Specifications Manual for Joint Commission National Quality Measures (v2024B)
Posted: 02/02/2024

Release Notes:
Release Notes
Version 2024B

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Release Notes for the TJC2024B Manual

Measure Information Forms

SectionRationaleDescription
HBIPS Updated HBIPS Initial Patient Population Algorithm and removed HBIPS-5 discharge measure related information due to retiring HBIPS-5. Update: HBIPS Initial Patient Population Algorithm

Remove: HBIPS-5 discharge measure related information.
PAL Removed reference to data element sex. Remove: While not required for the identification of the initial patient population or the calculation of the measures, the following data elements are collected for purposes of case identification:
  • Admission Date
  • Birthdate
  • Sex
PC-01 A new code table, Table 11.07.1 Early Term Gestational Age, was added to Appendix A. The guidance to use the table needs to be added to the Measure Information Form to alert abstractors to use the codes. The algorithm and narrative will also be updated to include the table. Denominator Included Populations:
Add:
  • ICD-10-PCS Principal Procedure Code or ICD-10-CM Other Diagnosis Codes for early term gestational age as defined in Appendix A, Table 11.07.1 Early Term Gestational Age
PC-02 A new code table, Table 11.10 Term Gestational Age, was added to Appendix A. The guidance to use the table needs to be added to the Measure Information Form to alert abstractors to use the codes. The algorithm and narrative are also being updated to include the table. The name of Table 11.09 was changed to Table 11.09 Multiple Gestations, Abnormal Presentations, and Conditions Justifying Cesarean Delivery due to the addition of absolute indications for cesarean section such as placenta previa, placenta accreta, placenta increta, and placenta percreta. A new reference is being added to support the addition of these exclusions. Denominator Included Populations: Add:
  • ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for term gestational age as defined in Appendix A, Table 11.10 Term Gestational Age

Denominator Excluded Populations: Change from:
  • ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for multiple gestations and other presentations as defined in Appendix A, Table 11.09 Multiple Gestations and Other Presentations
To:
  • ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for multiple gestations, abnormal presentations, and conditions justifying cesarean delivery as defined in Appendix A, Table 11.09 Multiple Gestations, Abnormal Presentations, and Conditions Justifying Cesarean Delivery

References: Add:

American College of Obstetricians and Gynecologists, & Society for Maternal-Fetal Medicine (2018). Obstetric Care Consensus No. 7: Placenta Accreta Spectrum. Obstetrics and gynecology, 132(6), e259–e275.

Data Elements

SectionRationaleDescription
Birthdate Remove references to HBIPS-5 due to retirement of measure. Definition
Change from:
* For HBIPS discharge measures, i.e., HBIPS-5, patient's age (in years) is calculated by Discharge Date minus Birthdate. For event measures, i.e., HBIPS-2, 3, patient's age at time of event (in years) is calculated by Event Date minus Birthdate.

Change to:
*For event measures, i.e., HBIPS-2, 3, patient's age at time of event (in years) is calculated by Event Date minus Birthdate.
Event Date Remove references to HBIPS-5 due to retirement of measure. Other Collected For
Remove: Not collected for HBIPS-5
Event Type Remove references to HBIPS-5 due to retirement of measure. Other Collected For:
Remove: Not collected for HBIPS-5
Gestational Age Gestational Age code tables were added to Appendix A. Guidance on how to use the tables is being added to the Gestational Age data element. Notes for Abstraction:

Add:

  • ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes

It is acceptable to identify gestational age with ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes. If the gestational age codes identified were not on Table 11.07.1 Early Term Gestational Age (PC-01) or Table 11.10 Term Gestational Age (PC-02), the gestational age code could still be used to determine the gestational age abstracted for this data element. If there is conflicting documentation select the gestational age documented in the medical record according to priority per the notes for abstraction guidance.

Suggested Data Sources:

Add:

  • ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes

Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade An additional note was added to align with TICI score data collection in GWTG. Notes for Abstraction
Add:
  • If a TICI 2b, 2c or 3 is the score documented, select "1".

Supplemental Materials

SectionRationaleDescription
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 2023 by the American Medical Association (AMA).

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 2024 by the American Medical Association (AMA).
Appendix D - Glossary of Terms Updated the definitions for hospital-based inpatient psychiatric services (HBIPS) and subset measure(s) to align with the retirement of HBIPS measures and TOB-2. Change from: The Hospital-Based Inpatient Psychiatric Services (HBIPS) is a national quality partnership of organizations focused on improving quality and performance in impatient psychiatric settings through performance measurement utilizing 5 process measures in 3 separate domains (assessment, patient safety, continuity/transition of care).

To: The Hospital-Based Inpatient Psychiatric Services (HBIPS) measure set is targeted towards improving quality and performance in inpatient psychiatric settings through 2 process measures.

Change from: A subset measure contains overlapping sets of patients. For example, the patients in the TOB-2a measure are a subset of those in the TOB-2 measure, i.e., the two measures have overlapping populations.

To: A subset measure contains overlapping sets of patients. For example, the patients in the SUB-2a measure are a subset of those in the SUB-2 measure, i.e., the two measures have overlapping populations.
Data Dictionary - Introduction to the Data Dictionary Remove (Optional for all HBIPS measures) due to retiring HBIPS-5. Remove Sex data element. Removed reference to data general data elements being submitted. Remove: (Optional for all HBIPS measures)

Remove:
  • Sex

Change from:

Regardless of which measure sets are selected by a hospital, certain general data elements must be collected by the hospital and submitted for every patient that falls into any of the selected Initial Patient Populations. These data elements are considered "general" to each patient's episode of care.

These data elements include:
  • Admission Date
  • Birthdate
  • Health Care Organization Identifier
  • Hispanic Ethnicity
  • Measure Set
  • Race
  • Sex

To:

Regardless of which measure sets are selected by a hospital, certain general data elements must be collected by the hospital for every patient that falls into any of the selected Initial Patient Populations. These data elements are considered "general" to each patient's episode of care.

These data elements include:
  • Admission Date
  • Birthdate
  • Health Care Organization Identifier
  • Hispanic Ethnicity
  • Measure Set
  • Race
Joint Commission Clinical Data Processing Flow - Transmission Data Processing Flow: Clinical Removed the reference of HBIPS discharge measure from various locations due to retiring of the HBIPS-5 measure. Change from: Note HBIPS: HBIPS contains two Initial Patient Populations, discharges and events. All events of the same type occurring on the same day are reported as one measure (i.e., added as total). However, different types of events occurring on the same day are reported as different measures (i.e., different numbers).

To: Note HBIPS: HBIPS contains Initial Patient Population for event measures. All events of the same type occurring on the same day are reported as one measure (i.e., added as total). However, different types of events occurring on the same day are reported as different measures (i.e., different numbers).

Change from: The general data elements, as defined in the Introduction to the Data Dictionary section, should be evaluated to ensure they exist and contain valid allowable values. The HBIPS measure set is unique in that it has three different groups of general data elements. The first group is "general" for all measures in the set. The second group is only "general" for the HBIPS discharge measures. The third group is only "general" for the HBIPS event measures. In addition, HBIPS data elements may be "measure set specific" for one type of HBIPS measure and "general" for the other type. For example, Psychiatric Care Setting is a "measure set specific" data element for the discharge measures and a "general" data element for the event measures.

To: The general data elements, as defined in the Introduction to the Data Dictionary section, should be evaluated to ensure they exist and contain valid allowable values. HBIPS data elements may be "measure set specific" or general. For example, Psychiatric Care Setting is a "general" data element for the event measures.
Sampling Removed the reference of HBIPS discharge measure from various locations due to retiring of HBIPS-5 measure. Remove: Reference of HBIPS discharge measures from multiple places.

General Release Notes

RationaleDescription
The data element Sex is being removed pending alignment with new CMS data elements for sex and gender identity. Remove: Sex data element in its entirety.

Release Notes
CPT® only copyright 2024 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2024B)
Discharges 07-01-24 (3Q24) through 12-31-2024 (4Q24)

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