| Section | Rationale | Description |
|---|---|---|
| ASR-IP-1 | The reference is being removed because an electronic link to it is not available. | Selected References Remove: Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S. Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association (NSA) (2000). |
| ASR-IP-2 | The reference is being removed because an electronic link to it is not available. | Selected References Remove: Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S. Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association (NSA) (2000). |
| ASR-IP-3 | The reference is being removed because an electronic link to it is not available. | Selected References Remove: Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S. Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association (NSA) (2000). |
| ASR-OP-1 | The reference is being removed because an electronic link to it is not available. | Selected References Remove: Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S. Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association (NSA) (2000). |
| CSTK-04 | Measure information was updated to reflect the INR target of 1.3 or less as published in the 2022 AHA ICH Guidelines. | Description Change from: Intracerebral hemorrhage (ICH) stroke patients with an INR value > 1.4 at hospital arrival who are treated with a procoagulant reversal agent (i.e., fresh frozen plasma, recombinant factor VIIa, prothrombin complex concentrates) to: Intracerebral hemorrhage (ICH) stroke patients with an INR value greater than or equal to 1.4 at hospital arrival who are treated with a procoagulant reversal agent (i.e., fresh frozen plasma, recombinant factor VIIa, prothrombin complex concentrates) Rationale Change last sentence from: According to the European Union Stroke Initiative (EUSI), patients with oral anticoagulation treatment (OAT) associated ICH and an INR above 1.4, should have OAT discontinued and the INR normalized with PCCs or FFP in addition to intravenous infusion of vitamin K. to: According to Greenberg and colleagues (2022), patients with oral anticoagulation treatment (OAT) associated ICH and an INR above 1.3, should have OAT discontinued and the INR normalized with PCCs or FFP in addition to intravenous infusion of vitamin K. Denominator Statement Change from: ICH stroke patients with INR value > 1.4 at hospital arrival to: ICH stroke patients with INR value greater than or equal to 1.4 at hospital arrival. Included Populations Change third bullet from:
Denominator Statement Change from: ICH stroke patients with INR value > 1.4 at hospital arrival. to: ICH stroke patients with INR value greater than or equal to 1.4 at hospital arrival. 4th Check Box Change from: INR Value >1.4 to: INR Value Greater Than or Equal to 1.4. Narrative Change Change Step 4c from: 4c If Clinical Trial equals N continue processing and proceed to check INR Value > 1.4. to: 4c If Clinical Trial equals N continue processing and proceed to check INR Value Greater Than or Equal to 1.4. Change Step 5 from: 5. Check INR Value > 1.4.
5. Check INR Value Greater Than or Equal to 1.4.
|
| STK-2 | The reference is being removed because an electronic link to it is not available. | Selected References Remove: Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S. Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association (NSA) (2000). |
| STK-3 | References were updated to provide current statistics supporting the prevalence of atrial fibrillation in the United States. | Selected References Add: Kornej, J., Borschel, C. S., Benjamin, E. J., Schnabel, R. B. "Epidemiology of Atrial Fibrillation in the 21st Century: Novel Methods and New Insights." [In eng]. Circulation Research 127, no. 1 (June 19 2020): 4-20. |
| STK-4 | The reference is being removed because an electronic link to it is not available. | Selected References Remove: Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S. Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association (NSA) (2000). |
| STK-5 | The reference is being removed because an electronic link to it is not available. | Selected References Remove: Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S. Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association (NSA) (2000). |
| THKR-IP | Fixed Typo in step 7 'a' and 'b' in algorithm narrative. | Fixed Typo in step 7 'a' and 'b' in algorithm narrative.
Change From:
7. Check ICD-10-PCS Other procedure code a. If the ICD-10PCS Principal Procedure Code has At least one on Table 14.05a, 14.06a, 14.07a, the patient is not in THKR Initial Patient Population. Patient is not eligible to be sampled for the THKR measure set. Set IP Initial Patient Population Reject Case Flag to equal Yes. Return to Data Processing Flow. b. If the ICD-10PCS Principal Procedure Code are All missing or None on Table 14.05a, 14.06a, 14.07a, continue processing and proceed to check ICD-10-CM Principal or Other Diagnosis Codes. Change To:7. Check ICD-10-PCS Other procedure code a. If the ICD-10PCS Other Procedure Code has At least one on Table 14.05a, 14.06a, 14.07a, the patient is not in THKR Initial Patient Population. Patient is not eligible to be sampled for the THKR measure set. Set IP Initial Patient Population Reject Case Flag to equal Yes. Return to Data Processing Flow. b. If the ICD-10PCS Other Procedure Code are All missing or None on Table 14.05a, 14.06a, 14.07a, continue processing and proceed to check ICD-10-CM Principal or Other Diagnosis Codes. |
| THKR-IP-5 | Provide clarification on when the general health and joint specific functional status assessments are to be completed. | Description
Change from:
Patients who completed the general health and joint specific functional status assessments within 365 days after surgery, as specified below: To:Patients who completed the general health and joint specific functional status assessments at 1 year (300-425 days) after surgery, as specified below: 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 365 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) at 1 year (300-425 days) after surgery. Measure Algorithm: Change from: Numerator: Number of patients who completed the general health and joint specific functional status assessments within 365 days after surgery. To: Numerator: Number of patients who completed the general health and joint specific functional status assessments at 1 year (300-425 days) after surgery.Algorithm Narrative: Change from: Numerator: Number of patients who completed the general health and joint specific functional status assessments within 365 days after surgery. To: Numerator: Number of patients who completed the general health and joint specific functional status assessments at 1 year (300-425 days) after surgery. |
| THKR-OP-5 | Provide clarification for when the general health and joint specific functional status assessments are to be completed. | Description
Change from:
Patients who completed the general health and joint specific functional status assessments, within 365 days after surgery, as specified below: To:Patients who completed the general health and joint specific functional status assessments, at 1 year (300-425 days) after surgery, as specified below: 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 365 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) at 1 year (300-425 days) after surgery. Measure Algorithm: Change from: Numerator: Number of patients who completed the general health and joint specific functional status assessments within 365 days after surgery. To: Numerator: Number of patients who completed the general health and joint specific functional status assessments at 1 year (300-425 days) after surgery.Algorithm Narrative Change from: Numerator: Number of patients who completed the general health and joint specific functional status assessments within 365 days after surgery. To: Numerator: Number of patients who completed the general health and joint specific functional status assessments at 1 year (300-425 days) after surgery. |
| Section | Rationale | Description |
|---|---|---|
| Clinical Trial | VTE-6 is retired effective 1/1/2025. | Removed any references to VTE. |
| Comfort Measures Only | VTE-6 is retired effective 1/1/2025. | Removed any references to VTE. |
| Influenza Vaccination Status | The update to Inclusion criteria will provide abstractor clarification and alignment with current CDC vaccination recommendations. Previous link was no longer active. | Change from: All patients discharged during October, November, December, January, February, or March Acceptable terms for influenza vaccines include those listed below or refer to the CDC Table: Influenza Vaccines- United States link for a list of Influenza vaccines at https://www.cdc.gov/flu/professionals/vaccination/index.htm. To: All patients discharged during October, November, December, January, February, or March Acceptable terms for influenza vaccines include those listed below or refer to the CDC Table: Influenza Vaccines- United States link for a list of Influenza vaccines at https://www.cdc.gov/flu/hcp/acip/. |
| INR Value Greater Than or Equal to 1.4 | The data element definition was updated to reflect the INR target of 1.3 or less as published in the 2022 AHA ICH Guidelines. | Name Change from: INR Value > 1.4 to: INR Value Greater Than or Equal to 1.4 Definition Change from: Documentation that the international normalized ratio (INR) value performed closest to hospital arrival was greater than 1.4. This value correlates to the ability of the blood to clot. Higher values greater than 1.4 are associated with an increased risk of hemorrhage. to: Documentation that the international normalized ratio (INR) value performed closest to hospital arrival was greater than or equal to 1.4. This value correlates to the ability of the blood to clot. Higher values greater than 1.3 are associated with an increased risk of hemorrhage. Question Change from: Is there documentation in the medical record that the INR value performed closest to hospital arrival was greater than 1.4? to: Is there documentation in the medical record that the INR value performed closest to hospital arrival was greater than or equal to 1.4? Allowable Values Change from: Y (Yes) There is documentation that the INR value performed closest to hospital arrival was greater than 1.4. N (No) There is no documentation that the INR value performed closest to hospital arrival was greater than 1.4, OR unable to determine from medical record documentation. to: Y (Yes) There is documentation that the INR value performed closest to hospital arrival was greater than or equal to 1.4. N (No) There is no documentation that the INR value performed closest to hospital arrival was greater than or equal to 1.4, OR unable to determine from medical record documentation. Notes for AbstractionChange first bullet from:
|
| Minutes of Physical Restraint | The data element was modified to provide clarification about therapeutic holds. | Inclusion Guidelines for Abstraction Add new third bullet:
¹,²,³ 42 CFR Part 482, Medicare and Medicaid Programs; Hospital Conditions of Participation: Patient's Rights To: 1, 2, 3, 4, 5 42 CFR Part 482, Medicare and Medicaid Programs; Hospital Conditions of Participation: Patient's Rights Exclusion Guidelines for Abstraction Add new first bullet:
|
| Postoperative Assessments Completion Date | Provide clarification on when the postoperative general health and joint specific functional status assessments are to be completed. | Notes for Abstraction
Change from:
|
| Procoagulant Reversal Agent Initiation | The data element was modified to align with updates to the GWTG data collection tool. | Inclusion Guidelines for Abstraction Change from:
|
| Section | Rationale | Description |
|---|---|---|
| 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 2024 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 2025 by the American Medical Association (AMA). |
| Appendix A - Code Tables | Changes to Appendix A ICD-10 tables to include ICD-10-CM and PCS 2025 terminology updates released for April 2025 of additions, deletions, and revisions. Removal of tables associated with the retired measure VTE-6. | Remove:
Tables associated with the retired measure VTE-6. Code table removals includes: Table 7.03 Table 7.04 Add:Code table updates include: Table 12.10 0CYS0Z0 Transplantation of larynx, allogeneic, open approach 0CYS0Z1 Transplantation of larynx, syngeneic, open approach |
| Sampling | Removed the reference of VTE discharge measure from various locations due to retiring of VTE-6 measure. | Remove: Reference of VTE measure from multiple places. |
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