Specifications Manual for Joint Commission National Quality Measures (v2024A1)
Posted: 10/6/2023

Release Notes:
Release Notes
Version 2024A1

This page does not need to be edited for each new release. The list of release notes is automatically generated based on the release identified in url param.

Select Release:

Release Notes for the TJC2024A1 Manual

Measure Information Forms

SectionRationaleDescription
HBIPS-5 HBIPS-5 is retired as of 1/1/2024. This is a notification that the HBIPS-5 measure will be removed from the manual in the next release.
PC-05 The data element Birth Weight was added to the measure to align with the PC-05 measure algorithm. Denominator Data Elements
Add
Birth Weight

Algorithm
Change From:
Check box - Birth Weight
a. If Birth Weight is missing, the case will proceed to a Measure Category Assignment of X.
b. If Birth Weight is less than 3000g, the case will proceed to a Measure Category Assignment of B.
c. If Birth Weight is greater than or equals 3000g, continue processing and proceed to check Admission to NICU.
Change To:
Check box - Birth Weight
a. If Birth Weight is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
b. If Birth Weight is less than 3000g or equals UTD, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
c. If Birth Weight is greater than or equals 3000g, continue processing and proceed to check Admission to NICU.
PC-06 Within the denominator exclusions birth weight was incorrectly put in as birthweight. The change is being made to correct the typo. Denominator Excluded Populations: Fourth bullet point

Change from:

birthweight

To:

birth weight

TOB-2 TOB-2 is retired as of 1/1/2024. This is a notification that the TOB-2 measure will be removed from the manual in the next release.

Data Elements

SectionRationaleDescription
Birth Weight The data element Birth Weight was added to the PC-05 measure to align with the PC-05 measure algorithm. Add PC-05
Failed Attempt at Thrombectomy The data element definition was updated to add Z codes that may be used to represent a failed attempt at thrombectomy. Inclusion Guidelines for Abstraction
Add second paragraph:
Patients with these "Z" codes, if medical record documentation states that the mechanical thrombectomy procedure was attempted but unsuccessful or aborted before removal of the LVO.
  • Z538 Procedure and treatment not carried out for other reasons
  • Z539 Procedure and treatment not carried out, unspecified reason

Exclusion Guidelines for Abstraction
Add second paragraph:
Patients with these "Z" codes, if medical record documentation does not indicate that the procedure attempted was a mechanical thrombectomy for removal of a LVO.
  • Z538 Procedure and treatment not carried out for other reasons
  • Z539 Procedure and treatment not carried out, unspecified reason

Supplemental Materials

SectionRationaleDescription
Appendix A - Code Tables The Z codes that were added to Table 8.1c are diagnosis codes not procedure codes and will not have procedure date/time. Remove codes: Z538 Procedure and treatment not carried out for other reasons Z539 Procedure and treatment not carried out, unspecified reason
Table of Contents HBIPS-5 and TOB-2 are retired as of 1/1/2024. HBIPS-5 and TOB-2 are denoted as (RETIRED Effective 1/1/2024)

Release Notes
CPT® only copyright 2024 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2024A1)
Discharges 01-01-24 (1Q24) through 06-30-24 (2Q24)

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)

CPT® only copyright 2024 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.

^