Specifications Manual for Joint Commission National Quality Measures (v2025A)

Posted: 09/13/2024

Release Notes:
Release Notes
Version 2025A

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Release Notes for the TJC2025A Manual

Measure Information Forms

Section	Rationale	Description
ACHF-01	Adding special notice header to MIF to indicate specific ACHF measures that are removed from the ACHF program only. These measures are still applicable to the Comprehensive Cardiac Center Certification; therefore, the specifications are not being retired completely.	Change to: SUSPENDED for Advanced Certification Heart Failure Centers, Effective January 1, 2025
ACHFOP-01	This measure has been retired effective with 1/1/2025 discharges.	This is a notification that the ACHFOP-01 measure will be removed from the manual in the next release.
ACHFOP-02	This measure has been retired effective with 1/1/2025 discharges.	This is a notification that the ACHFOP-02 measure will be removed from the manual in the next release.
ACHFOP-03	Adding special notice header to MIF to indicate specific ACHF measures that are removed from the ACHF program only. These measures are still applicable to the Comprehensive Cardiac Center Certification; therefore, the specifications are not being retired completely.	Change to: SUSPENDED for Advanced Certification Heart Failure Centers, Effective January 1, 2025
ACHFOP-04	This measure has been retired effective with 1/1/2025 discharges.	This is a notification that the ACHFOP-04 measure will be removed from the manual in the next release.
ACHFOP-05	This measure has been retired effective with 1/1/2025 discharges.	This is a notification that the ACHFOP-05 measure will be removed from the manual in the next release.
ACHFOP-06	Adding special notice header to MIF to indicate specific ACHF measures that are removed from the ACHF program only. These measures are still applicable to the Comprehensive Cardiac Center Certification; therefore, the specifications are not being retired completely.	Change to: SUSPENDED for Advanced Certification Heart Failure Centers, Effective January 1, 2025
ACHFOP-07	This measure has been retired effective with 1/1/2025 discharges.	This is a notification that the ACHFOP-07 measure will be removed from the manual in the next release.
PC-01	TJC will no longer maintain Consensus Based Entity (CBE) endorsement for chart abstracted PC measures. Reference updated with the most current version. Principal Procedure Code corrected to Principle Diagnosis Code in Denominator Included Populations. Removed Appendix A, Table 11.07.1 Early Term Gestational Age from the measure. The use of Gestational Age code tables in PC-01 and PC-02 has been removed from the 2025A manual since the intent of the measures is to capture the gestational age at time of delivery. The codes were initially added to decrease burden of abstraction and align with the eCQM version but due to the coding guidance and cases where the gestational age at delivery is different than admission it will be removed. Organizations can continue to use the gestational age at time of delivery since that is the intent of the measure. The gestational age data element has guidance in the 2024B manual to use the gestational age coding as the lowest priority source; however, we understand the algorithm can cause confusion.	Adoption Status (Header Note) Remove: NQF Endorsed. Selected References Add: ACOG Committee Opinion, No. 831: Medically indicated late-preterm and early-term deliveries. (2021, July). Obstetrics and Gynecology, 138(1), e35-e39. https://doi.org/10.1097/AOG.0000000000004447 Denominator Included Populations bullet point 3 Remove: ICD-10-PCS Principal Diagnosis 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. Algorithm Change: Remove: Check box for ICD-10-CM Principal or Other Diagnosis Codes, to check if at least one of ICD-10-PCS Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes on Table 11.07.1. PC-01: Elective Delivery Algorithm Narrative Change from: 2. Check ICD-10-CM Principal or Other Diagnosis Codes If at least one of the ICD-10-CM Principal or Other Diagnosis Codes is on Table 11.07, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing. If all ICD-10-CM Principal and Other Diagnosis Codes are missing or none of them on Table 11.07, continue processing and proceed to check ICD-10-CM Principal or Other Diagnosis Codes. Change to: 2. Check ICD-10-CM Principal or Other Diagnosis Codes If at least one of the ICD-10-CM Principal or Other Diagnosis Codes is on Table 11.07, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing. If all ICD-10-CM Principal and Other Diagnosis Codes are missing or none of them on Table 11.07, continue processing and proceed to check Gestational Age. Remove: 3. Check ICD-10-CM Principal or Other Diagnosis Codes If at least one of the ICD-10-CM Principal or Other Diagnosis Codes is on Table 11.07.1, the case will proceed to check ICD-10-CM Principal or Other Diagnosis Codes. If all ICD-10-CM Principal or Other Diagnosis Codes are missing or none on Table 11.07.1, proceed to check Gestational Age.
PC-02	TJC will no longer maintain Consensus Based Entity (CBE) endorsement for chart abstracted PC measures. Codes and rationale added for conditions (active genital herpes, placenta previa, vasa previa, and placenta accreta spectrum disorders) that are absolute indications for cesarean delivery. New references added to support the new exclusions. References updated to most recent version. Coding guidance FAQ link was added for Table 11.09 Removed Appendix A Code Table 11.10 Term Gestational Age. The use of Gestational Age code tables in PC-01 and PC-02 has been removed from the 2025A manual since the intent of the measures is to capture the gestational age at time of delivery. The codes were initially added to decrease burden of abstraction and align with the eCQM version but due to the coding guidance and cases where the gestational age at delivery is different than admission it will be removed. Organizations can continue to use the gestational age at time of delivery since that is the intent of the measure. The gestational age data element has guidance in the 2024B manual to use the gestational age coding as the lowest priority source; however, we understand the algorithm can cause confusion.	Adoption Status (Header Note) Remove: NQF Endorsed. Rationale Add: After fourth paragraph: In accordance with the American College of Obstetricians and Gynecologists (ACOG) recommendations (2020), cesarean delivery is indicated for patients with active genital lesions of genital herpes or prodromal symptoms (i.e., vulvar pain or burning at delivery) that may indicate viral shedding. Therefore, the measure will exclude encounters with a diagnosis of active genital herpes. In addition, the accepted approach to treat placenta accreta spectrum, or the range of pathologic adherence of the placenta that includes placenta increta, placenta percreta, and placenta accreta, as well as placenta previa, is cesarean delivery (ACOG & Society for Maternal-Fetal Medicine (SMFM), 2018). Vasa previa is an indication for cesarean delivery (SMFM Publications Committee, Sinkey, Odibo, & Dashe, 2015). Accordingly, placenta previa, vasa previa, and placenta accreta spectrum are all qualifying conditions to also be excluded from the measure. Denominator Excluded Populations Add: to the end of the first bullet (please see FAQ for additional coding guidance https://datacenter.cmqcc.org/support/download/c463ad71c0197fd1b1dd54db4bb09d31d8e8b35e) References Add: ACOG Practice Bulletin #220, Management of Genital Herpes in Pregnancy, May 2020 Society of Maternal-Fetal (SMFM) Publications Committee, Sinkey, R. G., Odibo, A. O., & Dashe, J. S. (2015). SMFM consult series #37: Diagnosis and management of vasa previa. American Journal of Obstetrics & Gynecology, 213(5), 615-619. https://doi.org/10.1016/j.ajog.2015.08.031 Denominator Included Populations bullet point 3 Remove: 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 Algorithm Change Remove: Check box for ICD-10-CM Principal or Other Diagnosis Codes, to check if at least one of ICD-10-PCS Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes on Table 11.10. PC-02 Cesarean Birth Algorithm Narrative Change from: 3. Check ICD-10 CM Principal or Other Diagnosis codes If all ICD-10 CM Principal or Other Diagnosis codes are missing or none of them on Table 11.08, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing. If at least one of the ICD-10 CM Principal or Other Diagnosis codes is on Table 11.08, continue processing and proceed to check ICD-10 CM Principal or Other Diagnosis codes. Change to: 3. Check ICD-10 CM Principal or Other Diagnosis codes If all ICD-10 CM Principal or Other Diagnosis codes are missing or none of them on Table 11.08, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing. If at least one of the ICD-10 CM Principal or Other Diagnosis codes is on Table 11.08, continue processing and proceed to check Gestational Age. Remove: 4. ICD-10 CM Principal or Other Diagnosis codes. If at least one of the ICD-10-CM Principal or Other Diagnosis Codes is on Table 11.10, the case will proceed to check Previous Births. If all ICD-10-CM Principal or Other Diagnosis Codes are missing or none on Table 11.10, proceed to check Gestational Age.
PC-05	TJC will no longer maintain Consensus Based Entity (CBE) endorsement for chart abstracted PC measures. References updated with most recent versions.	Adoption Status (Header Note) Remove: NQF Endorsed References Add: Meek, J.Y., & Noble, L., Section on Breastfeeding; Policy Statement: Breastfeeding and the Use of Human Milk. American Academy of Pediatrics July 2022; 150 (1). https://doi.org/10.1542/peds.2022-057988 Remove: American Academy of Pediatrics. Section on Breastfeeding. Policy Statement. Breastfeeding and the Use of Human Milk. Pediatrics 2012 Mar; 129 (3): e827-841.
PC-06	Code Z742 Need for assistance at home and no other household member able to render care is being added to Code Table 11.35 Social Indications to exclude cases where the newborn is staying for maternal condition. Code D181 is being added to Table 11.30 Congenital Malformations. References are being updated with the most recent versions.	References Add: American College of Obstetricians and Gynecologists. Operative Vaginal Delivery. (2020). Practice Bulletin, Number 219. Obstetrics and gynecology,135(4), e149–e159. https://doi.org/10.1097/AOG.0000000000003764 Practice Bulletin No 178: Shoulder Dystocia. Obstet Gynecol. 2017 May;129(5):e123-e133. doi: 10.1097/AOG.0000000000002043. PMID: 28426618. Puopolo, K.M., Lynfield, R., & Cummings, J.J. (2019). Management of Infants at Risk for Group B Streptococcal Disease. American Academy of Pediatrics, 144 (2). https://doi.org/10.1542/peds.2019-1881 Wilmink, F. A., Hukkelhoven, C. W., Lunshof, S., Mol, B. W., van der Post, J. A., & Papatsonis, D. N. (2010). Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry. American journal of obstetrics and gynecology, 202(3), 250.e1–250.e2508. https://doi.org/10.1016/j.ajog.2010.01.052 Remove: Wilmink, F.A., Hukkelhoven, C.W., Lunshof, S., et al. (2002). Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry. American Journal of Obstetrics and Gynecology, 250, e1-e8. Operative Vaginal Delivery. Practice Bulletin No. 17. American College of Obstetricians and Gynecologists. Obstet Gynecol 2000;1-8 Centers for Disease Control and Prevention. Prevention of Perinatal Group B Streptococcal Disease. MMWR 2010;59 (No. RR 10): 1-36 http://www.cdc.gov/mmwr/pdf/rr/rr5910.pdf Shoulder dystocia. ACOG Practice Bulletin No. 40. American College of Obstetrician and Gynecologists. Obstet Gynecol 2002;100:1045-50
THKR-IP-4	Removed links to the survey instruments since some links are no longer working.	Description Remove: Note: Links to the survey instruments are provided in the Selected References at the bottom of this section. Selected References Remove: Hyperlinks to Patient-Reported Outcome Survey Instruments: HOOS http://www.koos.nu/ HOOS Jr. https://www.hss.edu/files/hss-hoos-jr.pdf KOOS http://www.koos.nu/ KOOS Jr. https://www.hss.edu/files/hss-koos-jr.pdf VR-12 http://www.bu.edu/sph/research/research-landing-page/vr-36-vr-12-and-vr-6d/ PROMIS-Global http://www.nihpromis.org/measures/availableinstruments
THKR-IP-5	Removed links to the survey instruments since some links are no longer working.	Description Remove: Note: Links to the survey instruments are provided in the Selected References at the bottom of this section. Selected References Remove: Hyperlinks to Patient-Reported Outcome Survey Instruments: HOOS http://www.koos.nu/ HOOS Jr. https://www.hss.edu/files/hss-hoos-jr.pdf KOOS http://www.koos.nu/ KOOS Jr. https://www.hss.edu/files/hss-koos-jr.pdf VR-12 http://www.bu.edu/sph/research/research-landing-page/vr-36-vr-12-and-vr-6d/ PROMIS-Global http://www.nihpromis.org/measures/availableinstruments
THKR-OP-4	Removed links to the survey instruments since some links are no longer working.	Description Remove: Note: Links to the survey instruments are provided in the Selected References at the bottom of this section. Selected References Remove: Hyperlinks to Patient-Reported Outcome Survey Instruments: HOOS http://www.koos.nu/ HOOS Jr. https://www.hss.edu/files/hss-hoos-jr.pdf KOOS http://www.koos.nu/ KOOS Jr. https://www.hss.edu/files/hss-koos-jr.pdf VR-12 http://www.bu.edu/sph/research/research-landing-page/vr-36-vr-12-and-vr-6d/ PROMIS-Global http://www.nihpromis.org/measures/availableinstruments
THKR-OP-5	Removed links to the survey instruments since some links are no longer working.	Description Remove: Note: Links to the survey instruments are provided in the Selected References at the bottom of this section. Selected References Remove: Hyperlinks to Patient-Reported Outcome Survey Instruments: HOOS http://www.koos.nu/ HOOS Jr. https://www.hss.edu/files/hss-hoos-jr.pdf KOOS http://www.koos.nu/ KOOS Jr. https://www.hss.edu/files/hss-koos-jr.pdf VR-12 http://www.bu.edu/sph/research/research-landing-page/vr-36-vr-12-and-vr-6d/ PROMIS-Global http://www.nihpromis.org/measures/availableinstruments

Data Elements

Section	Rationale	Description
Gestational Age	Removed references to using ICD-10 diagnosis codes for gestational age. The use of Gestational Age code tables in PC-01 and PC-02 has been removed from the 2025A manual since the intent of the measures is to capture the gestational age at time of delivery. The codes were initially added to decrease burden of abstraction and align with the eCQM version but due to the coding guidance and cases where the gestational age at delivery is different than admission it will be removed. Organizations can continue to use the gestational age at time of delivery since that is the intent of the measure. The gestational age data element has guidance in the 2024B manual to use the gestational age coding as the lowest priority source; however, we understand the algorithm can cause confusion.	Notes for Abstraction Change from: If the gestational age in the delivery or operating room record is missing, obviously incorrect (in error, e.g. 3.6), or there is conflicting data, then continue to review the following data sources, starting with the document completed closest to or at the time of the delivery until a positive finding for gestational age is found: History and physical Clinician admission progress note Prenatal forms ICD-10 diagnosis code Change to: If the gestational age in the delivery or operating room record is missing, obviously incorrect (in error, e.g. 3.6), or there is conflicting data, then continue to review the following data sources, starting with the document completed closest to or at the time of the delivery until a positive finding for gestational age is found: History and physical Clinician admission progress note Prenatal forms Remove: 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 Remove: * ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes
Time Last Known Well	The data element definition was updated to align with modifications made in CMS Hospital Outpatient Manual, Version 18.0.	Notes for abstraction Change fourth sub-bullet exception under fifth bullet from: Multiple specific times on the same or different Code Stroke Forms, use abstraction guidelines for multiple times Last Known Well. To: Multiple specific times on the same or different Code Stroke Forms, use abstraction guidelines below that reference multiple times of last known well documented.

Section

Rationale

Description

Gestational Age

Removed references to using ICD-10 diagnosis codes for gestational age. The use of Gestational Age code tables in PC-01 and PC-02 has been removed from the 2025A manual since the intent of the measures is to capture the gestational age at time of delivery. The codes were initially added to decrease burden of abstraction and align with the eCQM version but due to the coding guidance and cases where the gestational age at delivery is different than admission it will be removed. Organizations can continue to use the gestational age at time of delivery since that is the intent of the measure. The gestational age data element has guidance in the 2024B manual to use the gestational age coding as the lowest priority source; however, we understand the algorithm can cause confusion.

Notes for Abstraction

Change from:

If the gestational age in the delivery or operating room record is missing, obviously incorrect (in error, e.g. 3.6), or there is conflicting data, then continue to review the following data sources, starting with the document completed closest to or at the time of the delivery until a positive finding for gestational age is found:

History and physical
Clinician admission progress note
Prenatal forms
ICD-10 diagnosis code

Change to:

History and physical
Clinician admission progress note
Prenatal forms

Remove:

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

Remove:

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

Time Last Known Well

The data element definition was updated to align with modifications made in CMS Hospital Outpatient Manual, Version 18.0.

Notes for abstraction
Change fourth sub-bullet exception under fifth bullet from:
Multiple specific times on the same or different Code Stroke Forms, use abstraction guidelines for multiple times Last Known Well.
To:
Multiple specific times on the same or different Code Stroke Forms, use abstraction guidelines below that reference multiple times of last known well documented.

Supplemental Materials

Section	Rationale	Description
Appendix A - Code Tables	Global changes to Appendix A ICD-10 tables to include ICD-10-CM and PCS 2025 terminology updates of additions, deletions and revisions. Two code tables 11.30 and 11.09 were updated to include codes based on clinical and expert feedback. Due to abstraction of data elements and coding guidelines of gestational age ICD-10 codes, tables 11.07.1 and 11.10 are being removed to reduce confusion.	Global Appendix A table updates include: Table 7.03 Table 10.01 Table 11.30 Table 11.35 Table 11.41 Clinical table 11.09 updates include the addition of genital herpes viral infection codes: A6000 A6003 A6004 A6009 A601 A609 Clinical table 11.30 updates include the addition of Lymphangioma code: D181 Remove: Table 11.07.1 Early Term Gestational Age and Table 11.10 Term Gestational Age
Appendix C - Medication Tables	Updated Table 9.1 and Table 9.2 based on pharmacist review.	Update medications listed for FDA-Approved Tobacco Cessation Medications and FDA-Approved Medications for Alcohol and Drug Dependence.
Introduction to the Manual	All references to Quality Check have been removed from the manual since this site is no longer active.	Remove: Quality Check paragraph.
Joint Commission National Quality Measures Data Processing - Transmission of Data	A new table was added to the Data Processing page for the Joint Commission Cardiac Certifications to differentiate which measures are used in specific certifications, ie. ACHF vs CCCC. A new table was added to the Data Processing page for Joint Commission Advanced Certification in Perinatal Care to show which measures are used in certification.	Add: Joint Commission Cardiac Certification Measure Table Add: Joint Commission Advanced Certification in Perinatal Care (ACPC) Measures Table
Sampling	Remove incorrect reference to STK in example of sampling methodology number two.	Order of Data Flow: Remove: If the hospital is submitting STK, sample independently using sampling methodology number two.

General Release Notes

Rationale	Description
The PDF version of the manual is not being published due to 508 Compliance issues.	The PDF version of the manual is not being published due to 508 Compliance issues. As alternative option, users can PDF each section of the web version by clicking on the ellipsis in the browser menu, then Print and select Adobe PDF.
Algorithm narratives have been added for certification measures for accessibility.	Algorithm Narratives have been added for certification measures.

Specifications Manual for Joint Commission National Quality Measures (v2025A)
Discharges 01-01-25 (1Q25) through 06-30-25 (2Q25)

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