| Section | Rationale | Description |
|---|---|---|
| CSTK-09 | The algorithm was updated to align with CSTK-11 algorithm flow logic. | Algorithm change Move "ICD-10-PCS Principal or Other Procedure Codes" decision box above "Initial NIHSS Less Than 6" decision box. |
| CSTK-11 | The algorithm was updated to harmonize with AHA GWTG. | Algorithm Change
Move "ICD-10-PCS Principal or Other Procedure Codes" decision box after "Failed Attempt at Thrombectomy" decision box. Move "Initial NIHSS Less Than 6" decision box above "Delayed Endovascular Rescue Procedure" decision box and below "ICD-10-PCS Principal or Other Procedure Codes" decision box. |
| HBIPS | Removed HBIPS-1 since its retired as of 1/1/2023. | Removed reference of HBIPS-1 from the Hospital Based Inpatient Psychiatric Services (HBIPS) measure set. |
| PC | A narrative of the algorithm has been added for accessibility. | Perinatal Care (PC) Initial Patient Population Algorithm Narrative has been added after the measure flow algorithm. |
| PC-01 | A narrative of the algorithm has been added for accessibility. | PC-01: Elective Delivery Narrative Algorithm was added after the measure flow algorithm. |
| PC-02 | Algorithm Change: There was an extra arrow in the PC-02 algorithm on page 2. Change data element name. A narrative of the algorithm has been added for accessibility. | Algorithm Change: Remove "PC-02 E" arrow going to the E Box on page 2. Change data element name from "Previous Live Births" to "Previous Births" on page 2 PC-02: Cesarean Birth Narrative Algorithm was added after the measure flow algorithm. |
| PC-05 | A narrative of the algorithm has been added for accessibility. | PC-05: Exclusive Breast Milk Feeding Narrative Algorithm was added after the measure flow algorithm. |
| PC-06 | A narrative of the algorithm has been added for accessibility. | PC-06: Unexpected Complications in Term Newborns Narrative Algorithm was added after the measure flow algorithm. |
| THKR-IP-5 | Numerator statement updated to align with numerator statement in THKR-4. | Change from:
Number of patients who completed the general health and joint specific functional status assessments within 90 days after surgery. Change to: Number of patients who completed the general health (VR-12 or PROMIS-Global) AND joint specific functional status assessments (HOOS Jr./subscales or KOOS Jr./subscales) within 90 days after surgery. |
| THKR-OP-5 | Numerator statement updated to align with numerator statement in THKR-4. | Change from:
Number of patients who completed the general health and joint specific functional status assessments within 90 days after surgery. Change to: Number of patients who completed the general health (VR-12 or PROMIS-Global) AND joint specific functional status assessments (HOOS Jr./subscales or KOOS Jr./subscales) within 90 days after surgery. |
| TOB-3 | Remove 'Not Applicable' from Included Population section of the Numerator, as there are included populations. | Remove:
Not Applicable |
| VTE | A narrative of the algorithm has been added for accessibility. | Venous Thromboembolism (VTE) Initial Patient Population Narrative Algorithm was added after the measure flow algorithm. |
| VTE-6 | A narrative of the algorithm has been added for accessibility. | VTE-6: Hospital Acquired Potentially-Preventable Venous Thromboembolism Narrative Algorithm was added after the measure flow algorithm. |
| Section | Rationale | Description |
|---|---|---|
| Birthdate | The data element definition was updated to align with the CMS manual for National Hospital Inpatient Quality Measures, Version 5.14 effective beginning with 7/1/2023 discharges. | Allowable Values Change from: MM = Month (01-12) DD = Day (01-31) YYYY = Year (1880-Current Year) To: MM = Month (01-12) DD = Day (01-31) YYYY = Year (1907-Current Year) |
| CMS Certification Number | This data element was inadvertently retired. | Adding it back to the Data Dictionary.
Allowable Values Change Allowable Values from: Any valid six digit CMS Certification Number. The first two digits are the numeric state code. The third digit of zero represents an acute facility. The third digit of “1” and fourth digit of “3” represents a Critical Access Hospital (CAH). To: Any valid six digit CMS Certification Number. The first two digits are the numeric or alphanumeric state code. The third digit of zero represents an acute facility. The third digit of “1” and fourth digit of “3” represents a Critical Access Hospital (CAH). |
| Comfort Measures Only | The data element definition was updated to align with current terminology from Crit Care Med. 2015 Jun;43(6):1291-325. | Inclusion Guidelines for Abstraction Add
|
| Health Care Organization Identifier | This data element was inadvertently retired. | Adding it back to the Data Dictionary. |
| IV Alteplase Prior to IA or Mechanical Reperfusion Therapy | The data element definition was updated to align with the data element definition for IV Alteplase Initiation. | Inclusion Guidelines for Abstraction Add: Reasonable Alternative to Alteplase:
Add:
|
| Measurement Value | This data element was inadvertently retired. | Adding it back to the Data Dictionary. |
| Previous Births | Update data element guidance to use Parity or previous births rather than number of previous live births if Parity is present to align with the eCQM version of PC-02. | Name:
Change from:
Previous Live Births Change to:Previous Births Definition: Change from:Documentation that the patient experienced a live birth prior to the current hospitalization. Change to:Documentation that the patient experienced a birth > = 20 weeks gestation regardless of the outcome (i.e. parity > 0) prior to the current hospitalization. Question: Change from:Did the patient experience a live birth prior to the current hospitalization? Change to:Did the patient experience a birth prior to the current hospitalization? Allowable Values: Change from:Y (Yes) There is documentation that the patient experienced one or more live births prior to the current hospitalization. N (No) There is no documentation that the patient experienced one or more live births prior to the current hospitalization OR unable to determine from medical record documentation. Change to:Y (Yes) There is documentation that the patient experienced one or more births prior to the current hospitalization. N (No) There is no documentation that the patient experienced one or more births prior to the current hospitalization OR unable to determine from medical record documentation. Notes for Abstraction: Change from:The delivery or operating room record should be reviewed first for documentation of parity greater than zero. If documentation of parity greater than zero is not present or is conflicting in the delivery or operating room record, then continue to review the acceptable data sources in the following order: history and physical, clinician admission progress note, prenatal forms, and discharge summary until a positive finding for parity greater than zero is found. If there is conflicting documentation throughout the acceptable sources and it cannot be determined from the medical record if there were previous live births, select No. Change to:The delivery or operating room record should be reviewed first for documentation of parity greater than zero. If documentation of parity greater than zero is not present or is conflicting in the delivery or operating room record, then continue to review the acceptable data sources in the following order: history and physical, clinician admission progress note, prenatal forms, and discharge summary until a positive finding for parity greater than zero is found. If there is conflicting documentation throughout the acceptable sources and it cannot be determined from the medical record if there were previous births, select No. Change from:Previous Live Births may be used in the absence of documentation of parity. If the number for previous live births documented is "one" and includes the delivery for the current hospitalization, do not include the current delivery to determine previous live births. Change to:In the absence of parity, documentation that the patient experienced a previous birth > = 20 weeks gestation regardless of the outcome may be used. If the number for parity documented is "one" and includes the delivery for the current hospitalization, do not include the current delivery to determine previous births. Guidelines for Abstraction: Change from: Inclusion: Select Yes:
Select No: Change from:* Number of previous live births equals 0 Change to:* Number of previous births equals 0 |
| Prior Uterine Surgery | Updated notes for abstraction for clarification of T and J incisions. | 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 or includes descriptors "high" or "vertical" or "mid" or "active segment" or "classical". Change to: In order to select “yes”, the current episode of care must contain documentation of one of the included surgeries below. Documentation of an inverted T or J incision would be acceptable for allowable value "yes" for prior uterine surgery. |
| Sex | The data element definition was updated to align with the CMS Specifications Manual for National Hospital Inpatient Quality Measures, Version 5.14, effective for discharges on and after July 1, 2023. | Definition Change from: The patient’s documented sex on arrival at the hospital. To: The patient’s documented sexual orientation and/or gender identity. Suggested Data Collection Question Change from: What was the patient’s sex on arrival? To: What is the patient’s sexual orientation and/or gender identity? Format Change Type from: Character To: Alphanumeric Change Occurs from: 1 To: 1 – 5 Allowable Values Change from: M = Male F = Female U = Unknown To: Select all that apply: 1 Male 2 Assigned/Designated Male at Birth 3 Female 4 Assigned/Designated Female at Birth 5 LGBTQ 6 Unknown Notes for Abstraction Change to: • Select any of the values that are applicable. The data element and values encompass both the patient’s current gender identity and one assigned at birth. • Consider the sex to be unable to be determined and select “Unknown” if the patient refuses to provide their sexual orientation and/or gender identity. If “Unknown” is selected, then no other value should be selected. Inclusion Guidelines for Abstraction Change to: LGBTQ (Value 5) • LGBTQIA, LGBTQ+, LGBTQIA2 • Lesbian, gay, or bisexual • MSM (men who have sex with men) • Queer, Genderqueer • Pansexual • Asexual • Transgender • Gender non-conforming • Two-spirit • Non-binary • Gender diverse • People/person with intersex traits |
| Site Identifier | New Data Element | The Site ID number is used for data submission to identify measure rates associated with only one certified hospital or facility. |
| Section | Rationale | Description |
|---|---|---|
| Acknowledgement - Acknowledgment and Conditions of Use | Updated copyright date for Current Procedural Terminology (CPT®) | Change From: The five character CPT® codes included in the Specifications Manual for Joint Commission National Quality Measures are obtained from Current Procedural Terminology (CPT®), copyright 2022 by the American Medical Association (AMA). Change to: The five character CPT® codes included in the Specifications Manual for Joint Commission National Quality Measures are obtained from Current Procedural Terminology (CPT®), copyright 2023 by the American Medical Association (AMA). |
| Appendix A - Code Tables | Code Z762 was removed from Appendix A table 11.35 Social Indications because it is unable to be coded on the newborn delivery encounter per coding guidelines since it must be a primary code. | Remove: Z762 Encounter for health supervision and care of other healthy infant and child |
| Appendix D - Glossary of Terms | Appendix D was updated to add new terms and acronyms to the glossary. | General Glossary of Terms Add: LGBTQ Lesbian, gay, bisexual, transgender, and queer LGBTQ+ Lesbian, gay, bisexual, transgender, queer or questioning, and plus LGBTQIA Lesbian, gay, bisexual, transgender, queer or questioning, intersex, and asexual LGBTQIA2 Lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and Two Spirited MSM Men having sex with men site identifier A numeric identifier, up to 6-digits, assigned by The Joint Commission to identify certified organizations. The Site ID number is unique from the Healthcare Care Organization ID number and used to identify performance measure data from a single hospital or other healthcare organization. |
| Appendix G - Resources | Appendix G was updated to change CMS contact information. | CMS Abstraction & Reporting Tool (CART) Change from: For technical assistance with CART, please contact the QualityNet help desk at qnetsupport@cms.hhs.gov, or call 1-866-288-8912. To: For technical assistance with CART, please contact the CCSQ Service Center at Qnetsupport@cms.hhs.gov , or call 1-866-288-8912. |
| Data Dictionary - Introduction to the Data Dictionary | The Introduction was updated to align with the CMS Specifications Manual for National Hospital Inpatient Quality Measures, Version 5.14, effective for discharges on and after July 1, 2023. | General Abstraction Guidelines Add: Medical Records The hospital must have one unified medical record service that has administrative responsibility for all medical records, both inpatient and outpatient records. The hospital must create and maintain a medical record for every individual, both inpatient and outpatient evaluated or treated in the hospital. The term “medical records” includes at least written documents, computerized electronic information, radiology film and scans, laboratory reports and pathology slides, videos, audio recordings, and other forms of information regarding the condition of a patient (42CFR482.24). The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services [42CFR428.24(c)]. |
| Introduction to the Manual | The Introduction was updated to align with the CMS Specifications Manual for National Hospital Inpatient Quality Measures, Version 5.14, effective for discharges on and after July 1, 2023. | Electronic Clinical Quality Measures (eCQMs) Overview Change to: Beginning in calendar year (CY) 2013, hospitals were provided the opportunity to voluntarily submit data for eCQMs. These quality measures were developed specifically to allow an electronic health record (EHR) system certified to the Office of the National Coordinator (ONC) standards to capture, export, calculate, and report the measure data. Since CY 2016, hospitals have been required to report eCQM data as a portion of the Hospital IQR Program and the Medicare Promoting Interoperability Program (previously known as the Medicare EHR Incentive Program). Hospitals that successfully submit eCQM data to meet Hospital IQR Program requirements will also satisfy the eCQM reporting requirements for the Medicare Promoting Interoperability Program for eligible hospitals and critical access hospitals (CAHs) with one submission. Refer to the Technical Specifications and Resources for the CMS Quality Reporting Document Architecture (QRDA) Category I Implementation Guide for the applicable reporting period, measure specification information, and program resources to support successful eCQM reporting on the eCQI Resource Center at: https://ecqi.healthit.gov/. Note: Critical access hospitals (CAHs) are encouraged, but not required, to participate in the Hospital IQR Program. CAHs are required to participate in the Medicare Promoting Interoperability Program. Review the Promoting Interoperability Programs page on the CMS.gov website for more information. |
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