| Section | Rationale | Description |
|---|---|---|
| ACHFOP-03 | The update to mineralocorticoid receptor antagonist (MRA) will provide abstractor clarification and alignment with 2022 Clinical Practice Guidelines which recommend prescribing MRAs across the spectrum of HFrEF, inclusive of a wide range of etiologies and disease severities. | Performance Measure Name Change from: Hospital Outpatient Aldosterone Receptor Antagonists To: Hospital Outpatient Mineralocorticoid Receptor Antagonists (MRA) Description Change from: Patients with a diagnosis of heart failure, a New York Heart Association (NYHA) class III-IV, and heart failure with a left ventricular ejection fraction (LVSD) ≤35% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction who are prescribed an aldosterone receptor antagonist. To: Patients with a diagnosis of heart failure, a New York Heart Association (NYHA) class II-IV, and heart failure with a left ventricular ejection fraction (LVSD) ≤40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction who are prescribed a mineralocorticoid receptor antagonist (MRA). Rationale Change to: The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure states a benefit of prescribing Mineralocorticoid Receptor Antagonists across the spectrum of HFrEF, inclusive of a wide range of etiologies and disease severities. An MRA (spironolactone or eplerenone) is recommended in patients with HFrEF and NYHA class II to IV symptoms to reduce morbidity and mortality, if eGFR is >30 mL/min/1.73 m2 and serum potassium is <5.0 mEq/L. Hyperkalemia is a major risk of MRA therapy; therefore, careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely monitored thereafter (Heidenreich et al., 2022). Numerator Statement Change from: Patients who are prescribed an aldosterone receptor antagonist (i.e. Aldactone, Aldactazide [Hydrochlorothiazide + Spironolactone], Eplerenone, Inspra, Spironolactone) when seen in the outpatient setting. To: Patients who are prescribed a mineralocorticoid receptor antagonist (MRA) (i.e. Aldactone, Aldactazide [Hydrochlorothiazide + Spironolactone], Eplerenone, Inspra, Spironolactone) when seen in the outpatient setting. Numerator Data Elements Change from:
Change from: Heart failure patients with a NYHA class III-IV and current or prior documentation of left ventricular ejection fraction (LVSD) ≤35%. To: Heart failure patients with a NYHA class II-IV and current or prior documentation of left ventricular ejection fraction (LVSD) ≤40%. Denominator Included Populations Change third and fourth bullet from:
Change last bullet from:
Change from:
Add:
Denominator Change from: Heart failure patients with a NYHA class III-IV and current or prior documentation of left ventricular ejection fraction (LVSD) ≤35%. To: Heart failure patients with a NYHA class II-IV and current or prior documentation of left ventricular ejection fraction (LVSD) ≤40%. Check Box LVSD Change from: If LVSD quals 2, 3 or 5, the case will proceed to a Measure Category Assignment of B. If LVSD quals 1 or 4, continue processing and proceed to New York Heart Association (NYHA) Classification . To: If LVSD quals 5, the case will proceed to a Measure Category Assignment of B. If LVSD quals 1,2,3 or 4, continue processing and proceed to New York Heart Association (NYHA) Classification . Check Box New York Heart Association (NYHA) Classification Change from: If New York Heart Association (NYHA) Classification quals 1,2 or 5, the case will proceed to 2nd New York Heart Association (NYHA) Classification If New York Heart Association (NYHA) Classification quals 3 or 4, continue processing and proceed to Mineralocorticoid Receptor Antagonist Prescribed for LVSD in the Outpatient Setting. To: If New York Heart Association (NYHA) Classification quals 1 or 5, the case will proceed to 2nd New York Heart Association (NYHA) Classification If New York Heart Association (NYHA) Classification quals 2, 3 or 4, continue processing and proceed to Mineralocorticoid Receptor Antagonist Prescribed for LVSD in the Outpatient Setting. 2nd Check Box New York Heart Association (NYHA) Classification Change from: If New York Heart Association (NYHA) Classification quals 1 or 2, the case will proceed to a Measure Category Assignment of B. If New York Heart Association (NYHA) Classification quals 5, the case will proceed to a Measure Category Assignment of D. To: If New York Heart Association (NYHA) Classification quals 1, the case will proceed to a Measure Category Assignment of B. If New York Heart Association (NYHA) Classification quals 5, the case will proceed to a Measure Category Assignment of D. |
| CCCIP | The revisions to CCCC initial patient population will provide abstractor clarification regarding mandatory and optional measures included in the program. Additionally, the update changing aldosterone to mineralocorticoid receptor antagonist (MRA) will provide abstractor clarification and alignment with 2022 clinical practice guidelines. | Comprehensive Cardiac Center (CCC) Initial Patient Population
Paragraphs two and three Change from:
The measures chosen for implementation within the CCC certification program address major aspects of cardiac care, within the following 4 domains: cardiac rehabilitation, myocardial infarction (MI), heart failure (HF), and cardiac surgery (coronary artery bypass graft, cardiac valve repair/replacement and percutaneous coronary intervention [PCI]). The measures are separated into mandatory and optional measures and then again by inpatient and outpatient status. The certification program also includes 5 measures that are currently used in The Joint Commission’s Advanced Heart Failure Certification program (ACHF-01, ACHF-02, ACHF-06, ACHFOP-03, and ACHFOP-06). Organizations should follow the ACHF and ACHFOP initial patient population algorithm’s that are posted to The Joint Commission’s Measure Specifications Manual to determine the patient population for the heart failure measures. There are 5 mandatory measures: high-intensity statin, aldosterone antagonist, beta-blockers, post-discharge appointment and post-discharge evaluation that all certified organizations must abstract. The additional 3 inpatient and 5 outpatient measures are optional. It is highly recommended that the all organizations collect the optional measures to assist them with advancing quality of care for the cardiac patients they serve. Change to:The measures chosen for implementation within the CCC certification program address major aspects of cardiac care, within the following 4 domains: cardiac rehabilitation, myocardial infarction (MI), heart failure (HF), and cardiac surgery (coronary artery bypass graft, cardiac valve repair/replacement and percutaneous coronary intervention [PCI]). The measures are separated into mandatory and optional measures and then again by inpatient and outpatient status. It is highly recommended that all organizations collect the optional measures to assist them with advancing quality of care for the cardiac patients they serve. The certification program also includes 5 measures that are currently used in The Joint Commission’s Advanced Heart Failure Certification program (ACHF-01, ACHF-02, ACHF-06, ACHFOP-03, and ACHFOP-06). Organizations should follow the ACHF and ACHFOP initial patient population algorithm’s that are posted to The Joint Commission’s Measure Specifications Manual to determine the patient population for the heart failure measures. There are 5 mandatory measures:
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| CCCIP-02 | The update to mineralocorticoid receptor antagonist (MRA) will provide abstractor clarification and alignment with 2022 Clinical Practice Guidelines which recommends prescribing MRAs across the spectrum of HFrEF, inclusive of a wide range of etiologies and disease severities. | Performance Measure Name Change from: Aldosterone Antagonist Prescribed at Discharge To: Mineralocorticoid Receptor Antagonist (MRA) Prescribed at Discharge Description Change from: Patients with a diagnosis of heart failure with a left ventricular ejection fraction (LVSD) ≤35% who were prescribed an aldosterone antagonist at discharge. To: Patients with a diagnosis of heart failure with a left ventricular ejection fraction (LVSD) ≤40% who were prescribed a mineralocorticoid receptor antagonist (MRA) at discharge. Rationale Change to: The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure states a benefit of prescribing Mineralocorticoid Receptor Antagonists across the spectrum of HFrEF, inclusive of a wide range of etiologies and disease severities. An MRA (spironolactone or eplerenone) is recommended in patients with HFrEF and NYHA class II to IV symptoms to reduce morbidity and mortality, if eGFR is >30 mL/min/1.73 m2 and serum potassium is <5.0 mEq/L. Hyperkalemia is a major risk of MRA therapy; therefore, careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely monitored thereafter (Heidenreich et al., 2022). Numerator Statement Change from: Patients who are prescribed an aldosterone receptor antagonist (i.e. Aldactone, Aldactazide [Hydrochlorothiazide + Spironolactone], Eplerenone, Inspra, Spironolactone) at hospital discharge. To: Patients who are prescribed an mineralocorticoid receptor antagonist (i.e. Aldactone, Aldactazide [Hydrochlorothiazide + Spironolactone], Eplerenone, Inspra, Spironolactone) at hospital discharge. Numerator Data Elements Change from: Aldosterone Receptor Antagonist Prescribed for LVSD at Discharge To: Mineralocorticoid Receptor Antagonist (MRA) Prescribed for LVSD at Discharge Denominator Statement Change from: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) ≤35%. To: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) ≤40%. Denominator Included Populations Change second bullet from:
Change second bullet from:
Change from: Reason for No Aldosterone Receptor Antagonist Prescribed at Discharge To: Reason for No Mineralocorticoid Receptor Antagonist Prescribed at Discharge Selected References Add:
Numerator Change from: Patients who are prescribed a Aldosterone receptor antagonist (i.e. Aldactone, Aldactazide [Hydrochlorothiazide + Spironolactone], Eplerenone, Inspra, Spironolactone) at hospital discharge. To: Patients who are prescribed a mineralocorticoid receptor antagonist (i.e. Aldactone, Aldactazide [Hydrochlorothiazide + Spironolactone], Eplerenone, Inspra, Spironolactone) at hospital discharge. Denominator Change from: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) ≤35% To: Heart failure patients with current or prior documentation of left ventricular ejection fraction (LVSD) ≤40%. Check Box Name Change from: Aldosterone Receptor Antagonist Prescribed for LVSD at Discharge To: Mineralocorticoid Receptor Antagonist Prescribed for LVSD at Discharge Check Box LVSD Change from: If LVSD quals 2, 3 or 5, the case will proceed to a Measure Category Assignment of B. If LVSD quals 1 or 4, continue processing and proceed to Aldosterone Receptor Antagonist Prescribed for LVSD at Discharge. To: If LVSD quals 5, the case will proceed to a Measure Category Assignment of B. If LVSD quals 1,2,3 or 4, continue processing and proceed to Mineralocorticoid Receptor Antagonist Prescribed for LVSD at Discharge. |
| CCCOP | The revisions to CCCC initial patient population will provide abstractor clarification regarding mandatory and optional measures included in the program. Additionally, the update changing aldosterone to mineralocorticoid receptor antagonist (MRA) will provide abstractor clarification and alignment with 2022 clinical practice guidelines. | Comprehensive Cardiac Center (CCC) Initial Patient Population
Paragraphs two and three Change from:
The measures chosen for implementation within the CCC certification program address major aspects of cardiac care, within the following 4 domains: cardiac rehabilitation, myocardial infarction (MI), heart failure (HF), and cardiac surgery (coronary artery bypass graft, cardiac valve repair/replacement and percutaneous coronary intervention [PCI]). The measures are separated into mandatory and optional measures and then again by inpatient and outpatient status. The certification program also includes 5 measures that are currently used in The Joint Commission’s Advanced Heart Failure Certification program (ACHF-01, ACHF-02, ACHF-06, ACHFOP-03, and ACHFOP-06). Organizations should follow the ACHF and ACHFOP initial patient population algorithm’s that are posted to The Joint Commission’s Measure Specifications Manual to determine the patient population for the heart failure measures. There are 5 mandatory measures: high-intensity statin, aldosterone antagonist, beta-blockers, post-discharge appointment and post-discharge evaluation that all certified organizations must abstract. The additional 3 inpatient and 5 outpatient measures are optional. It is highly recommended that the all organizations collect the optional measures to assist them with advancing quality of care for the cardiac patients they serve. Change to:The measures chosen for implementation within the CCC certification program address major aspects of cardiac care, within the following 4 domains: cardiac rehabilitation, myocardial infarction (MI), heart failure (HF), and cardiac surgery (coronary artery bypass graft, cardiac valve repair/replacement and percutaneous coronary intervention [PCI]). The measures are separated into mandatory and optional measures and then again by inpatient and outpatient status. It is highly recommended that all organizations collect the optional measures to assist them with advancing quality of care for the cardiac patients they serve. The certification program also includes 5 measures that are currently used in The Joint Commission’s Advanced Heart Failure Certification program (ACHF-01, ACHF-02, ACHF-06, ACHFOP-03, and ACHFOP-06). Organizations should follow the ACHF and ACHFOP initial patient population algorithm’s that are posted to The Joint Commission’s Measure Specifications Manual to determine the patient population for the heart failure measures. There are 5 mandatory measures:
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| CSTK | The measure information was modified to increase capture of failed attempts at thrombectomy. | 1) Updated CSTK IPP algorithm flow to add Table 8.1c to the sub-population 1 and sub-population 2 branch.
2) Change from:
Ischemic Stroke With IV t-PA, IA t-PA, or MER
The population of the CSTK 2-Ischemic Stroke With IV t-PA, IA t-PA, or MER measures (CSTK-01, CSTK-02, CSTK-05, CSTK-08, CSTK-09, CSTK-10, CSTK-11, CSTK-12) are identified using 5 data elements: • Admission Date • Birthdate • Discharge Date • ICD-10-CM Principal Diagnosis Code • ICD-10-PCS Principal or Other Procedure Codes Patients admitted to the hospital for inpatient acute care are included in the CSTK-2 Ischemic Stroke With IV t-PA, IA t-PA, or MER subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.1 AND ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 8.1a OR Table 8.1b, a Patient Age (Admission Date – Birthdate) ≥ 18 years and a Length of Stay (Discharge Date - Admission Date) ≤ 120 days. Change to: Ischemic Stroke With IV t-PA, IA t-PA, or MER The population of the CSTK 2-Ischemic Stroke With IV t-PA, IA t-PA, or MER measures (CSTK-01, CSTK-02, CSTK-05, CSTK-08, CSTK-09, CSTK-10, CSTK-11, CSTK-12) are identified using 5 data elements: • Admission Date • Birthdate • Discharge Date • ICD-10-CM Principal Diagnosis Code • ICD-10-PCS Principal or Other Procedure Codes Patients admitted to the hospital for inpatient acute care are included in the CSTK-2 Ischemic Stroke With IV t-PA, IA t-PA, or MER subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.1 AND ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 8.1a OR Table 8.1b OR Table 8.1c, a Patient Age (Admission Date – Birthdate) ≥ 18 years and a Length of Stay (Discharge Date - Admission Date) ≤ 120 days. |
| CSTK-01 | The measure algorithm was revised to add Table 8.1c. | Numerator Included Populations Add:
Check Box ICD-10-PCS Principal or Other Procedure Codes Change from: If is all missing or None on Table 8.1a or 8.1b, continue processing and proceed to CSTK-01 NR. If any on Table 8.1a or 8.1b, continue processing to and proceed to ICD-10-PCS Principal or Other Procedure Date and Time Note Box To: If is all missing or None on Table 8.1a and 8.1b and 8.1c, continue processing and proceed to CSTK-01 NR. If any on Table 8.1a or 8.1b or 8.1c, continue processing to and proceed to ICD-10-PCS Principal or Other Procedure Date and Time Process Box. Process Box: ICD-10-PCS Principal or Other Procedure Date and Time Change from: Note: The earliest procedure code is the earliest procedure performed that is on Table 8.1a or/and 8.1b - If there is only one procedure code on Table 8.1a or 8.1b, select that procedure’s date and time even if UTD - If there is more than one procedure code on Table 8.1a or/and 8.1b on the earliest date, select the procedure’s date and the earliest non-UTD time. To: Note: The earliest procedure code is the earliest procedure performed that is on Table 8.1a or/and 8.1b or/and 8.1c - If there is only one procedure code on Table 8.1a or 8.1b or 8.1c, select that procedure’s date and time even if UTD - If there is more than one procedure code on Table 8.1a or/and 8.1b or/and 8.1c or on the earliest date, select the procedure’s date and the earliest non-UTD time. |
| CSTK-03 | The Measure Information Form was updated to align references with current clinical practice guidelines for subarachnoid hemorrhage. | Selected References Add: Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC 3rd, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS; on behalf of the American Heart Association/American Stroke Association. 2022 Guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2022;53:e282–e361. doi: 10.1161/STR.0000000000000407. Hoh BL, Ko NU, Amin-Hanjani S, Chou SH-Y, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R; Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2023;54:e8. doi: 10.1161/STR.000000000000043. Remove: Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guidelines for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43:1-27. Hemphill JC III, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald L, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the management of spontaneous intracerebral hemorrhage:a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:1-29. |
| CSTK-04 | The reference list was revised to add an updated 2022 guideline from the American Heart Association/American Stroke Association. | Selected References Add: 5. Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC III, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2022;53(7):e282-e361. Remove: 7. Hemphill JC III, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald L, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the management of spontaneous intracerebral hemorrhage:a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:1-29. |
| CSTK-06 | The Measure Information Form was updated to align references with current clinical practice guidelines for subarachnoid hemorrhage. | Selected References Add: Hoh BL, Ko NU, Amin-Hanjani S, Chou SH-Y, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R; Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2023;54:e26-e33. doi: 10.1161/STR.000000000000043. Remove: Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guidelines for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43:1-27. |
| CSTK-08 | The measure information was modified to increase capture of failed attempts at thrombectomy. | Denominator Included Populations Change from:
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| CSTK-11 | The measure information was modified to increase capture of failed attempts at thrombectomy. | Denominator Included Populations Change from:
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| CSTK-12 | The measure information was modified to increase capture of failed attempts at thrombectomy. | Denominator Included Populations Change from:
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| ED-1 | A narrative of the algorithm has been added for accessibility. | ED-1: Median Time from ED Arrival to ED Departure for Admitted ED Patients Narrative Algorithm was added after the measure flow algorithm. |
| ED-2 | A narrative of the algorithm has been added for accessiblity. | ED-2: Admit Decision Time to ED Departure Time for Admitted Patients Narrative Algorithm was added after the measure flow algorithm. |
| HBIPS | A narrative of the algorithm has been added for accessibility. | Hospital Based Inpatient Psychiatric Services (HBIPS) Initial Patient Population Algorithm Narrative has been added after the measure flow algorithm. |
| HBIPS-2 | A narrative of the algorithm has been added for accessibility. Updates to the rationale and reference list to reflect current evidence. | HBIPS-2: Hours of Physical Restraint Use Narrative Algorithm was added after the measure flow algorithm.
Rationale
Change from: Mental health providers that value and respect an individual's autonomy, independence and safety seek to avoid the use of dangerous or restrictive interventions at all times (Donat, 2003). The use of seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when restraint and seclusion are used; such use is rigorously monitored and analyzed to prevent future use. Providers also seek to prevent violence or aggression from occurring in their treatment environments by focusing their attention on prevention activities that have a growing evidence base (Donat, 2003). To: Mental health providers that value and respect an individual's autonomy, independence and safety seek to avoid the use of dangerous or restrictive interventions at all times (Donat, 2003). The use of seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when restraint and seclusion are used; such use is rigorously monitored and analyzed to prevent future use. Providers also seek to prevent violence or aggression from occurring in their treatment environments by focusing their attention on prevention activities that have a growing evidence base (Donat, 2003). Seclusion or restraint should be initiated only when less restrictive measures have proven ineffective, and the behavioral emergency poses serious and imminent danger to the person, staff, or others. Such interventions should be discontinued as soon as the behavioral criteria for release has been met, and never used as punishment (APNA, 2022). Providers should first attempt verbal de-escalation, and establish clear protocols to guide decision-making for the initiation and removal of restraint and seclusion (APA, 2022). Selected ReferencesAdd:
Numerator Statement Change from: The total number of hours that all psychiatric inpatients spent in physical restraint To: The total number of hours that all psychiatric inpatients were maintained in physical restraint |
| HBIPS-3 | A narrative of the algorithm has been added for accessibility. Updates to the rationale and references to reflect current evidence. | HBIPS-3: Hours of Seclusion Use Narrative Algorithm was added after the measure flow algorithm.
Rationale
Change from: Mental health providers that value and respect an individual's autonomy, independence and safety seek to avoid the use of dangerous or restrictive interventions at all times (Donat, 2003). The use of seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when restraint and seclusion are used; such use is rigorously monitored and analyzed to prevent future use. Providers also seek to prevent violence or aggression from occurring in their treatment environments by focusing their attention on prevention activities that have a growing evidence base (Donat, 2003). To: Mental health providers that value and respect an individual's autonomy, independence and safety seek to avoid the use of dangerous or restrictive interventions at all times (Donat, 2003). The use of seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when restraint and seclusion are used; such use is rigorously monitored and analyzed to prevent future use. Providers also seek to prevent violence or aggression from occurring in their treatment environments by focusing their attention on prevention activities that have a growing evidence base (Donat, 2003). Seclusion or restraint should be initiated only when less restrictive measures have proven ineffective, and the behavioral emergency poses serious and imminent danger to the person, staff, or others. Such interventions should be discontinued as soon as the behavioral criteria for release has been met, and never used as punishment (APNA, 2022). Providers should first attempt verbal de-escalation, and establish clear protocols to guide decision-making for the initiation and removal of restraint and seclusion (APA, 2022). Selected ReferencesAdd:
Algorithm Numerator Statement Change from: The total number of hours that all psychiatric inpatients spent in seclusion To: The total number of hours that all psychiatric inpatients were held in seclusion |
| HBIPS-5 | A narrative of the algorithm has been added for accessiblity. | HBIPS-5: Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification Narrative Algorithm was added after the measure flow algorithm. |
| IMM-2 | A narrative of the algorithm has been added for accessibility. | IMM-2: Influenza Immunization Narrative Algorithm has been added after the measure flow algorithm. |
| PC | Removing less than or equal to 120 day Length of Stay inclusion criteria to align with eCQM maternal initial patient population. Change verbiage within the PC-Newborn population, algorithm, and narrative to Human Milk Feeding to align with the verbiage in PC-05. | Perinatal Care (PC) Initial Patient Population-Mothers
Change from: Patients admitted to the hospital for inpatient acute care are included in the PC Mother Initial sampling group if they have: ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 11.01.1 Delivery, a Patient Age (Admission Date — Birthdate) >= 8 years and < 65 and a Length of Stay (Discharge Date - Admission Date) ≤ 120 days. To: Patients admitted to the hospital for inpatient acute care are included in the PC Mother Initial sampling group if they have: ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 11.01.1 Delivery, a Patient Age (Admission Date — Birthdate) >= 8 years and < 65. Perinatal Care (PC) Initial Patient Population-Newborns Change from: Within the PC-Newborn population, there are two baby measures, Exclusive Breast Milk Feeding and Unexpected Complications in Term Newborns. The patients in each measure are processed independently. Patients in the newborn population always run against the Unexpected Complication in Term Newborns measure and they may run against Exclusive Breast Milk Feeding measure if sampled. To: Within the PC-Newborn population, there are two baby measures, Exclusive Human Milk Feeding and Unexpected Complications in Term Newborns. The patients in each measure are processed independently. Patients in the newborn population always run against the Unexpected Complication in Term Newborns measure and they may run against Exclusive Human Milk Feeding measure if sampled. Change: all references to Exclusive Breast Milk Feeding within the document To: Exclusive Human Milk Feeding PC Initial Patient Population Algorithm Remove: any references to length of stay Change from: Exclusive Breast Milk Feeding To: Exclusive Human Milk Feeding PC Initial Patient Population Algorithm Narrative Change from: Exclusive Breast Milk Feeding To: Exclusive Human Milk Feeding |
| PC-01 | Removed length of stay greater than 120 days exclusion to align with maternal initial patient population. | Excluded Populations
Remove:
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| PC-02 | Removed length of stay greater than 120 days exclusion to align with maternal initial patient population. | Excluded Populations
Remove:
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| PC-05 | Changes to the measure information form verbiage are being made in order to be more inclusive. | Performance Measure Name
Change from: Exclusive Breast Milk Feeding To: Exclusive Human Milk Feeding Description Change from: Exclusive breast milk feeding during the newborn's entire hospitalization The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization. To: Exclusive human milk feeding during the newborn's entire hospitalization The measure is reported as an overall rate which includes all newborns that were exclusively fed human milk during the entire hospitalization. Rationale Change from: Exclusive breast milk feeding for the first 6 months of neonatal life has long been the expressed goal of World Health Organization (WHO), Department of Health and Human Services (DHHS), American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG). ACOG has recently reiterated its position (ACOG, 2018). A Cochrane review substantiates the benefits (Kramer et al., 2012). Much evidence has now focused on the prenatal and intrapartum period as critical for the success of exclusive (or any) breastfeeding (Centers for Disease Control and Prevention [CDC], 2020; CDC, 2013; Petrova et al., 2007; Taveras et al., 2004). Exclusive breast milk feeding rate during birth hospital stay has been calculated by the California Department of Public Health for the last several years using newborn genetic disease testing data. Healthy People 2020 and the CDC have also been active in promoting this goal. To: Exclusive human milk feeding for the first 6 months of neonatal life has long been the expressed goal of World Health Organization (WHO), Department of Health and Human Services (DHHS), American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG). ACOG has recently reiterated its position (ACOG, 2018). A Cochrane review substantiates the benefits (Kramer et al., 2012). Much evidence has now focused on the prenatal and intrapartum period as critical for the success of exclusive (or any) human milk feeding (Centers for Disease Control and Prevention [CDC], 2020; CDC, 2013; Petrova et al., 2007; Taveras et al., 2004). Exclusive human milk feeding rate during birth hospital stay has been calculated by the California Department of Public Health for the last several years using newborn genetic disease testing data. Healthy People 2020 and the CDC have also been active in promoting this goal. Numerator Statement Change from: Newborns that were fed breast milk only since birth To: Newborns that were fed human milk only since birth Data Elements Change from: Exclusive Breast Milk Feeding To: Exclusive Human Milk Feeding Denominator Exclusions Remove: Length of Stay >120 Days Add: Patients whose term status or gestational age is missing and birthweight < 3000 gm Measure Analysis Suggestions Change from: In order to identify areas for improvement in breast milk feeding rates, hospitals may wish to review documentation for reasons. Education efforts can be targeted based on the specific reasons identified. To: In order to identify areas for improvement in human milk feeding rates, hospitals may wish to review documentation for reasons. Education efforts can be targeted based on the specific reasons identified. PC-05 Algorithm Changes On page1 Change from: Exclusive Breast Milk Feeding To: Exclusive Human Milk Feeding. On page2 Change from: Check box Exclusive Breast Milk Feeding To: Exclusive Human Milk Feeding. Check box -Term Newborn Change from: If Term Newborn is missing, the case will proceed to a Measure Category Assignment of X. If Term Newborn equals 2 or 3, the case will proceed to a Measure Category Assignment of B To: If Term Newborn is missing or equals 3, continue processing and proceed to check BirthWeight. Add new: Check box - BirthWeight If BirthWeight is missing, the case will proceed to a Measure Category Assignment of X. If BirthWeight is less than 3000g, the case will proceed to a Measure Category Assignment of B. If BirthWeight is greater than or equals 3000g, continue processing and proceed to check Admission to NICU. |
| PC-06 | Abstraction guidance was added to assist facilities in abstraction of cases where there is a co-located neonatal intensive care unit operating under a separate license. Narrative verbiage changed to be easier to understand. | Data Collection Approach:
Add: Please see Appendix G for information on Guidance for Chart Abstraction when there is a Co-located NICU Appendix G Narrative step 12b Change from: If all ICD-10-CM Principal and Other Diagnosis Codes are missing or none of them on Table 11.20.2, continue processing and proceed to step 14 to check Length of Stay. To: If none of them on Table 11.20.2 and at least one of the ICD-10-CM Principal or Other Diagnosis Codes is on Table 11.20.3, the case will proceed to step 14 to check Length of Stay. |
| STK-1 | The reference list was revised to add an updated 2022 guideline from the American Heart Association/American Stroke Association. | Selected References Add:
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| STK-10 | The reference list was revised to add an updated 2022 guideline from the American Heart Association/American Stroke Association. | Selected References Add:
|
| STK-8 | The reference list was revised to add an updated 2022 guideline from the American Heart Association/American Stroke Association. | Selected References Add:
|
| STK-VOL-1 | The Measure Information Form was updated to remove the word "eligible" from the specifications. | Measure Name Change to: Ischemic Stroke Patients Who Receive Mechanical Endovascular Reperfusion Therapy Description Change from: Percentage of eligible patients with ischemic stroke who receive mechanical endovascular reperfusion therapy. To: Percentage of patients with ischemic stroke who receive mechanical endovascular reperfusion therapy. |
| SUB-2 | A narrative of the algorithm has been added for accessibility. Update to rationale and references to reflect current evidence. | SUB-2: Alcohol Use Brief Intervention Provided or Offered Narrative Algorithm has been added after the measure flow algorithm.
Rationale Change To: Excessive use of alcohol and drugs has a substantial harmful impact on health and society in the United States. It is a drain on the economy and a source of enormous personal tragedy (The National Quality Forum, A Consensus Report, 2007). More than 140,000 people in America die each year due to alcohol-related causes, which is the fourth-leading cause of death in the United States (CDC, 2022, NIAAA, 2023). Substance abuse costs the US economy approximately $400 billion dollars each year in lost productivity, crime, and healthcare spending (HHS, 2016). Substance use disorder treatment in US emergency departments and inpatient settings reached more than $13 billion dollars in 2017 (Peterson, 2021). According to the 2020 National Survey on Drug Use and Health (NSDUH), 40.3 million Americans, aged 12 or older, had a substance use disorder (SUD) in the past year (CDC, 2022). As of 2021, 10.6% of the US population age 12 and older (29.5 million people) had an alcohol use disorder in the past year (SAMHSA, 2021). Clinical trials have demonstrated that brief interventions, especially prior to the onset of addiction, significantly improve health and reduce costs, and that similar benefits occur in those with addictive disorders who are referred to treatment (Fleming, 2002, Di Clemente, 2017). Individuals with psychiatric disorders are more likely to have co-occurring substance use disorders. In 2019, 3.6 million people were diagnosed with both a serious mental illness and substance use disorder—which is increasing year over year. While there are substantial evidence-based interventions for substance use, few patients receive substance use care: of the 21.6 million people in 2019 who needed substance use treatment in 2019, 12.2% (or 2.6 million people) received care in a specialty facility (SAMHSA, 2020). Selected ReferencesChange To:
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| SUB-3 | A narrative of the algorithm has been added for accessibility. Update to rationale and references to reflect current evidence. | SUB-3: Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge Narrative Algorithm has been added after the measure flow algorithm.
Rationale Change To: Excessive use of alcohol and drugs has a substantial harmful impact on health and society in the United States. It is a drain on the economy and a source of enormous personal tragedy (The National Quality Forum, A Consensus Report, 2007). More than 140,000 people in America die each year due to alcohol-related causes, which is the fourth-leading cause of death in the United States (CDC, 2022, NIAAA, 2023). Substance abuse costs the US economy approximately $400 billion dollars each year in lost productivity, crime, and healthcare spending (HHS, 2016). Substance use disorder treatment in US emergency departments and inpatient settings reached more than $13 billion dollars in 2017 (Peterson, 2021). According to the 2020 National Survey on Drug Use and Health (NSDUH), 40.3 million Americans, aged 12 or older, had a substance use disorder (SUD) in the past year (CDC, 2022). As of 2021, 10.6% of the US population age 12 and older (29.5 million people) had an alcohol use disorder in the past year (SAMHSA, 2021). Clinical trials have demonstrated that brief interventions, especially prior to the onset of addiction, significantly improve health and reduce costs, and that similar benefits occur in those with addictive disorders who are referred to treatment (Fleming, 2002, Di Clemente, 2017). Individuals with psychiatric disorders are more likely to have co-occurring substance use disorders. In 2019, 3.6 million people were diagnosed with both a serious mental illness and substance use disorder—which is increasing year over year. While there are substantial evidence-based interventions for substance use, few patients receive substance use care: of the 21.6 million people in 2019 who needed substance use treatment in 2019, 12.2% (or 2.6 million people) received care in a specialty facility (SAMHSA, 2020). Selected ReferencesChange To:
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| THKR-IP-5 | Update the time period to submit post-operative assessments of general and joint specific functional status assessments to align with a more realistic timeline for optimal healing and regain of function. | Description
Change from:
Patients who completed the general health and joint specific functional status assessments, within 90 days after surgery, as specified below: Hips: [VR-12 or PROMIS-Global] AND [HOOS Jr. (6 questions) or HOOS Pain, Function Daily Living Subscales (27 questions)] Knees: [VR-12 or PROMIS-Global] and {KOOS Jr. (7 questions) or KOOS Stiffness, Pain, Function Daily Living Subscales (28 questions)] To:Patients who completed the general health and joint specific functional status assessments, within 365 days after surgery, as specified below: Hips: [VR-12 or PROMIS-Global] AND [HOOS Jr. (6 questions) or HOOS Pain, Function Daily Living Subscales (27 questions)] Knees: [VR-12 or PROMIS-Global] and {KOOS Jr. (7 questions) or KOOS Stiffness, Pain, Function Daily Living Subscales (28 questions)] Numerator Statement Change from: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. 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 365 days after surgery. Algorithm Change Numerator statement: Change from: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. 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 365 days after surgery. Decision box "Post Assessment day": The exit condition for "D" change from "<30 day(s) or >150 days" to "<300 day(s) or >425 days". The exit condition for "E" change from ">=30 day(s) or <=150 days" to ">=300 and <=425 days". |
| THKR-OP-5 | Update the time period to submit post-operative assessments of general and joint specific functional status assessments to align with a more realistic timeline for optimal healing and regain of function. | Description
Change from:
Patients who completed the general health and joint specific functional status assessments, within 90 days after surgery, as specified below: Hips: [VR-12 or PROMIS-Global] AND [HOOS Jr. (6 questions) or HOOS Pain, Function Daily Living Subscales (27 questions)] Knees: [VR-12 or PROMIS-Global] and {KOOS Jr. (7 questions) or KOOS Stiffness, Pain, Function Daily Living Subscales (28 questions)] To:Patients who completed the general health and joint specific functional status assessments, within 365 days after surgery, as specified below: Hips: [VR-12 or PROMIS-Global] AND [HOOS Jr. (6 questions) or HOOS Pain, Function Daily Living Subscales (27 questions)] Knees: [VR-12 or PROMIS-Global] and {KOOS Jr. (7 questions) or KOOS Stiffness, Pain, Function Daily Living Subscales (28 questions)] Numerator Statement Change from: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. 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 365 days after surgery. Algorithm Change Numerator statement: Change from: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. 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 365 days after surgery. Decision box "Post Assessment day": The exit condition for "D" change from "<30 day(s) or >150 days" to "<300 day(s) or >425 days". The exit condition for "E" change from ">=30 day(s) or <=150 days" to ">=300 and <=425 days". |
| TOB-2 | A narrative of the algorithm has been added for accessibility. Update to rationale and references to reflect current evidence. | TOB-2: Tobacco Use Treatment Provided or Offered Narrative Algorithm has been added after the measure flow algorithm.
Rationale Change To: Tobacco use is the single greatest cause of disease in the United States today and accounts for more than 480,000 deaths each year (CDC MMWR 2014). Smoking is a known cause of multiple cancers, heart disease, stroke, complications of pregnancy, chronic obstructive pulmonary disease, other respiratory problems, poorer wound healing, and many other diseases (CDC, 2020). Tobacco use creates a heavy cost to society as well as to individuals. Smoking-attributable health care expenditures are estimated to be at least $240 billion per year in direct medical expenses for adults, and over $185 billion in lost productivity (CDC, 2022). There is strong and consistent evidence that tobacco dependence interventions, if delivered in a timely and effective manner, significantly reduce the user's risk of suffering from tobacco-related disease and improve outcomes for those already suffering from a tobacco-related disease (CDC, 2021, DHHS, 2020, Choi et al, 2021, DHHS, 2000; Baumeister, 2007; Lightwood, 2003 and 1997; Rigotti, 2012). Effective, evidence-based tobacco dependence interventions have been clearly identified and include brief clinician advice, individual, group, or telephone counseling, and use of FDA-approved medications. These treatments are clinically effective and extremely cost-effective relative to other commonly used disease prevention interventions and medical treatments. Hospitalization (both because hospitals are a tobacco-free environment and because patients may be more motivated to quit as a result of their illness) offers an ideal opportunity to provide cessation assistance that may promote the patient's medical recovery. Selected ReferencesChange To:
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| TOB-3 | A narrative of the algorithm has been added for accessibility. Update to rationale and references to reflect current evidence. | TOB-3: Tobacco Use Treatment Provided or Offered at Discharge Narrative Algorithm has been added after the measure flow algorithm.
Rationale Change To: Tobacco use is the single greatest cause of disease in the United States today and accounts for more than 480,000 deaths each year (CDC MMWR 2014). Smoking is a known cause of multiple cancers, heart disease, stroke, complications of pregnancy, chronic obstructive pulmonary disease, other respiratory problems, poorer wound healing, and many other diseases (CDC, 2020). Tobacco use creates a heavy cost to society as well as to individuals. Smoking-attributable health care expenditures are estimated to be at least $240 billion per year in direct medical expenses for adults, and over $185 billion in lost productivity (CDC, 2022). There is strong and consistent evidence that tobacco dependence interventions, if delivered in a timely and effective manner, significantly reduce the user's risk of suffering from tobacco-related disease and improve outcomes for those already suffering from a tobacco-related disease (CDC, 2021, DHHS, 2020, Choi et al, 2021, DHHS, 2000; Baumeister, 2007; Lightwood, 2003 and 1997; Rigotti, 2012). Effective, evidence-based tobacco dependence interventions have been clearly identified and include brief clinician advice, individual, group, or telephone counseling, and use of FDA-approved medications. These treatments are clinically effective and extremely cost-effective relative to other commonly used disease prevention interventions and medical treatments. Hospitalization (both because hospitals are a tobacco-free environment and because patients may be more motivated to quit as a result of their illness) offers an ideal opportunity to provide cessation assistance that may promote the patient's medical recovery. Selected ReferencesChange To:
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| Section | Rationale | Description |
|---|---|---|
| Discharge Time | The data element definition was updated to align with the CMS inpatient manual, Version 5.15 for discharges on and after January 1, 2024. | Notes for Abstraction: Remove sixth and seventh bullets:
|
| Exclusive Human Milk Feeding | Name of data element and verbiage within the data element changed to be more inclusive and align with the PC-05 measure. | Data Element Name
Change from: Exclusive Breast Milk Feeding To: Exclusive Human Milk Feeding Anywhere the verbiage says breast milk feeding: Change from: Breast milk To: Human milk |
| Initial Hunt and Hess Scale Time | The data element definition was updated to provide clarification for abstractors. | Notes for Abstraction Add to first bullet: Note:
|
| Initial ICH Score Time | The data element definition was updated to provide clarification for abstractors. | Notes for Abstraction Add to first bullet: Note:
|
| Initial NIHSS Score Time | The data element definition was updated to provide clarification for abstractors. | Notes for Abstraction Add to first bullet: Note:
|
| MER Eligibility | Inclusion terms were updated to provide clarification for abstractors. | Inclusion Guidelines for Abstraction Add:
|
| Mineralocorticoid Receptor Antagonist (MRA) Prescribed in the Outpatient Setting | The update to mineralocorticoid receptor antagonist (MRA) will provide abstractor clarification and alignment with 2022 Clinical Practice Guidelines. | Name Change from: Aldosterone Receptor Antagonist Prescribed in the Outpatient Setting To: Mineralocorticoid Receptor Antagonist (MRA) Prescribed in the Outpatient Setting Definition Change from: Documentation that an aldosterone receptor antagonist was prescribed for New York Heart Association (NYHA) class III-IV and LVSD ≤35% in the outpatient setting. To: Documentation that a mineralocorticoid receptor antagonist (MRA) was prescribed for New York Heart Association (NYHA) class II-IV and LVSD ≤40% in the outpatient setting. Question Change from: Was an aldosterone receptor antagonist prescribed for a NYHA class III-IV and LVSD ≤35% in the outpatient setting? To: Was a mineralocorticoid receptor antagonist (MRA) prescribed for a NYHA class II-IV and LVSD ≤40% in the outpatient setting? Allowable Values Change from: Y (Yes) An aldosterone receptor antagonist was prescribed for a NYHA class III-IV and an LVSD ≤35%. N (No) An aldosterone receptor antagonist was not prescribed for a NYHA class III-IV and an LVSD ≤35% or unable to determine from medical record documentation. To: Y (Yes) A mineralocorticoid receptor antagonist (MRA) was prescribed for a NYHA class II-IV and an LVSD ≤40%. N (No) A mineralocorticoid receptor antagonist (MRA) was not prescribed for a NYHA class II-IV and an LVSD ≤40% or unable to determine from medical record documentation. Notes for Abstraction Change second bullet from:
Change from: All other aldosterone receptor antagonist medications other than those listed as inclusions. To: All other mineralocorticoid receptor antagonist (MRA) medications other than those listed as inclusions. |
| Mineralocorticoid Receptor Antagonist (MRA) Prescribed for LVSD at Discharge | The update to mineralocorticoid receptor antagonist (MRA) will provide abstractor clarification and alignment with 2022 Clinical Practice Guidelines which recommends prescribing MRAs across the spectrum of HFrEF, inclusive of a wide range of etiologies and disease severities. | Name Change from: Aldosterone Receptor Antagonist Prescribed for LVSD at Discharge To: Mineralocorticoid Receptor Antagonist (MRA) Prescribed for LVSD at Discharge Definition Change from: Documentation that aldosterone receptor antagonist was prescribed for LVSD at discharge. To: Documentation that mineralocorticoid receptor antagonist (MRA) was prescribed for LVSD at discharge. Question Change from: Was an aldosterone receptor antagonist for an LVSD ≤35% prescribed at discharge? To: Was a mineralocorticoid receptor antagonist (MRA) for an LVSD ≤40% prescribed at discharge? Allowable Values Change from: Y (Yes) An aldosterone receptor antagonist for an LVSD ≤35% was prescribed at discharge. N (No) An aldosterone receptor antagonist for an LVSD ≤35% was not prescribed at discharge or unable to determine from medical record documentation. To: Y (Yes) A mineralocorticoid receptor antagonist (MRA) for an LVSD ≤40% was prescribed at discharge. N (No) A mineralocorticoid receptor antagonist (MRA) for an LVSD ≤40% was not prescribed at discharge or unable to determine from medical record documentation. Notes for Abstraction Change second and third bullet from:
Change from:
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| Postoperative Assessments Completion Date | The update will reflect the updated time period to submit postoperative functional/health status assessments. | Notes for Abstraction
Change to: Patients who have completed the general health and joint specific functional status assessments within 365 days after surgery (300-425 days). Example: Patient had surgery on 2/17/2021. Postoperative general health and joint specific functional status assessments were completed on 2/18/2022. The case would pass the measure. |
| Reason for No Mineralocorticoid Receptor Antagonist (MRA) Prescribed in the Outpatient Setting | The update to mineralocorticoid receptor antagonist (MRA) will provide abstractor clarification and alignment with 2022 Clinical Practice Guidelines. | Name
Change from:
Reason for No Aldosterone Receptor Antagonist Prescribed in the Outpatient Setting Change to:Reason for No Mineralocorticoid Receptor Antagonist (MRA) Prescribed in the Outpatient Setting Definition Change from:Documentation of a reason for not prescribing an aldosterone antagonist in the outpatient setting by a physician/APN/PA or pharmacist. Change to:Documentation of a reason for not prescribing a mineralocorticoid receptor antagonist (MRA) in the outpatient setting by a physician/APN/PA or pharmacist. Question Change from:Did a physician/APN/PA or pharmacist document a contraindication to or a reason against an aldosterone antagonist prescription in the outpatient setting? Change to:Did a physician/APN/PA or pharmacist document a contraindication to or a reason against a mineralocorticoid receptor antagonist (MRA) prescription in the outpatient setting? Allowable Values Change from:Y (Yes) There is documentation by a physician/APN/PA or pharmacist of a contraindication to or a reason for not prescribing an aldosterone receptor antagonist in the outpatient setting. N (No) There is no documentation by a physician/APN/PA or pharmacist of a contraindication to or a reason for not prescribing an aldosterone receptor antagonist in the outpatient setting or unable to determine from medical record documentation. Change to:Y (Yes) There is documentation by a physician/APN/PA or pharmacist of a contraindication to or a reason for not prescribing a mineralocorticoid receptor antagonist (MRA) in the outpatient setting. N (No) There is no documentation by a physician/APN/PA or pharmacist of a contraindication to or a reason for not prescribing a mineralocorticoid receptor antagonist (MRA) in the outpatient setting or unable to determine from medical record documentation. Notes for Abstraction Change from:
None Change to: All other mineralocorticoid receptor antagonist (MRA) medications other than those listed as inclusions. |
| Reason for No Mineralocorticoid Receptor Antagonist (MRA) Prescribed at Discharge | The update to mineralocorticoid receptor antagonist (MRA) will provide abstractor clarification and alignment with 2022 Clinical Practice Guidelines. | Name
Change from:
Reason for No Aldosterone Receptor Antagonist Prescribed at Discharge Change to:Reason for No Mineralocorticoid Receptor Antagonist (MRA) Prescribed at Discharge Definition Change from:Documentation of reasons for not prescribing an aldosterone antagonist at discharge by a physician/APN/PA or pharmacist. Change to:Documentation of reasons for not prescribing a mineralocorticoid receptor antagonist (MRA) at discharge by a physician/APN/PA or pharmacist. Question Change from:Did a physician/APN/PA or pharmacist document a contraindication to or reason against an aldosterone antagonist prescription at discharge? Change to:Did a physician/APN/PA or pharmacist document a contraindication to or reason against a mineralocorticoid receptor antagonist (MRA) prescription at discharge? Allowable Values Change from:Y (Yes) There is documentation by a physician/APN/PA or pharmacist of a contraindication to or reason against an aldosterone antagonist prescription at discharge. N (No) There is no documentation by a physician/APN/PA or pharmacist of a contraindication to or reason against an aldosterone antagonist prescription at discharge, or unable to determine from medical record documentation. Change to:Y (Yes) There is documentation by a physician/APN/PA or pharmacist of a contraindication to or reason against a mineralocorticoid receptor antagonist prescription at discharge. N (No) There is no documentation by a physician/APN/PA or pharmacist of a contraindication to or reason against a mineralocorticoid receptor antagonist prescription at discharge, or unable to determine from medical record documentation. Notes for Abstraction Change from:
|
| Reason for No VTE Prophylaxis – Hospital Admission | The data element definition was updated to recognize recently available treatment to reverse Factor Xa Inhibitor medications. | Notes for Abstraction Change tenth bullet from:
|
| Section | Rationale | Description |
|---|---|---|
| Appendix A - Code Tables | Global changes to Appendix A to include ICD-10 CM and PCS 2024 updates additions, deletions and revisions.
Several ICD-10 Tables updated based on clinical, expert panel, and public feedback. ICD-10 Tables added to Appendix A for the PC Measures. ICD-10 Table 11.09 renamed to reflect intent of the code set. | Appendix A Tables updated to include 2024 ICD-10 updates: Table 10.01 Table 10.02 Table 11.07 Table 11.30 Table 11.31 Table 14.10 Table 2.2 Table 2.3 Updates based on clinical, expert panel, and public feedback. Table 8.1c Removed Codes: 03JY3ZZ Inspection of Upper Artery, Percutaneous Approach 03JY4ZZ Inspection of Upper Artery, Percutaneous Endoscopic Approach Added Codes: 03HH3DZ Insertion of Intraluminal Device into Right Common Carotid Artery, Percutaneous Approach 03HH4DZ Insertion of Intraluminal Device into Right Common Carotid Artery, Percutaneous Endoscopic Approach 03HJ3DZ Insertion of Intraluminal Device into Left Common Carotid Artery, Percutaneous Approach 03HJ4DZ Insertion of Intraluminal Device into Left Common Carotid Artery, Percutaneous Endoscopic Approach 03HK3DZ Insertion of Intraluminal Device into Right Internal Carotid Artery, Percutaneous Approach 03HK4DZ Insertion of Intraluminal Device into Right Internal Carotid Artery, Percutaneous Endoscopic Approach 03HL3DZ Insertion of Intraluminal Device into Left Internal Carotid Artery, Percutaneous Approach 03HL4DZ Insertion of Intraluminal Device into Left Internal Carotid Artery, Percutaneous Endoscopic Approach 03HM3DZ Insertion of Intraluminal Device into Right External Carotid Artery, Percutaneous Approach 03HM4DZ Insertion of Intraluminal Device into Right External Carotid Artery, Percutaneous Endoscopic Approach 03HN3DZ Insertion of Intraluminal Device into Left External Carotid Artery, Percutaneous Approach 03HN4DZ Insertion of Intraluminal Device into Left External Carotid Artery, Percutaneous Endoscopic Approach 047K3ZZ Dilation of Right Femoral Artery, Percutaneous Approach 047K4ZZ Dilation of Right Femoral Artery, Percutaneous Endoscopic Approach 047L3ZZ Dilation of Left Femoral Artery, Percutaneous Approach 047L4ZZ Dilation of Left Femoral Artery, Percutaneous Endoscopic Approach 04HK3DZ Insertion of Intraluminal Device into Right Femoral Artery, Percutaneous Approach 04HK4DZ Insertion of Intraluminal Device into Right Femoral Artery, Percutaneous Endoscopic Approach 04HL3DZ Insertion of Intraluminal Device into Left Femoral Artery, Percutaneous Approach 04HL4DZ Insertion of Intraluminal Device into Left Femoral Artery, Percutaneous Endoscopic Approach Z538 Procedure and treatment not carried out for other reasons Z539 Procedure and treatment not carried out, unspecified reason Table 10.01 Removed Codes: F1090 Alcohol use, unspecified, uncomplicated F1091 Alcohol use, unspecified, in remission Table 10.02 added Codes: F1090 Alcohol use, unspecified, uncomplicated F1091 Alcohol use, unspecified, in remission Table 11.09 O43213 Placenta accreta, third trimester O43219 Placenta accreta, unspecified trimester O43223 Placenta increta, third trimester O43229 Placenta increta, unspecified trimester O43233 Placenta percreta, third trimester O43239 Placenta percreta, unspecified trimester O648XX0 Obstructed labor due to other malposition and malpresentation, not applicable or unspecified O648XX1 Obstructed labor due to other malposition and malpresentation, fetus 1 O648XX2 Obstructed labor due to other malposition and malpresentation, fetus 2 O648XX3 Obstructed labor due to other malposition and malpresentation, fetus 3 O648XX4 Obstructed labor due to other malposition and malpresentation, fetus 4 O648XX5 Obstructed labor due to other malposition and malpresentation, fetus 5 O648XX9 Obstructed labor due to other malposition and malpresentation, other fetus O694XX0 Labor and delivery complicated by vasa previa, not applicable or unspecified O694XX1 Labor and delivery complicated by vasa previa, fetus 1 O694XX2 Labor and delivery complicated by vasa previa, fetus 2 O694XX3 Labor and delivery complicated by vasa previa, fetus 3 O694XX4 Labor and delivery complicated by vasa previa, fetus 4 O694XX5 Labor and delivery complicated by vasa previa, fetus 5 O694XX9 Labor and delivery complicated by vasa previa, other fetus Table 13.1: F1090 Alcohol use, unspecified, uncomplicated Tables added to Appendix A for PC Measures to indicate coded weeks gestation: Table 11.07.1 Table 11.10 Table 11.09 renamed to: Multiple Gestations, Abnormal Presentations, and Conditions Justifying Cesarean Delivery |
| Appendix D - Glossary of Terms | Appendix D was updated to align with glossary terms and acronyms in the CMS manual, Version 5.15 effective for discharges on and after January 1, 2024. | General Glossary of Terms Add: aggregate (data collection and reporting) Data from multiple data elements and patients are compiled into the final overall numerator, denominator, and exclusion totals for the measure. measure set A unique grouping of performance measures carefully selected to provide, when viewed together, a robust picture of the care provided in a given area (e.g., cardiovascular care, pregnancy). Change the following terms to: clinical performance measure to: clinical quality measure (CQM) CQMs can be measures of processes, experiences and/or outcomes of patient care, observations or treatment that relate to one or more quality aims for health care such as effective, safe, efficient, patient-centered, equitable, and timely care. CMS certification number This is Hospital's six digit acute care CMS Certification Number (CCN). CCN is collected for CMS by hospitals for each patient record. Currently, CCN number in used for eCQM data reporting in the Direct Data Submission platform, but it’s not reported in the Direct Data Submission platform, chart-abstracted module. The first two digits in CCN 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). critical access hospital (CAH) A Medicare participating hospital can become, and remain, a certified CAH by meeting these regulatory requirements (this isn’t an all-inclusive list but includes basic criteria):
national hospital inpatient quality measure Quality measures are tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include effective, safe, efficient, patient-centered, equitable, and timely care. national hospital inpatient quality measure set A unique grouping of performance measures carefully selected to provide, when viewed together, a robust picture of the care provided in a given area (e.g., cardiovascular care, pregnancy). |
| Appendix G - Resources | Appendix G was updated to align with definitions in the CMS manual, Version 5.15 effective for discharges on and after January 1, 2024. Resource added for PC-06 Unexpected Complications in Term Newborns for guidance on chart-abstraction when there is a co-located NICU. | Resources Add: CMS Abstraction, Measure, or Electronic Clinical Quality Measures (eCQMs) Questions For questions you may go to https://qualitynet.cms.gov/ then select “Hospitals-Inpatient” under “Questions & Answers” to submit your questions. Questions & Answers is an online questions and answers database that allows for the submission and retrieval of questions and answers based on the measure set and keyword criterion. For questions regarding eCQM specifications, value sets, and appropriateness of mapping, please submit questions to the Office of the National Coordinator for Health Information Technology (ONC) eCQM Issue Tracker at https://oncprojectracking.healthit.gov/support/projects/CQM/summary. The eCQM Issue Tracker is an online database that allows for the submission and retrieval of questions and answers based on the measure and keyword criterion. Change to: CMS Hospital Inpatient Quality Reporting (IQR) Program For information on measures that are required for the CMS Hospital IQR Program and/or used for Public Reporting, refer to the Hospital IQR Program Measures and/or the Acute Care Hospital Quality Reporting Program Measures documents, for the appropriate fiscal year, at https://qualitynet.cms.gov/. Please go to the QualityNet web site and select Hospitals-Inpatient on the QualityNet home page, Measures on the Hospitals-Inpatient page, and Learn More under Hospital Inpatient Quality Reporting (IQR) Inpatient Measures on the Hospital Inpatient Measures page. You may also refer to the IPPS final rule at http://www.cms.gov/AcuteInpatientPPS/. Information regarding the Hospital IQR Program electronic clinical quality measures (eCQM) reporting is available on QualityNet at https://qualitynet.cms.gov/. From the QualityNet web site, select Electronic Clinical Quality Measures (eCQMs) Reporting under Hospital Inpatient Quality Reporting Program under Hospitals-Inpatient. Add: PC-06 Unexpected Complications in Term Newborns: Guidance for Chart Abstraction when there is a Co-located NICU |
| Data Dictionary - Introduction to the Data Dictionary | The Introduction to the Data Dictionary was updated to align with the CMS manual, version 5.15 effective for discharges on and after January 1, 2024. | Medical Record Add second paragraph: All medical records must be promptly completed. Every medical record must be complete with all documentation of orders, diagnosis, evaluations, treatments, test results, care plans, discharge plans, consents, interventions, discharge summary, and care provided along with the patient’s response to those treatments, interventions, and care. The record must be completed promptly after discharge in accordance with State law and hospital policy but no later than 30 days after discharge [42CFR482.24(b)]. Physician/Advance Practice Nurse/Physician Assistant Documentation Add the following terms:
Change the first bullet from:
Change first bullet to:
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| Global Initial Patient Population | A narrative of the algorithm has been added for accessibility. | Global Initial Patient Population Narrative Algorithm was added after the measure flow algorithm. |
| Introduction to the Manual | The Introduction to the Manual was updated to align with the CMS manual, version 5.15 effective for discharges on and after January 1, 2024. | Related National Activities Remove: National Quality Forum The NQF has approved a set of national voluntary consensus standards for measuring the quality of hospital care. These measures will permit consumers, providers, purchasers, and quality improvement professionals to evaluate and compare the quality of care in general acute care hospitals across the nation using a standard set of measures. Change to: Electronic Clinical Quality Measures (eCQMs) Overview Beginning in calendar year (CY) 2013, CMS provided hospitals with the opportunity to voluntarily submit eCQM data. These quality measures were developed specifically to allow an electronic health record (EHR) system certified to the Office of the National Coordinator for Health Information Technology (ONC) standards to capture, export, calculate, and report measure data. Since CY 2016, hospitals have been required to report eCQM data for 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 fulfill the Medicare Promoting Interoperability Program requirement for eCQM reporting 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. Note: Critical access hospitals (CAHs) are required to participate in the Medicare Promoting Interoperability Program and are encouraged but not required to participate in the Hospital IQR Program. Review the Medicare Promoting Interoperability Programs information on the CMS.gov website for more information. Change to:Hospital Value-Based Purchasing (VBP) Program The Hospital VBP Program is part of the CMS’ long-standing effort to link Medicare’s payment system to healthcare quality in the inpatient setting. The program implements value-based purchasing within the payment system that accounts for the largest share of Medicare spending, affecting payment for inpatient stays in approximately 3,000 hospitals across the county. Hospitals are paid for inpatient acute care services based on the quality of care (as evaluated using a select set of quality and cost measures), not just quantity of the services they provide. Section 1886 (o) of the Social Security Act set forth the statutory requirements for the Hospital VBP Program. The Hospital VBP Program is designed to promote better clinical outcomes for hospital patients, as well as improve their experience of care during hospital stays, while reducing costs to make care affordable. Specifically, the Hospital VBP Program seeks to incentivize hospitals to improve the quality and safety of care that Medicare beneficiaries and all patients receive during acute-care inpatient stays by:
Measures Management System (MMS) The Measures Management System (MMS) is a standardized system for developing and maintaining the quality measures used in various CMS initiatives and programs. MMS also supports quality-related activities across the agency. Quality measures are tools that help improve the quality of healthcare through an approach that is consistent and accountable. The primary goals of the MMS are to:
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| Sampling | 1. Updated verbiage in Population and Sampling Specifications section at 3 places to align with the PC-05 Measure Name change 2. Guidance offering process steps for record re-abstraction to check inter-rater reliability was added to the Sampling Chapter. | Population and Sampling Specifications Change from: Exclusive Breast Milk Feeding To: Exclusive Human Milk Feeding Add new section: Inter-rater Reliability |
| Rationale | Description |
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| CSTK-07 has been suspended since 2016 and now is retired. | CSTK-07 has been suspended since 2016 and now is retired. |
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