriptors "high" or "vertical" or "mid" or "active segment" or "classical".

Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate Prescribed for LVSD at Discharge

Rationale: Update left ventricular systolic function (LVSF) to align with AHA/ACC heart failure guidelines.

Notes for Abstraction

Change From:

- If there is documentation in the medical record of LVSD greater than or equal to 40%, this data element is not required.

Change To:

- If there is documentation in the medical record of LVSD greater than or equal to 41%, this data element is not required.

Supplemental Materials

Section	Rationale	Description
Appendix A - Code Tables	PC-06 Appendix A tables 11.30,11.31, and 11.35 updates based on clinical feedback and Q&A.	11.35 Social Indications ADD: Z76.2 Encounter for health supervision and care of other healthy infant and child to table 11.35 Social Indications 11.31 Fetal Conditions ADD: I47.1 – Supraventricular tachycardia 11.30 Congenital Malformations Z87.710 Personal history of (corrected) hypospadias Z87.718 Personal history of other specified (corrected) congenital malformations of genitourinary system Z87.720 Personal history of (corrected) congenital malformations of eye Z87.721 Personal history of (corrected) congenital malformations of ear Z87.728 Personal history of other specified (corrected) congenital malformations of nervous system and sense organs Z87.730 Personal history of (corrected) cleft lip and palate Z87.738 Personal history of other specified (corrected) congenital malformations of digestive system Z87.74 Personal history of (corrected) congenital malformations of heart and circulatory system Z87.75 Personal history of (corrected) congenital malformations of respiratory system Z87.76 Personal history of (corrected) congenital malformations of integument, limbs and musculoskeletal system Z87.790 Personal history of (corrected) congenital malformations of face and neck Z87.798 Personal history of other (corrected) congenital malformations
Joint Commission National Quality Measures Data Processing - Transmission of Data	Data processing section was updated to include (PSC) With MT and Without MT certification measure.	Add column Primary Stroke Center (PSC) With MT to Joint Commission Stroke Certification Measure Table. Change column name from: Primary Stroke Center (PSC) To: Primary Stroke Center (PSC) Without MT Add measure row, STK-VOL-1 in the Joint Commission Stroke Certification Measure table. Change from: Submission of CSTK Data This measure set is reported for three certification programs, Comprehensive Stroke Center (CSC) certification, Thrombectomy-capable Stroke Center (TSC) Certification, and Primary Stroke Center (PSC) Certification. CSTK data is different from other measure sets since discharged patient requires follow-up within a certain number of days after the discharge date. The CSTK-05 measure has been used as the benchmark to define which records require a follow-up. Certification programs, Comprehensive Stroke Center (CSC), and Thrombectomy-capable Stroke Center (TSC) require follow-ups after their first discharge visit, but Primary Stroke Center (PSC) Certification does not require a follow-up. To Submission of CSTK Data This measure set is reported for three certification programs, Comprehensive Stroke Center (CSC) certification, Thrombectomy-capable Stroke Center (TSC) Certification, and Primary Stroke Center (PSC) Certification. CSTK data is different from other measure sets since discharged patient requires follow-up within a certain number of days after the discharge date. The CSTK-05 measure has been used as the benchmark to define which records require a follow-up. Certification programs, Comprehensive Stroke Center (CSC), Thrombectomy-capable Stroke Center (TSC), and Primary Stroke Center (PSC) With MT require follow-ups after their first discharge visit, but Primary Stroke Center (PSC) Wihtout MT Certification does not require a follow-up. Change second bullet in Sites with TSC certification section from: The follow-up measure for TSC is CSTK-02. To: The follow-up measure for TSC is CSTK-10. Add new section Sites with PSC certification (With MT) Change PSC certification section name from: Sites with PSC certification To: Sites with PSC certification ( Without MT)
Table of Contents	The new Stroke Volume Measure is now included in the manual.	Updated Table of Contents, Added the new Stroke Volume Measure to the list.

Section

Rationale

Description

Appendix A - Code Tables

PC-06 Appendix A tables 11.30,11.31, and 11.35 updates based on clinical feedback and Q&A.

11.35 Social Indications ADD:

Z76.2 Encounter for health supervision and care of other healthy infant and child to table 11.35 Social Indications

11.31 Fetal Conditions ADD:

I47.1 – Supraventricular tachycardia

11.30 Congenital Malformations

Z87.710 Personal history of (corrected) hypospadias
Z87.718 Personal history of other specified (corrected) congenital malformations of genitourinary system
Z87.720 Personal history of (corrected) congenital malformations of eye
Z87.721 Personal history of (corrected) congenital malformations of ear
Z87.728 Personal history of other specified (corrected) congenital malformations of nervous system and sense organs
Z87.730 Personal history of (corrected) cleft lip and palate
Z87.738 Personal history of other specified (corrected) congenital malformations of digestive system
Z87.74 Personal history of (corrected) congenital malformations of heart and circulatory system
Z87.75 Personal history of (corrected) congenital malformations of respiratory system
Z87.76 Personal history of (corrected) congenital malformations of integument, limbs and musculoskeletal system
Z87.790 Personal history of (corrected) congenital malformations of face and neck
Z87.798 Personal history of other (corrected) congenital malformations

Joint Commission National Quality Measures Data Processing - Transmission of Data

Data processing section was updated to include (PSC) With MT and Without MT certification measure.

Add column Primary Stroke Center (PSC) With MT to Joint Commission Stroke Certification Measure Table.

Change column name from: Primary Stroke Center (PSC)
To: Primary Stroke Center (PSC) Without MT

Add measure row, STK-VOL-1 in the Joint Commission Stroke Certification Measure table.

Change from:

Submission of CSTK Data
This measure set is reported for three certification programs, Comprehensive Stroke Center (CSC) certification, Thrombectomy-capable Stroke Center (TSC) Certification, and Primary Stroke Center (PSC) Certification. CSTK data is different from other measure sets since discharged patient requires follow-up within a certain number of days after the discharge date. The CSTK-05 measure has been used as the benchmark to define which records require a follow-up. Certification programs, Comprehensive Stroke Center (CSC), and Thrombectomy-capable Stroke Center (TSC) require follow-ups after their first discharge visit, but Primary Stroke Center (PSC) Certification does not require a follow-up.

To
Submission of CSTK Data
This measure set is reported for three certification programs, Comprehensive Stroke Center (CSC) certification, Thrombectomy-capable Stroke Center (TSC) Certification, and Primary Stroke Center (PSC) Certification. CSTK data is different from other measure sets since discharged patient requires follow-up within a certain number of days after the discharge date. The CSTK-05 measure has been used as the benchmark to define which records require a follow-up. Certification programs, Comprehensive Stroke Center (CSC), Thrombectomy-capable Stroke Center (TSC), and Primary Stroke Center (PSC) With MT require follow-ups after their first discharge visit, but Primary Stroke Center (PSC) Wihtout MT Certification does not require a follow-up.

Change second bullet in Sites with TSC certification section from: The follow-up measure for TSC is CSTK-02.
To: The follow-up measure for TSC is CSTK-10.

Add new section Sites with PSC certification (With MT)

Change PSC certification section name from: Sites with PSC certification
To: Sites with PSC certification ( Without MT)

Table of Contents

The new Stroke Volume Measure is now included in the manual.

Updated Table of Contents, Added the new Stroke Volume Measure to the list.

Specifications Manual for Joint Commission National Quality Measures (v2022B)
Discharges 07-01-2022 (3Q22) through 12-31-2022 (4Q22)

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