Section | Rationale | Description |
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ASR-IP-1 | The measure rationale and references were updated to include 2025 stroke statistics from the American Heart Association. | Rationale Change from: The administration of IV alteplase to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials (Class I, Level of Evidence A, American Heart Association/American Stroke Association (AHA/ASA), 2019). These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA approved. Although the benefit of IV alteplase has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for alteplase therapy in recent years. Updated recommendations from the AHA/ASA in 2019 identify tenecteplase as a reasonable alternative to alteplase in acute ischemic stroke patients with minor neurological impairment and no major intracranial occlusion (0.4-mg/kg single IV bolus), or who are also eligible to undergo mechanical thrombectomy (0.25 -mg/kg single IV bolus, maximum 25 mg). Clinical evidence at this time is unclear whether tenecteplase is as effective as or more effective than alteplase (Class IIb, Level of Evidence BR). The administration of IV tenecteplase for ischemic stroke within or beyond 3 hours of stroke symptom onset has not been FDA approved. To:The administration of IV alteplase to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials (Class I, Level of Evidence A, American Heart Association/American Stroke Association (AHA/ASA), 2019). These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA approved. Although the benefit of IV alteplase has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for alteplase therapy in recent years. Updated recommendations from the AHA/ASA in 2019 identified IV tenecteplase (TNK) as a reasonable alternative to alteplase. In March, 2025, IV TNK received FDA-approval for the treatment of acute ischemic stroke (AIS) in adults. The approval is based on a large multi-center non-inferiority study demonstrating that the efficacy of TNK and alteplase are comparable. Symptomatic intracranial hemorrhage (ICH) is a potential complication with both agents. However, a systematic review of 26 studies comparing IV TNK with alteplase suggests slightly less risk of an event (RR 0.89, 95% CI, 0.65-1.23) with TNK (Martin, 2025). Selected ReferencesAdd:
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ASR-OP-1 | The measure rationale and references were updated to include 2025 stroke statistics from the American Heart Association. | Rationale Change from: The administration of IV alteplase to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials (Class I, Level of Evidence A, American Heart Association/American Stroke Association (AHA/ASA), 2019). These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA approved. Although the benefit of IV alteplase has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for alteplase therapy in recent years. Updated recommendations from the AHA/ASA in 2019 identify tenecteplase as a reasonable alternative to alteplase in acute ischemic stroke patients with minor neurological impairment and no major intracranial occlusion (0.4-mg/kg single IV bolus), or who are also eligible to undergo mechanical thrombectomy (0.25 -mg/kg single IV bolus, maximum 25 mg). Clinical evidence at this time is unclear whether tenecteplase is as effective as or more effective than alteplase (Class IIb, Level of Evidence BR). The administration of IV tenecteplase for ischemic stroke within or beyond 3 hours of stroke symptom onset has not been FDA approved. To:The administration of IV alteplase to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials (Class I, Level of Evidence A, American Heart Association/American Stroke Association (AHA/ASA), 2019). These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA approved. Although the benefit of IV alteplase has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for alteplase therapy in recent years. Updated recommendations from the AHA/ASA in 2019 identified IV tenecteplase (TNK) as a reasonable alternative to alteplase. In March, 2025, IV TNK received FDA-approval for the treatment of acute ischemic stroke (AIS) in adults. The approval is based on a large multi-center non-inferiority study demonstrating that the efficacy of TNK and alteplase are comparable. Symptomatic intracranial hemorrhage (ICH) is a potential complication with both agents. However, a systematic review of 26 studies comparing IV TNK with alteplase suggests slightly less risk of an event (RR 0.89, 95% CI, 0.65-1.23) with TNK (Martin, 2025). Selected ReferencesAdd:
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CSTK-02 | The rationale for the measure and references were updated to address 2025 stroke statistics from the American Heart Association. | Rationale Change from: The Modified Rankin Scale (mRS) is the accepted standard for assessing recovery post-stroke. As such, it has become the most widely used clinical outcome measure for stroke clinical trials. Scores are used to measure the degree of disability or dependence in activities of daily living. Score reliability and reproducibility are improved through use of a structured interview by a trained evaluator. Interviews may be conducted in-person or over the phone. According to guideline recommendations from the American Heart Association/American Stroke Association, standardized interviews to obtain a mRS score should be conducted for acute ischemic stroke patients treated with IV or IA alteplase therapy or mechanical endovascular reperfusion therapy at 3 months (90 days); however, recovery may continue well beyond 3 months for many ischemic stroke patients. To: The Modified Rankin Scale (mRS) is the accepted standard for assessing recovery post-stroke. As such, it has become the most widely used clinical outcome measure for stroke clinical trials. Scores are used to measure the degree of disability or dependence in activities of daily living. Score reliability and reproducibility are improved through use of a structured interview by a trained evaluator. Interviews may be conducted in-person or over the phone. According to guideline recommendations from the American Heart Association/American Stroke Association, standardized interviews to obtain a mRS score should be conducted for acute ischemic stroke patients treated with IV or IA alteplase therapy or mechanical endovascular reperfusion therapy at 3 months (90 days); however, recovery may continue well beyond 3 months for many ischemic stroke patients. Recent clinical studies (e.g., AURORA, BEST, BASICS, BAOCHE, ATTENTION) have evaluated stroke disability at 90 days following endovascular therapy (EVT) for patients with large vessel occlusions. Patients undergoing EVT were more likely to achieve favorable outcomes and functional independence as assessed by mRS score of 0-2 when compared to medical management. Selected ReferencesAdd:
Remove: *SUSPENDED for Thrombectomy-Capable Stroke Centers, Effective July 1, 2022* |
CSTK-06 | A misspelling of vasospasm was noted and updated to provide clarification. | Change from:
Cerebral vasopasm is a serious complication following SAH, occurring in 30% to 70% of patients and accounting for nearly 50% of the deaths in patients surviving to treatment. To: Cerebral vasospasm is a serious complication following SAH, occurring in 30% to 70% of patients and accounting for nearly 50% of the deaths in patients surviving to treatment. |
CSTK-10 | The rationale for the measure and references were updated to address 2025 stroke statistics from the American Heart Association. | Rationale Change from: The Modified Rankin Scale (mRS) is the accepted standard for assessing recovery post-stroke. As such, it has become the most widely used clinical outcome measure for stroke clinical trials. Scores are used to measure the degree of disability or dependence in activities of daily living. Score reliability and reproducibility are improved through use of a structured interview by a trained evaluator. Interviews may be conducted in-person or over the phone. According to guideline recommendations from the American Heart Association/American Stroke Association, standardized interviews to obtain a mRS score should be conducted for acute ischemic stroke patients treated with IV or IA alteplase therapy or mechanical endovascular reperfusion therapy at 3 months (90 days); however, recovery may continue well beyond 3 months for many ischemic stroke patients. To: The Modified Rankin Scale (mRS) is the accepted standard for assessing recovery post-stroke. As such, it has become the most widely used clinical outcome measure for stroke clinical trials. Scores are used to measure the degree of disability or dependence in activities of daily living. Score reliability and reproducibility are improved through use of a structured interview by a trained evaluator. Interviews may be conducted in-person or over the phone. According to guideline recommendations from the American Heart Association/American Stroke Association, standardized interviews to obtain a mRS score should be conducted for acute ischemic stroke patients treated with IV or IA alteplase therapy or mechanical endovascular reperfusion therapy at 3 months (90 days); however, recovery may continue well beyond 3 months for many ischemic stroke patients. Recent clinical studies (e.g., AURORA, BEST, BASICS, BAOCHE, ATTENTION) have evaluated stroke disability at 90 days following endovascular therapy (EVT) for patients with large vessel occlusions. Patients undergoing EVT were more likely to achieve favorable outcomes and functional independence as assessed by mRS score of 0-2 when compared to medical management. Selected ReferencesAdd:
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HBIPS | Updates to the HBIPS IPP and Algorithm are to provide abstractor clarification and to align with the updated technical guidance provided in the data entry guide. | HBIPS Initial Patient Population
Remove:
The HBIPS measure set is unique in that there is one Initial Patient Population within the measure set, event measures (HBIPS-2 and HBIPS-3). Change from (right below strata table):Patients for which an event occurs (Event Date exists) while in a Psychiatric Care Setting (='Y') in the hospital are included in one of the Strata Initial Populations for the event measures. There is no sampling for the HBIPS event measures. All patients in the Initial Population for HBIPS event measures are automatically sampled. To:Patients for which an event occurs (Event Date exists) while in a Psychiatric Care Setting (='Y') in the hospital are included in one of the Strata Initial Patient Populations for the event measures. There is no sampling for the HBIPS event measures. The measures in HBIPS-EVT (HBIPS-2 and HBIPS-3) are not eligible for sampling and will use the entire Initial Patient Population for reporting. Add: (after the strata examples before algorithm and also in the note boxes 2 and 3 in the algorithm) NOTE: Initial Patient Population Size – Psychiatric Inpatient Days Medicare Only and Psychiatric Inpatient Days Non-Medicare Only for HBIPS Event measures are not derived from those cases that pass through the Initial Patient Population algorithm. Instead, these data are derived from the HBIPS census data calculated by (Psychiatric Inpatient Days – Total Leave Days). Please refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance.The following Initial Patient Population algorithm is used to identify cases with events that occur in the psychiatric setting that will be used to run through algorithms HBIPS 2 and 3 to determine the numerator. Algorithm- note boxes 2 and 3 Change From:Note: Initial Patient Population Size – Medicare Only and Non-Medicare Only for HBIPS Event measures are not derived from those cases that pass through the Initial Patient Population algorithm. Instead, these data are derived from the HBIPS census data calculated by (Psychiatric Inpatient Days - Total Leave Days). To:Note: Initial Patient Population Size – Psychiatric Inpatient Days Medicare Only and Psychiatric Inpatient Days Non-Medicare Only for HBIPS Event measures are not derived from those cases that pass through the Initial Patient Population algorithm. Instead, these data are derived from the HBIPS census data calculated by (Psychiatric Inpatient Days – Total Leave Days). Please refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance. Update in algorithm narrative note after step 5, same as updated in the algorithm flow. |
HBIPS-2 | Updates to the HBIPS Measure Information Forms, data elements, and Algorithm are to provide abstractor clarification and to align with the updated technical guidance provided in the data entry guide. The aggregated denominator box information from algorithm has been clarified in more detail and moved to the technical guidance in the data entry guide, located in Confluence. | Numerator Basis
Add:
* Please refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance.
Denominator Basis Add: * Please refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance for aggregated denominator.Algorithm Remove: Algorithm Narrative for Measure calculation for Aggregated Denominator box. |
HBIPS-3 | Updates to the HBIPS Measure Information Forms, data elements, and Algorithm are to provide abstractor clarification and to align with the updated technical guidance provided in the data entry guide. The aggregated denominator box information from algorithm has been clarified in more detail and moved to the technical guidance in the data entry guide, located in Confluence. | Numerator Basis
Add:
* Please refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance.
Denominator Basis Add: * Please refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance for aggregated denominator.Algorithm Remove: Algorithm Narrative for Measure calculation for Aggregated Denominator box. |
IMM-2 | The updates to IMM MIF include an updated rationale with more recent data, will provide abstractor clarification, alignment with updated CDC influenza vaccination guidance, and more up to date references. | Rationale
Change from:
Up to 1 in 5 people in the United States get influenza every season (CDC, Key Facts 2015). Each year an average of approximately 226,000 people in the US are hospitalized with complications from influenza and between 3,000 and 49,000 die from the disease and its complications (Thompson 2003). Combined with pneumonia, influenza is the nation’s 8th leading cause of death (Heron 2012). Up to two-thirds of all deaths attributable to pneumonia and influenza occur in the population of patients that have been hospitalized during flu season regardless of age (Fedson 2000). The Advisory Committee on Immunization Practices (ACIP) recommends seasonal influenza vaccination for all persons 6 months of age and older to highlight the importance of preventing influenza. Vaccination is associated with reductions in influenza among all age groups (Kostova 2013). The influenza vaccination is the most effective method for preventing influenza virus infection and its potentially severe complications. Screening and vaccination of inpatients is recommended, but hospitalization is an underutilized opportunity to provide vaccination to persons 6 months of age or older. To:An estimated 9.3 to 41 million people in the United States get influenza every season. Each year approximately 120,000 to 710,000 people in the US are hospitalized with complications from influenza and between 6,300 and 52,000 die from the disease and its complications (Center for Disease Control and Prevention [CDC], 2024a). Combined with pneumonia, influenza is in the nation’s top 10 leading causes of death for ages 1 through 44 (CDC, 2023). About 14.1% of people of all ages hospitalized with influenza were admitted to the intensive care unit during the 2021-22 flu season, down from 22.3% during the 2013-14 flu season (Naquin et al., 2024). The Advisory Committee on Immunization Practices (ACIP) recommends seasonal influenza vaccination for all persons 6 months of age and older to highlight the importance of preventing influenza. Flu vaccines substantially reduced the risk of flu related medical visits and hospitalizations for all age groups during the 2023-24 flu season (CDC, 2024b). The influenza vaccination is the most effective method for preventing influenza virus infection and its potentially severe complications. Screening and vaccination of inpatients is recommended, but hospitalization is an underutilized opportunity to provide vaccination to persons 6 months of age or older. Included Populations (Numerator) Change from:
Selected References Change from:
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PC-02 | Coding guidance FAQ link was added for clarification of coding for genital herpes. | Denominator Excluded Populations Add: to the end of the first bullet under FAQs for additional coding guidance https://datacenter.cmqcc.org/support/download/a7955e52541df8ed63aa8e884909d81caeb1f659 |
PC-06 | Changes were made to the measure concerning transfers to another facility or other healthcare facility. Previously, all transfers to other facilities were severe complications. Transfers will now go through the algorithm to assess for severe complication codes or no codes, which will be severe complications, and moderate complication codes, which will now be moderate complications.
This change will result in a new Algorithm and Narrative Algorithm also. Due to the extensive changes to the algorithm, for this manual publication only, the steps numbers are included, and changes are highlighted in green. | Description:
Change: from:
Unexpected complications among full term newborns with no preexisting conditions.
Severe complications include neonatal death, transfer to another hospital for higher level of care, severe birth injuries such as intracranial hemorrhage or nerve injury, neurologic damage, severe respiratory and infectious complications such as sepsis.
Moderate complications include diagnoses or procedures that raise concern but at a lower level than the list for severe e.g. use of CPAP or bone fracture. Examples include less severe respiratory complications e.g. Transient Tachypnea of the Newborn, or infections with a longer length of stay not including sepsis, infants who have a prolonged length of stay of over 5 days.
To: Unexpected complications among full term newborns with no preexisting conditions. Severe complications include neonatal death, severe birth injuries such as intracranial hemorrhage or nerve injury, neurologic damage, severe respiratory and infectious complications such as sepsis. It also includes transfer to another hospital for higher level of care with severe complication codes or NO Moderate or Severe ICD-10-CM Principal Diagnosis Code, ICD-10-CM Other Diagnosis Codes, ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes. Moderate complications include diagnoses or procedures that raise concern but at a lower level than the list for severe e.g. use of CPAP or bone fracture. Examples include less severe respiratory complications e.g. Transient Tachypnea of the Newborn, or infections with a longer length of stay not including sepsis, infants who have a prolonged length of stay of over 5 days. Transfer to another hospital for higher level of care with any moderate complication codes are also included. Included Populations: Severe Complications: Change: Second bullet from:
To:
Change: Step 4 Check Discharge Disposition Change the branch b and c to b. If Discharge Disposition equals 2, 3 or 6, the branch will go to step 23 to check Severe Complications. c. If Discharge Disposition equals 1, 4, 5, 7 or 8, the branch will go to step 5 to check ICD-10-CM Principal or Other Diagnosis Codes. Change: Step 8 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 11.45 , the branch will go to step 9 to check Discharge Disposition. Add: New Check box for Discharge Disposition 9. Check Discharge Disposition If Discharge Disposition is 4 or 5, the branch will go to step 23 to check Severe Complications. If Discharge Disposition is 1, 7, or 8 the branch will go to step 10 to check Length of Stay. Change to: Step 12 Check ICD-10-PCS Principal or Other Procedure Codes.(BR> If at least one of the ICD-10-PCS Principal or Other Procedure Codes is on Table 11.48, the branch will go to step 27 to check Moderate Complications. If all ICD-10-PCS Principal or Other Procedure Codes are missing or none of them on Table 11.48, the branch will go to step 13 to check Discharge Disposition. Add: New Check box for Discharge Disposition 13. Check Discharge Disposition If Discharge Disposition is 4 or 5, the branch will go to step 17 to check ICD-10-CM Principal or Other Diagnosis Codes If Discharge Disposition is 1, 7, or 8, the branch will go to step 14 to check ICD-10-CM Principal or Other Diagnosis Codes Change to: Step 18 Check ICD-10-PCS Principal or Other Procedure Codes If at least one of the ICD-10-PCS Principal or Other Procedure Codes is on Table 11.51, or 11.52 , the branch will go to step 27 to check Moderate Complications. If all ICD-10-PCS Principal or Other Procedure Codes are missing or none of them on Table 11.51, 11.52, the branch will go to step 19 to check Discharge Disposition. Add: New Check box for Discharge Disposition 19. Check Discharge Disposition. If Discharge Disposition is 4 or 5, the branch will go to step 23 to check Severe Complications. If Discharge Disposition is 1, 7, or 8, the branch will go to step 20 to check Length of Stay. Narrative Change Step 4b,4c from: 4b. If Discharge Disposition equals 3, 4, 5 or 6, the case will proceed to Step 20 to check Severe Complications. 4c. If Discharge Disposition equals 1, 2, 7 or 8, continue processing and proceed to check ICD-10-CM Principal or Other Diagnosis Codes.
4c. If Discharge Disposition equals 1, 4, 5, 7 or 8, continue processing and proceed to check ICD-10-CM Principal or Other Diagnosis Codes. Change Step 8a from: 8. Check ICD-10-CM Principal or Other Diagnosis Codes a. If at least one of the ICD-10-CM Principal or Other Diagnosis Codes is on Table 11.45, the case will proceed to check Length of Stay. To: 8. Check ICD-10-CM Principal or Other Diagnosis Codes a. If at least one of the ICD-10-CM Principal or Other Diagnosis Codes is on Table 11.45, the case will proceed to step 9 to check Discharge Disposition. Add: Step 9: 9. Check Discharge Disposition a. If Discharge Disposition is 4 or 5 proceed to step 23 to check Severe Complications. b. If Discharge Disposition is 1, 7, or 8 proceed to step 10 to Check to check Length of Stay. Change all step number after step 9. Change: Step 11 from: 11. Check ICD-10-PCS Principal or Other Procedure Codes a. If at least one of the ICD-10-PCS Principal or Other Procedure Codes is on Table 11.48, the case will proceed to Step 24 to check Moderate Complications. b. If all ICD-10-PCS Principal or Other Procedure Codes are missing or none of them on Table 11.48, continue processing and proceed to check ICD-10-CM Principal or Other Diagnosis Codes. To: 12. Check ICD-10-PCS Principal or Other Procedure Codes a. If at least one of the ICD-10-PCS Principal or Other Procedure Codes is on Table 11.48, the case will proceed to Step 27 to check Moderate Complications. b. If all ICD-10-PCS Principal or Other Procedure Codes are missing or none of them on Table 11.48, continue processing and proceed to step 13 to check Discharge Disposition. Add: Step 13: 13. Check Discharge Disposition a. If Discharge Disposition is 4 or 5 proceed to step 17 to check ICD-10-CM Principal or Other Diagnosis Codes. b. If Discharge Disposition is 1, 7, or 8 proceed to step 14 to check ICD-10-CM Principal or Other Diagnosis Codes. Change all step number after step 13. Change: Step 16 from: 16. Check ICD-10-PCS Principal or Other Procedure Codes
18. Check ICD-10-PCS Principal or Other Procedure Codes
19. Check Discharge Disposition a. If Discharge Disposition is 4 or 5 proceed to step 23 to check Severe Complications. b. If Discharge Disposition is 1, 7, or 8 proceed to step 20 to check Length of Stay. Change all step number after step 19. |
STK-3 | The rationale for the measure and references were updated to address 2025 stroke statistics from the American Heart Association. | Rationale Change from: Nonvalvular atrial fibrillation (NVAF) is a common arrhythmia and an important risk factor for stroke. It is one of several conditions and lifestyle factors that have been identified as risk factors for stroke. It has been estimated that over 2 million adults in the United States have NVAF. While the median age of patients with atrial fibrillation is 75 years, the incidence increases with advancing age. For example, The Framingham Heart Study noted a dramatic increase in stroke risk associated with atrial fibrillation with advancing age, from 1.5% for those 50 to 59 years of age to 23.5% for those 80 to 89 years of age. Furthermore, a prior stroke or transient ischemic attack (TIA) are among a limited number of predictors of high stroke risk within the population of patients with atrial fibrillation. Therefore, much emphasis has been placed on identifying methods for preventing recurrent ischemic stroke as well as preventing first stroke. Prevention strategies focus on the modifiable risk factors such as hypertension, smoking, and atrial fibrillation. Analysis of five placebo-controlled clinical trials investigating the efficacy of warfarin in the primary prevention of thromboembolic stroke, found the relative risk of thromboembolic stroke was reduced by 68% for atrial fibrillation patients treated with warfarin. In recent years, novel oral anticoagulant agents (NOACs) have been developed and approved by the U.S. Food and Drug Administration (FDA) for stroke prevention, and may be considered as an alternative to warfarin for select patients. The administration of anticoagulation therapy, unless there are contraindications, is an established effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients with TIA or prior stroke. To: Atrial fibrillation (AF) is a common arrhythmia and an important risk factor for stroke. It is one of several conditions and lifestyle factors that have been identified as risk factors for stroke. It has been estimated that 6.6 million individuals in the United States have AF, and the prevalence is expected to increase to 12.1 million by 2030. While the median age of patients with atrial fibrillation is 75 years, the incidence increases with advancing age (14.2 per 1000 PY at 65–69 years of age to 50.8 per 1000 PY at ≥85 years of age). Furthermore, a prior stroke or transient ischemic attack (TIA) are among a limited number of predictors of high stroke risk within the population of patients with atrial fibrillation. Nonparoxysmal AF compared to paroxysmal AF has been associated with a higher risk of stroke in this patient population. Therefore, much emphasis has been placed on identifying methods for preventing recurrent ischemic stroke as well as preventing first stroke. Prevention strategies focus on the modifiable risk factors such as hypertension, smoking, and atrial fibrillation. Anticoagulation therapy is recommended for secondary stroke prevention for ischemic stroke patients with AF, unless contraindicated. Globally, the use of direct oral anticoagulant medications has continued to increase since 2018 and the prevalence of vitamin K antagonist use decreased. However, about 10% of patients are still treated with antiplatelet medications only. Selected References Add:
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STK-4 | The measure rationale and references were updated to include 2025 stroke statistics from the American Heart Association. | Rationale Change from: The administration of IV alteplase to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials (Class I, Level of Evidence A, American Heart Association/American Stroke Association (AHA/ASA), 2019). These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA approved. Although the benefit of IV alteplase has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for alteplase therapy in recent years. Updated recommendations from the AHA/ASA in 2019 identify tenecteplase as a reasonable alternative to alteplase in acute ischemic stroke patients with minor neurological impairment and no major intracranial occlusion (0.4-mg/kg single IV bolus), or who are also eligible to undergo mechanical thrombectomy (0.25 -mg/kg single IV bolus, maximum 25 mg). Clinical evidence at this time is unclear whether tenecteplase is as effective as or more effective than alteplase (Class IIb, Level of Evidence BR). The administration of IV tenecteplase for ischemic stroke within or beyond 3 hours of stroke symptom onset has not been FDA approved. To:The administration of IV alteplase to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials (Class I, Level of Evidence A, American Heart Association/American Stroke Association (AHA/ASA), 2019). These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA approved. Although the benefit of IV alteplase has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for alteplase therapy in recent years. Updated recommendations from the AHA/ASA in 2019 identified IV tenecteplase (TNK) as a reasonable alternative to alteplase. In March, 2025, IV TNK received FDA-approval for the treatment of acute ischemic stroke (AIS) in adults. The approval is based on a large multi-center non-inferiority study demonstrating that the efficacy of TNK and alteplase are comparable. Symptomatic intracranial hemorrhage (ICH) is a potential complication with both agents. However, a systematic review of 26 studies comparing IV TNK with alteplase suggests slightly less risk of an event (RR 0.89, 95% CI, 0.65-1.23) with TNK (Martin, 2025). Selected ReferencesAdd:
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STK-6 | The rationale for the measure and references were updated to include 2025 stroke statistics from the American Heart Association. | Rationale Add a fifth sentence to the end of the paragraph: Patients with a history of prior stroke or TIA and LDL-C <70 mg/dL have a lower risk of another stroke or cardiovascular event without increased risk for ICH compared to those patients with LDL-C 90-110 mg/dL (Martin, 2025). Selected References Add:
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THKR-IP | Removing statement for patient who is hospitalized overnight to improve understanding of Initial Patient Population. | THKR-IP Initial Patient Population
Change from:
The THKR measure set is unique in that there are two distinct strata within the measure set, each identified by a specific group of principal procedure codes, or lack thereof. The patients in each stratum are counted in the Initial Patient Population of multiple measures. The inpatient population is defined as a patient who is hospitalized overnight. To: The THKR measure set is unique in that there are two distinct strata within the measure set, each identified by a specific group of principal procedure codes, or lack thereof. The patients in each stratum are counted in the Initial Patient Population of multiple measures. |
THKR-IP-1 | Updated to include the Reason for No Regional Anesthesia data element. | Denominator - Excluded Populations (last bullet)
Change from:
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THKR-IP-2 | Updated Table 14.10 name to be more inclusive of additional fracture codes added. | Excluded Populations
Change from:
Table 14.10 (femur, hip, pelvic fracture) To: Table 14.10 (Fractures) |
THKR-IP-3 | Updated Table 14.10 name to be more inclusive of additional fracture codes added. | Excluded Populations
Change from:
Table 14.10 (femur, hip, pelvic fracture) To: Table 14.10 (Fractures) |
THKR-IP-4 | Updated Table 14.10 name to be more inclusive of additional fracture codes added. | Excluded Populations
Change from:
Table 14.10 (femur, hip, pelvic fracture) To: Table 14.10 (Fractures) |
THKR-IP-5 | Updated Denominator Excluded Populations and added Pre-Collection Mortality data element to exclude patients who expire after the principal procedure and prior to the end of the data collection period. Updated Table 14.10 name to be more inclusive of additional fracture codes added. | Denominator:
Excluded Populations Change from:Table 14.10 (femur, hip, pelvic fracture) To: Table 14.10 (Fractures) (last bullet) Add:
Data Elements (last bullet) Add: Pre-Collection Mortality Algorithm:Add: New check box for Pre-Collection Mortality after 2nd check box for ICD-10-CM Principal or Other Diagnosis Codes. If Pre-Collection Mortality is missing, the branch will go to Measure Category Assignment of X. If Pre-Collection Mortality equals Y, the branch will go to Measure Category Assignment of B. If Pre-Collection Mortality equals N, the branch will go to Check ICD-10-PCS Principal Procedure Date. Narrative: Change: Step 2a, 2b From: a. If ICD-10-CM Principal or Other Diagnosis Codes is At least one on Table 14.10, the case will proceed to a Measure Category Assignment of B and will be Not In Measure Population. For Overall Rate (THKR-IP-5a). Proceed to Step 8. b. If ICD-10-CM Principal or Other Diagnosis Codes is None on Table 14.10, the case will continue processing and proceed to Check ICD-10-PCS Principal Procedure Date. To: a. If ICD-10-CM Principal or Other Diagnosis Codes is At least one on Table 14.10, the case will proceed to a Measure Category Assignment of B and will be Not In Measure Population. For Overall Rate (THKR-IP-5a). Proceed to Step 9. b. If ICD-10-CM Principal or Other Diagnosis Codes is None on Table 14.10, the case will continue processing and proceed to Check Pre-Collection Mortality. Add: Step 3: 3. Check Pre-Collection Mortality a. If Pre-Collection Mortality is missing, the case will proceed to a Measure Category Assignment of X and Case Will Be Rejected. For Overall Rate (THKR-IP-5a). Proceed to Step 9. b. If Pre-Collection Mortality equals Y, the case will proceed to a Measure Category Assignment of B and will be Not In Measure Population. For Overall Rate (THKR-IP-5a). Proceed to Step 9. c. If Pre-Collection Mortality equals N, the case will continue processing and proceed to Check ICD-10-PCS Principal Procedure Date. Change all step numbers after step 3. |
THKR-OP-1 | Updated to include the Reason for No Regional Anesthesia data element. | Denominator - Excluded Populations (last bullet)
Change from:
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THKR-OP-2 | Updated Table 14.10 name to be more inclusive of additional fracture codes added. | Excluded Populations
Change from:
Table 14.10 (femur, hip, pelvic fracture) To: Table 14.10 (Fractures) |
THKR-OP-3 | Updated Table 14.10 name to be more inclusive of additional fracture codes added. | Excluded Populations
Change from:
Table 14.10 (femur, hip, pelvic fracture) To: Table 14.10 (Fractures) |
THKR-OP-4 | Updated Table 14.10 name to be more inclusive of additional fracture codes added. | Excluded Populations
Change from:
Table 14.10 (Femur, hip, pelvic fracture) To: Table 14.10 (Fractures) |
THKR-OP-5 | Updated Denominator Excluded Populations and added Pre-Collection Mortality data element to exclude patients who expire after the principal procedure and prior to the end of the data collection period. Updated Table 14.10 name to be more inclusive of additional fracture codes added. | Denominator:
Excluded Populations Change from:Table 14.10 (Femur, hip, pelvic fracture) To: Table 14.10 (Fractures) (last bullet) Add:
Data Elements (last bullet) Add: Pre-Collection Mortality Algorithm:Add: New check box for Pre-Collection Mortality after 2nd check box for ICD-10-CM Principal or Other Diagnosis Codes. If Pre-Collection Mortality is missing, the branch will go to Measure Category Assignment of X. If Pre-Collection Mortality equals Y, the branch will go to Measure Category Assignment of B. If Pre-Collection Mortality equals N, the branch will go to Check CPT Code Procedure Date. Narrative: Change: Step 2a, 2b from: a. If ICD-10-CM Principal or Other Diagnosis Codes is At least one on Table 14.10, the case will proceed to a Measure Category Assignment of B and will be Not In Measure Population. For Overall Rate (THKR-OP-5a). Proceed to Step 8. b. If ICD-10-CM Principal or Other Diagnosis Codes is None on Table 14.10, the case will continue processing and proceed to Check CPT Code Procedure Date. To: a. If ICD-10-CM Principal or Other Diagnosis Codes is At least one on Table 14.10, the case will proceed to a Measure Category Assignment of B and will be Not In Measure Population. For Overall Rate (THKR-OP-5a). Proceed to Step 9. b. If ICD-10-CM Principal or Other Diagnosis Codes is None on Table 14.10, the case will continue processing and proceed to Check Pre-Collection Mortality. Add: Step 3: 3. Check Pre-Collection Mortality a. If Pre-Collection Mortality is missing, the case will proceed to a Measure Category Assignment of X and Case Will Be Rejected. For Overall Rate (THKR-OP-5a). Proceed to Step 9. b. If Pre-Collection Mortality equals Y, the case will proceed to a Measure Category Assignment of B and will be Not In Measure Population. For Overall Rate (THKR-OP-5a). Proceed to Step 9. c. If Pre-Collection Mortality equals N, the case will continue processing and proceed to Check CPT Code Procedure Date. Change all step number after step 3. |
Section | Rationale | Description |
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Discharge Date | The removal of the sentence referencing HBIPS is no longer applicable due to the retirement of HBIPS-1 and HBIPS-5. This data element is not collected for HBIPS-2 and HBIPS-3 since they are event measures. | Remove: For HBIPS only, if the patient was in an acute-care hospital and had multiple admissions to the psychiatric unit during his or her hospitalization, this information should be abstracted only once at the time of discharge from the hospital. |
IA Alteplase or MER Initiation Time | The data element definition was updated to add an alternative inclusion term similar to procedure start time. | Inclusion Guidelines for Abstraction Add:
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IA Route of Alteplase Administration | The U.S. Food and Drug Administration (FDA) approved intravenous (I.V.) tenecteplase for the treatment of acute ischemic stroke in adults on March 3, 2025. | Inclusion Guidelines for Abstraction
Remove:
Only Acceptable Thrombolytic Therapy for Stroke: Exclusion Guidelines for Abstraction Add:
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Influenza Vaccination Status | The updates to IMM data element Influenza Vaccination Status will provide abstractor clarification and alignment with updated CDC influenza vaccination guidance. | Allowable Values
Change from:
4 There was documentation of an allergy/sensitivity to influenza vaccine, anaphylactic latex allergy or anaphylactic allergy to eggs OR is not likely to be effective because of bone marrow transplant within the past 6 months OR history of Guillian-Barré syndrome within 6 weeks after a previous influenza vaccination OR symptomatic suspected or confirmed COVID-19. to: 4 Patients who have documentation of a severe allergic reaction (e.g. anaphylaxis) after previous dose of influenza vaccine or to vaccine component, OR history of Guillian-Barré syndrome within 6 weeks after a previous influenza vaccination OR moderate or severe acute illness with or without fever. Notes for Abstraction Add:
Guidelines for Abstraction (Inclusion) 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/hcp/acip/.
to: All patients discharged during October, November, December, January, February, or March Acceptable terms for influenza vaccines include, but are not limited to, 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/.
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IV Alteplase Initiation | The U.S. Food and Drug Administration (FDA) approved intravenous (I.V.) tenecteplase for the treatment of acute ischemic stroke in adults on March 3, 2025. | Inclusion Guidelines for Abstraction
Change from:
Only FDA-Approved Thrombolytic Therapy for Stroke:
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IV Alteplase Prior to IA or Mechanical Reperfusion Therapy | The U.S. Food and Drug Administration (FDA) approved intravenous (I.V.) tenecteplase for the treatment of acute ischemic stroke in adults on March 3, 2025. | Inclusion Guidelines for Abstraction
Change from:
Only FDA-Approved Thrombolytic Therapy for Stroke:
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IV OR IA Alteplase Administered at This Hospital or Within 24 Hours Prior to Arrival | The U.S. Food and Drug Administration (FDA) approved intravenous (I.V.) tenecteplase for the treatment of acute ischemic stroke in adults on March 3, 2025. | Inclusion Guidelines for Abstraction
Change from:
Only FDA-Approved Thrombolytic Therapy for Stroke:
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Non-aneurysmal | Radiology reports and brain imaging reports were added as data sources as recommended by GWTG. | Suggested Data Sources
Add:
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Pre-Collection Mortality | Added new data element to exclude patients who expire after the principal procedure and prior to the end of the data collection period. | N/A |
Psychiatric Inpatient Days - Medicare Only | Added clarification to the notes for abstraction for Psychiatric Inpatient Days Medicare Only and Non-Medicare Only data elements. This will align with the definition in the data entry guide that provides technical guidance. | Change from:
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Psychiatric Inpatient Days-Non-Medicare Only | Added clarification to the notes for abstraction for Psychiatric Inpatient Days Medicare Only and Non-Medicare Only data elements. This will align with the definition in the data entry guide that provides technical guidance. | Change from:
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Reason for Extending the Initiation of IV Alteplase | The U.S. Food and Drug Administration (FDA) approved intravenous (I.V.) tenecteplase for the treatment of acute ischemic stroke in adults on March 3, 2025. | Inclusion Guidelines for Abstraction
Change from:
Exclusion Guidelines for Abstraction Change third bullet to:
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Reason for No Regional Anesthesia | Updated data element definitions, allowable values, notes for abstraction, and guidelines for abstraction to provide abstractor clarification. | Question
Change from:
Is there physician/APN/PA documentation why regional anesthesia was not used or attempted for the procedure?
To:
Is there documentation as to justification for why regional anesthesia was not used or attempted for the procedure?
Definition Change from: Reasons why regional anesthesia was not used or attempted for the procedure:
Allowable Values Change from:Y (Yes) There is physician/APN/PA documentation why regional anesthesia was not used or attempted. N (No) There is no physician/APN/PA documentation why regional anesthesia was not used or attempted or unable to determine from medical record documentation. To:Y (Yes) There is documentation as to justification for why regional anesthesia was not used or attempted. N (No) There is no documentation as to justification for why regional anesthesia was not used or attempted or unable to determine from medical record documentation. Notes for Abstraction Change from:
Guidelines for Abstraction - Inclusion Change from:
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Reason for Not Initiating IV Alteplase | The U.S. Food and Drug Administration (FDA) approved intravenous (I.V.) tenecteplase for the treatment of acute ischemic stroke in adults on March 3, 2025. | Inclusion Guidelines for Abstraction
Change from:
Exclusion Guidelines for Abstraction Change third bullet to:
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Regional Anesthesia | Updated definition to clarify intent of data element. | Definition Change from: Documentation that the procedure was performed using regional anesthesia or that regional anesthesia was attempted. Regional anesthesia includes neuraxial anesthesia (spinal and epidural blocks) as well as peripheral nerve blocks. Change to: Documentation that the procedure was performed using regional anesthesia or that regional anesthesia was attempted for the purpose of anesthesia during the operative episode. This does not include regional anesthesia used for the purpose of postoperative analgesia. Regional anesthesia includes neuraxial anesthesia (spinal and epidural blocks) as well as peripheral nerve blocks. Documentation that the procedure was performed using regional anesthesia or that regional anesthesia was attempted for the purpose of anesthesia during the operative episode. Regional anesthesia includes neuraxial anesthesia (spinal and epidural blocks) as well as peripheral nerve blocks. |
Section | Rationale | Description |
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Appendix A - Code Tables | Multiple tables were updated to include the 2026 ICD-10 updates. | Table 10.01, 11.05,11.30,12.10, 14.02a, 8.2e were updated to align with the 2026 ICD-10 updates. The revisions include additions, deletions, and revisions to descriptions.
Rationale: Multiple tables were updated to include the 2026 ICD-10 updates. Table 14.10 was updated to include an additional 3323 codes terminology. Rationale: Based on feedback and review with SME this update was to align with the CMS THA/TKA measure. Change Detail: Table 10.01 Name was updated to Mental Disorders-ED from Mental Disorders-HBIPS/ED. Rationale: Due to the removal of the HBIPS measures that utilized this table, the title was updated. |
Appendix C - Medication Tables | Medication Tables 10.0 Antipsychotic Medications and 10.1 Short-acting Intramuscular Antipsychotic Medications tables have been transferred to the IPF Manual effective Jan 1, 2026. Medication Tables 9.1 FDA-Approved Tobacco Cessation Medications and 9.2 FDA-Approved Medications for Alcohol and Drug Dependence were updated to remove discontinued medications | Remove:
Medication Tables 10.0 Antipsychotic Medications and 10.1 Short-acting Intramuscular Antipsychotic Medications
Remove: Medications from Table 9.1 FDA-Approved Tobacco Cessation Medications:
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Appendix D - Glossary of Terms | Updated measure-specific data elements to include current measure set example. Removed reference to retired measure SCIP-INF-1-3 in prophylactic antibiotic. Rearranged Process Measure and Sample Size definitions for proper alphabetical order. Updated broken reference link to American College of Obstetricians and Gynecologists. | Change from:
measure-specific data elements Data elements used by one specific measure or several measures in one specific measure set, such as Infection Prior to Anesthesia in the SCIP measures.
To: measure-specific data elements Data elements used by one specific measure or several measures in one specific measure set, such as Gestational Age in the PC measures. Change from: prophylactic antibiotic An antibiotic used to prevent, rather than treat or cure, disease. For the purposes of SCIP-Inf-1-3, antibiotics given to prevent postoperative infection will be collected. Because the overuse of antibiotics can lead to resistance, antibiotics taken to prevent infection should be used only for a short time.To: prophylactic antibiotic An antibiotic used to prevent, rather than treat or cure, disease. Because the overuse of antibiotics can lead to resistance, antibiotics taken to prevent infection should be used only for a short time. Change from:
To:
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Appendix G - Resources | Updated broken link for CMQCC FAQ document. | Change from:
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 Datav2.pdf
To: There is also information on the FAQ provided by CMQCC on page 5-6. The link to the FAQ is: https://www.cmqcc.org/files/Unexpected_Newborn_Complications_FAQs_2018 Datav2.pdf |
Introduction to the Manual | Removed statement related to CMS Compare websites as it is no longer applicable for the Accelerate PI™ Performance Report. | Accelerate PI™ Performance Report Remove: In addition, the report uses a select subset of the most recent and available external data from the US Centers for Medicare & Medicaid Services (CMS) Compare websites that meet Joint Commission unique criteria for impact and actionability. |
Using the The Joint Commission's National Measure Specifications Manual | The Joint Commission launched a new website and the location of the ORYX Performance Measure Reporting Requirements changed. | Change from: Measurement tab To: Performance Measurement page |
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