Release Notes:
Data Element
Version 2010B
| Data Element Name: | Pre-Arrival LDL-Cholesterol Test |
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| Collected For: | AMI-T1a, AMI-T2, , (CMS Optional Test Measures) |
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| Definition: | LDL-cholesterol (LDL-c) test was performed within one year prior to hospital arrival. |
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| Suggested Data Collection Question: | Was an LDL-cholesterol (LDL-c) test performed within one year prior to hospital arrival? |
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| Format: | | Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Y (Yes) LDL-c test was performed within one year prior to hospital arrival.
N (No) LDL-c test was not performed within one year prior to hospital arrival or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- If there is documentation that LDL-c/lipid testing was done prior to arrival but the exact timeframe is not specified or determinable, select “No.” EXCEPTION: If documentation describes the LDL-c/lipid testing as having been done in the “recent” past, it should be inferred that it was done within one year prior to arrival.
- In the absence of explicit documentation that an LDL-c test was or was not performed within one year prior to hospital arrival, it should be inferred that a test was done within one year if:
- There is documentation of an LDL-c value from a test performed within one year prior to hospital arrival (e.g., “LDL-c 135 in November”), or
- There is physician/advanced practice nurse/physician assistant (physician/APN/PA) documentation which qualitatively describes the patient’s LDL-c from a test performed within one year prior to hospital arrival (e.g., “Labs last month showed elevated lipids,” ”CABG in June. Cholesterol levels now good on Lipitor”), or
- There is documentation that lipid testing was performed within one year prior to hospital arrival (e.g., “Cholesterol testing done in April”).
- Documentation must suggest that the qualitative description of LDL-c is from a test done within one year prior to arrival: Do not make assumptions. In the following examples, “No” should be selected:
- “Lipids have been good - patient on Zocor” per H&P
- Physician/APN/PA notes “Risk factor - dyslipidemia” in progress note
- “Pt. denies hypercholesterolemia” per physician/APN/PA progress note
- ER physician/APN/PA notes “No hx hyperlipidemia”
- Do not include pre-arrival lipid testing or qualitative descriptions of pre-arrival lipid test results if it can be determined that LDL-c measurement was not part of the lipid testing. In the following examples, “No” should be selected:
- Lipid profile done during hospitalization 6 months ago, per H&P, but the laboratory report from the hospitalization included in the chart lists only cholesterol and triglyceride values.
- Physician/APN/PA notes “Labs from office visit on 04-03-2008 showed elevated cholesterol,” but the 04-03-2008 laboratory report from the outpatient records included in the chart lists only a total cholesterol value.
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Progress notes
- Discharge summary
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
LDL-cholesterol (LDL-c)
- Low den lipoprotein
- Low density lipoprotein (LDL)
- Value described as “bad cholesterol”
Qualitative description of LDL-c
- Cholesterol level qualitatively described (e.g., low, normal, elevated, ↑)
- Dyslipidemia (presence or absence)
- Dyslipoproteinemia (presence or absence)
- Hyperbetalipoproteinemia (presence or absence)
- Hypercholesterolemia (presence or absence)
- Hyperlipemia (presence or absence)
- Hyperlipidemia (presence or absence)
- Hyperlipoproteinemia (presence or absence)
- LDL level qualitatively described (e.g., low, normal, elevated, above goal, below target, ↑)
- LDL-cholesterol (LDL-c) level qualitatively described (e.g., low, normal, elevated, ↑)
- Lipid levels qualitatively described (e.g., low, normal, elevated, ↑)
Lipid testing
- Cholesterol analysis
- Cholesterol check (✓)
- Cholesterol panel
- Cholesterol profile
- Cholesterol testing
- Fasting lipids
- LDL: HDL
- LDL: HDL ratio
- Lipid analysis
- Lipid check (✓)
- Lipid panel
- Lipid profile
- Lipids
- Lipoprotein analysis
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LDL-cholesterol
VLDL (very low density lipoprotein)
Qualitative description of LDL-c
Alpha lipoproteinemia (presence or absence)
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Pre-Arrival LDL-Cholesterol Test
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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