Appendix G

Resources

The following are available resources to those using the Specifications Manual for National Quality Measures.

Healthcare Organizations
If you are a Joint Commission accredited healthcare organization with questions about Joint Commission National Quality Measures, please contact the Department of Quality Measurement at at http://manual.jointcommission.org/

PC-06 Unexpected Complications in Term Newborns: Guidance for Chart Abstraction when there is a Co-located NICU

When the delivery hospital and the NICU are within the same building, but operating under separate licenses (co-located), the admissions to the NICU are often identified by ADT systems as transfers to another institution and are therefore getting flagged as numerator cases if they meet the Unexpected Newborn Complications (PC-06) denominator criteria.

For the purposes of this metric, it is imperative that every delivery hospital have a mechanism to track the ICD-10 diagnosis and procedure codes for ALL their births across the entirety of the newborn's stay, including both the delivery and NICU admission even if that care is under a different license. This measure is intended to reflect outcomes of both L&D practices and newborn care; it is very important for the delivery hospital to know the outcomes of their infants for their own quality improvement (QI) purposes. After meeting with some hospitals with co-located NICUs and getting feedback about how they have adapted data collection processes in order to properly abstract the measure, we wanted to provide some guidance on how this is being done.

Guidance for abstracting Chart Abstracted PC-06 measure when the delivery hospital has a co-located NICU:

The delivery hospital should have a contract with the co-located NICU, which allows sharing of necessary data for the newborns transferred from the delivery hospital. Pertinent data needed would be a personal identifier, ICD-10 diagnosis and procedure codes, discharge date and discharge disposition from the NICU. Sharing of this data is important for all OB quality improvement activities, not just for reporting this measure!
The delivery hospital updates the abstraction data for the transferred newborns with the appropriate NICU data. This includes combining the ICD-10 codes from the delivery and NICU stays, as well as updating the discharge disposition to reflect the discharge disposition from the co-located NICU. Infants without ICD-10 codes on any of the severe or moderate complications tables, not meeting length of stay criteria, and discharged home would be excluded from the numerator.
1. For example, a newborn was transferred to the co-located NICU from the delivery hospital for stabilization. The newborn was discharged home within 3 days after a cesarean birth and has no ICD-10 codes for moderate or severe complications. Initially the infant would be a severe complication due to the transfer to the co-located NICU, however upon abstraction with the NICU data included the infant would not be in the numerator.
The method in which the hospitals share and keep track of the information is up to the individual hospitals and may be manual to create updated combined reports. Remember, the updated information is only for measure reporting purposes and should not change data in the medical record.

There is also information on the FAQ provided by CMQCC on page 5-6. The link to the FAQ is: https://www.cmqcc.org/sites/default/files/Unexpected_Newborn_Complications_FAQs_2018%20Datav2.pdf

Vendors
If you are a software vendor with questions about Joint Commission National Quality Measures, please contact the Department of Quality Measurement at http://manual.jointcommission.org/

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.

CMS Abstraction & Reporting Tool (CART)
For technical assistance with CART, please contact the CCSQ Service Center at Qnetsupport@cms.hhs.gov , or call 1-866-288-8912.

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.

National Uniform Billing Committee (NUBC)
For further information regarding the UB-04 and NUBC related data elements, please refer to the NUBC manual, “Official UB-04 Data Specifications Manual© Copyright American Hospital Association” or website at https://www.nubc.org/.

Specifications Manual for Joint Commission National Quality Measures (v2024B)
Discharges 07-01-24 (3Q24) through 12-31-2024 (4Q24)

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