CMS Web-Based PC 01 Perinatal Measure Educational Packet

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1 CMS Web-Based PC 01 Perinatal Measure Educational Packet The CMS inpatient web-based measure is: Elective Delivery o Documents the number of patients with elective vaginal deliveries or elective cesarean sections 37 weeks and < 39 weeks of gestation completed. Note: Data collected and reported to CMS is aggregated. The collection and submission for The Joint Commission (TJC) is patient-level data. Initial Patient Population: The total number of patients admitted with ICD-9-CM Principal or Other Diagnosis Codes as identified in the Specifications Manual Appendix A, Tables 11.01, 11.02, 11.03, or 11.04, patient age 8 and < 65 years and a Length of Stay 120 days. Numerator: Number of patients with elective deliveries between 37 weeks and < 39 weeks of gestation completed. Denominator: Total number of patients delivering newborns with 37 weeks and < 39 weeks of gestation completed. Exclusions - Total number of patients with the following exclusions: ICD-9-CM Principal Diagnosis Code or ICD-9 CM Other Diagnosis Codes for condition possibly justifying elective delivery prior to 39 weeks of gestation as defined in Appendix A, Table Enrolled in clinical trials Gestational age < 37 or 39 weeks For the purpose of the Hospital Inpatient Quality Reporting Program, data entry is achieved through the secure side of QualityNet.org via an online tool available to authorized users. Data collection and submission to TJC remains unchanged. CMS Data Submission Period: Data collection for this web-based measure is effective with the January 1, 2013, reporting period, then follows the same reporting requirements as for other CMS inpatient measures collected for the Hospital Inpatient Quality Reporting Program. Discharges Data Submission Period January 1 March 30 July 1 August 15 April 1 June 30 October 1 November 15 July 1 September 30 January 1 February 15 October 1 December 31 April 1 May 15 Page 1 of 15

2 Instructions to Complete the Online Web-Based Tool Log in to the Secure QualityNet website Under the Web-Based Data Collection Box, click View/Edit Structural/Web-Based Measures/Data Acknowledgement (DACA) Click the Inpatient Web-Based Measures Click the Current Fiscal Year (FY) Click View/Edit on the appropriate quarter The Measure Data Details asks the following questions: 1. What was your hospital s initial patient population? The total number of patients admitted with ICD-9-CM Principal or Other Diagnosis Codes as identified in the Specifications Manual Appendix A, Tables 11.01, 11.02, 11.03, or 11.04, patient age 8 and < 65 years and a Length of Stay 120 days. 2. What was your hospital s sample size? If you are sampling, please use the appropriate sample size for your initial population from TJC Specifications Manual. 3. What was your hospital s sampling frequency? Please indicate if you sampled: Monthly; Quarterly; Not sampled; Did 100%; or N/A Submission not required (use this only if your facility does not do deliveries). 4. Numerator What was the number of patients with elective deliveries? The number of patients with elective deliveries between 37 weeks and < 39 weeks of gestation completed to include the ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for one or more of the following according to TJC Specifications Manual: Medical induction of labor as defined in Appendix A, Table Cesarean section as defined in Appendix A, Table while not in Labor or experiencing Spontaneous Rupture of Membranes 5. Denominator What was the total number of patients delivering newborns with 37 weeks and < 39 weeks of gestation completed? The total number of patients delivering newborns with 37 weeks and < 39 weeks of gestation completed with an ICD-9-CM Principal Diagnosis Code or ICD-9CM Other Diagnosis Codes for planned cesarean section in labor as defined in Appendix A, Table of TJC Specifications Manual. Page 2 of 15

3 6. Exclusions What was the exclusion count for the ICD-9-CM Principal or Other Diagnosis Code for Elective Delivery? Exclusions include all of the following: ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix A, Table Less than 8 years of age Greater than or equal to 65 years of age Length of stay > 120 days 7. What was the exclusion count for those enrolled in a clinical trial? Count the number of excluded patients enrolled in a clinical trial related to delivery. 8. What was the exclusion count for other uterine surgery? Count the number of excluded patients that had a prior uterine delivery. 9. What was the exclusion count for gestational age patients < 37 or 39 weeks? Count the number of excluded patients that delivered newborns < 37 or 39 weeks of gestation. 10. In the results section, put in the total exclusion count, and click calculate. 11. Check your work to be sure that it makes sense and then save your work. Page 3 of 15

4 Specifications Manual Appendix A Table 11.01: Complications Mainly Related to Pregnancy HEM EARLY PREG NEC-DELIV HEM EARLY PREG-DELIVERED PLACENTA PREVIA-DELIVER PLACENTA PREV HEM-DELIV PREM SEPAR PLACEN-DELIV COAG DEF HEMORR-DELIVER ANTEPARTUM HEM NEC-DELIV ANTEPARTUM HEM NOS-DELIV ESSEN HYPERTEN-DELIVERED ESSEN HYPERTEN-DEL W P/P RENAL HYPERTEN PG-DELIV RENAL HYPERTEN-DEL P/P OLD HYPERTEN NEC-DELIVER OLD HYPERTEN-DELIV W P/P TRANS HYPERTEN-DELIVERED TRANS HYPERTEN-DEL W P/P MILD/NOS PREECLAMP-DELIV MILD PREECLAMP-DEL W P/P SEVERE PREECLAMP-DELIVER SEV PREECLAMP-DEL W P/P ECLAMPSIA-DELIVERED ECLAMPSIA-DELIV W P/P TOX W OLD HYPERTEN-DELIV TOX W OLD HYP-DEL W P/P HYPERTENS NOS-DELIVERED HYPERTENS NOS-DEL W P/P MILD HYPEREM GRAV-DELIV HYPEREM W METAB DIS-DEL LATE VOMIT OF PREG-DELIV VOMIT COMPL PREG-DELIVER VOMIT OF PREG NOS-DELIV EARLY ONSET DELIVERY-DEL POST TERM PREG-DEL PROLONGED PREG-DEL PAPYRACEOUS FETUS-DELIV EDEMA IN PREG-DELIVERED Page 4 of 15

5 EDEMA IN PREG-DEL W P/P RENAL DIS NOS-DELIVERED RENAL DIS NOS-DEL W P/P RECURNT PREG LOSS-DELIV NEURITIS-DELIVERED NEURITIS-DELIVERED W P/P ASYM BACTERIURIA-DELIVER ASY BACTERURIA-DEL W P/P GU INFECTION-DELIVERED GU INFECTION-DELIV W P/P LIVER/BIL TRCT DISR-DEL PREG COMPL NEC-DELIVERED PREG COMPL NEC-DEL W P/P PREG COMPL NOS-DELIVERED SYPHILIS-DELIVERED SYPHILIS-DELIVERED W P/P GONORRHEA-DELIVERED GONORRHEA-DELIVER W P/P OTHER VD-DELIVERED OTHER VD-DELIVERED W P/P TUBERCULOSIS-DELIVERED TUBERCULOSIS-DELIV W P/P MALARIA-DELIVERED MALARIA-DELIVERED W P/P RUBELLA-DELIVERED RUBELLA-DELIVERED W P/P OTH VIRAL DIS-DELIVERED OTH VIRAL DIS-DEL W P/P INFECT DIS NEC-DELIVERED INFECT DIS NEC-DEL W P/P INFECT NOS-DELIVERED INFECT NOS-DELIVER W P/P DIABETES-DELIVERED DIABETES-DELIVERED W P/P THYROID DYSFUNC-DELIVER THYROID DYSFUN-DEL W P/P ANEMIA-DELIVERED ANEMIA-DELIVERED W P/P DRUG DEPENDENCE-DELIVER Page 5 of 15

6 DRUG DEPENDEN-DEL W P/P MENTAL DISORDER-DELIVER MENTAL DIS-DELIV W P/P CONGEN CV DIS-DELIVERED CONGEN CV DIS-DEL W P/P CV DIS NEC PREG-DELIVER CV DIS NEC-DELIVER W P/P BONE DISORDER-DELIVERED BONE DISORDER-DEL W P/P ABN GLUCOSE TOLER-DELIV ABN GLUCOSE-DELIV W P/P OTH CURR COND-DELIVERED OTH CURR COND-DEL W P/P TOBACCO USE DISOR-DELLIV TOBACCO USE DIS-DEL-P/P OBESITY-DELIVERED OBESITY-DELIVERED W P/P BARIATRIC SURG STAT-DEL BARIATRIC SURG-DEL W P/P COAGULATION DEF-DELIV COAGULATN DEF-DEL W P/P EPILEPSY-DELIVERED EPILEPSY-DELIVERED W P/P SPOTTING-DELIVERED UTERINE SIZE DESCREP-DEL UTERINE SIZE-DEL W P/P SPON LABR W PLAN C/S-DEL LBR W PLAN C/S-DEL W P/P Table 11.02: Normal Delivery and Other Indications of Care 650 NORMAL DELIVERY TWIN PREGNANCY-DELIVERED TRIPLET PREGNANCY-DELIV QUADRUPLET PREG-DELIVER TWINS W FETAL LOSS-DEL TRIPLETS W FET LOSS-DEL QUADS W FETAL LOSS-DEL Page 6 of 15

7 MULT GES W FET LOSS-DEL MULT GEST-FET REDUCT DEL MULTI GESTAT NEC-DELIVER MULT GESTATION NOS-DELIV UNSTABLE LIE-DELIVERED CEPHALIC VERS NOS-DELIV BREECH PRESENTAT-DELIVER TRANSVER/OBLIQ LIE-DELIV FACE/BROW PRESENT-DELIV HIGH HEAD AT TERM-DELIV MULT GEST MALPRES-DELIV PROLAPSED ARM-DELIVERED MALPOSITION NEC-DELIVER MALPOSITION NOS-DELIVER PELVIC DEFORM NOS-DELIV CONTRACT PELV NOS-DELIV INLET CONTRACTION-DELIV OUTLET CONTRACTION-DELIV FETOPELV DISPROPOR-DELIV FETAL DISPROP NOS-DELIV HYDROCEPH FETUS-DELIVER OTH ABN FET DISPRO-DELIV DISPROPORTION NEC-DELIV DISPROPORTION NOS-DELIV CONGEN ABN UTERUS-DELIV CONG ABN UTER-DEL W P/P UTERINE TUMOR-DELIVERED UTERINE TUMOR-DEL W P/P PREV C-DELIVERY-DELIVRD RETROVERT UTERUS-DELIVER RETROVERT UTER-DEL W P/P ABN UTERUS NEC-DELIVERED ABN UTERUS NEC-DEL W P/P CERVICAL INCOMPET-DELIV CERV INCOMPET-DEL W P/P ABN CERVIX NEC-DELIVERED ABN CERVIX NEC-DEL W P/P ABNORM VAGINA-DELIVERED ABNORM VAGINA-DEL W P/P Page 7 of 15

8 ABNORMAL VULVA-DELIVERED ABNORMAL VULVA-DEL W P/P ABN PELV ORG NEC-DELIVER ABN PELV NEC-DELIV W P/P FETAL CNS MALFORM-DELIV FETAL CHROMOSO ABN-DELIV FAMIL HEREDIT DIS-DELIV FET DAMG D/T VIRUS-DELIV FET DAMG D/T DIS-DELIVER FET DAMAG D/T DRUG-DELIV RADIAT FETAL DAMAG-DELIV DECREASE FETAL MOVMT DEL FETAL ABNORM NEC-DELIVER FETAL ABNORM NOS-DELIVER FETAL-MATERNAL HEM-DELIV RH ISOIMMUNIZAT-DELIVER ABO ISOIMMUNIZAT-DELIVER FETAL DISTRESS-DELIVERED INTRAUTER DEATH-DELIVER POOR FETAL GROWTH-DELIV EXCESS FETAL GRTH-DELIV OTH PLACENT COND-DELIVER FET/PLAC PROB NEC-DELIV FET/PLAC PROB NOS-DELIV POLYHYDRAMNIOS-DELIVERED OLIGOHYDRAMNIOS-DELIVER PREM RUPT MEMBRAN-DELIV PROLONG RUPT MEMB-DELIV ARTIFIC RUPT MEMBR-DELIV AMNIOTIC INFECTION-DELIV AMNIOTIC PROB NEC-DELIV AMNIOTIC PROB NOS-DELIV FAIL MECH INDUCT-DELIVER FAIL INDUCTION NOS-DELIV PYREXIA IN LABOR-DELIVER SEPTICEM IN LABOR-DELIV GRAND MULTIPARITY-DELIV ELDERLY PRIMIGRAVIDA-DEL ELDERLY MULTIGRAVIDA-DEL Page 8 of 15

9 ABN FTL HRT RATE/RHY-DEL COMPLIC LABOR NEC-DELIV COMPLIC LABOR NOS-DELIV Table Number 11.03: Complication Mainly in the Course of Labor and Delivery OBSTRUC/FET MALPOS-DELIV BONY PELV OBSTRUCT-DELIV ABN PELV TIS OBSTR-DELIV PERSIST OCCIPTPOST-DELIV SHOULDER DYSTOCIA-DELIV LOCKED TWINS-DELIVERED FAIL TRIAL LAB NOS-DELIV FAILED FORCEPS NOS-DELIV OBSTRUCT LABOR NEC-DELIV OBSTRUCT LABOR NOS-DELIV PRIM UTERINE INERT-DELIV SEC UTERINE INERT-DELIV UTERINE INERT NEC-DELIV PRECIPITATE LABOR-DELIV UTER DYSTOCIA NOS-DELIV ABNORMAL LABOR NOS-DELIV PROLONG 1ST STAGE-DELIV PROLONG LABOR NOS-DELIV PROLONG 2ND STAGE-DELIV DELAY DEL 2ND TWIN-DELIV CORD PROLAPSE-DELIVERED CORD AROUND NECK-DELIVER CORD COMPRESS NEC-DELIV CORD ENTANGLE NEC-DELIV SHORT CORD-DELIVERED VASA PREVIA-DELIVERED VASC LESION CORD-DELIVER CORD COMPLICAT NEC-DELIV CORD COMPLICAT NOS-DELIV DEL W 1 DEG LACERAT-DEL DEL W 2 DEG LACERAT-DEL Page 9 of 15

10 DEL W 3 DEG LACERAT-DEL DEL W 4 DEG LACERAT-DEL OB PERINEAL LAC NOS-DEL OB PERINEAL HEMATOMA-DEL OB PERINEAL TRAU NEC-DEL OB PERINEAL TRAU NOS-DEL PRELABOR RUPT UTERUS-DEL RUPTURE UTERUS NOS-DELIV INVERS UTERUS-DEL W P/P LACERAT OF CERVIX-DELIV HIGH VAGINAL LACER-DELIV OB INJ PELV ORG NEC-DEL DAMAGE TO PELVIC JT-DEL OB PELVIC HEMATOMA-DELIV PELVIC HEMATOM-DEL W PP OB TRAUMA NEC-DELIVERED OB TRAUMA NEC-DEL W P/P OB TRAUMA NOS-DELIVERED OB TRAUMA NOS-DEL W P/P THRD-STAGE HEM-DEL W P/P POSTPA HEM NEC-DEL W P/P DELAY P/P HEM-DEL W P/P P/P COAG DEF-DEL W P/P RETND PLAC NOS-DEL W P/P RET PROD CONC-DEL W P/P PULM COMPL IN DEL-DELIV PULM COMPLIC-DEL W P/P HEART COMPL IN DEL-DELIV HEART COMPL-DEL W P/P CNS COMPL LAB/DEL-DELIV CNS COMPLIC-DEL W P/P ANESTH COMPL NEC-DELIVER ANESTH COMPL NEC-DEL P/P ANESTH COMPL NOS-DELIVER ANESTH COMPL NOS-DEL P/P MATERNAL DISTRESS-DELIV MATERN DISTRES-DEL W P/P OBSTETRIC SHOCK-DELIVER OBSTET SHOCK-DELIV W P/P Page 10 of 15

11 MATERN HYPOTEN SYN-DELIV MATERN HYPOTEN-DEL W P/P AC REN FAIL-DELIV W P/P OTH OB COMPL-DELIVERED OTH OB COMPL-DELIV W P/P FORCEP DELIV NOS-DELIVER BREECH EXTR NOS-DELIVER CESAREAN DELIVERY NOS COMP LAB/DELIV NEC-DELIV COMPL DEL NEC-DEL W P/P COMP LAB/DELIV NOS-DELIV COMPL DEL NOS-DEL W P/P Table Number 11.04: Complication of the Puerperium MAJOR PUERP INF-DEL P/P PUERP ENDOMET DEL W P/P PUERPRL Septicemias or Bacteremias-DEL W P/P PRP SPTC THRMB-DEL W P/P MAJ PRP INF NEC-DL W P/P VARICOSE VEIN LEG-DELIV VARIC VEIN LEG-DEL W P/P VARICOSE VULVA-DELIVERED VARICOSE VULVA-DEL W P/P THROMBOPHLEBITIS-DELIVER THROMBOPHLEB-DELIV W P/P DEEP THROM ANTEPAR-DELIV THROMB POSTPAR-DEL W P/P THROMBOSIS NEC-DELIVERED THROMB NEC-DELIV W P/P VENOUS COMPL NEC-DELIVER VEN COMP NEC-DELIV W P/P VENOUS COMPL NOS-DELIVER VEN COMP NOS-DELIV W P/P PUERP PYREXIA-DEL W P/P OB AIR EMBOLISM-DELIVER OB AIR EMBOL-DELIV W P/P AMNIOTIC EMBOLISM-DELIV Page 11 of 15

12 AMNIOT EMBOL-DELIV W P/P PULM EMBOL NOS-DELIVERED PULM EMBOL NOS-DEL W P/P OB PYEMIC EMBOL-DELIVER OB PYEM EMBOL-DEL W P/P PULMON EMBOL NEC-DELIVER PULM EMBOL NEC-DEL W P/P PUERP CEREBVAS DIS-DELIV CEREBVAS DIS-DELIV W P/P DISRUPT C-SECT-DEL W P/P DISRUPT PERIN-DEL W P/P OB SURG COMPL-DEL W P/P PLACENT POLYP-DEL W P/P PUERP COMP NEC-DEL W P/P PUERP COMP NOS-DEL W P/P INFECT NIPPLE-DELIVERED INFECT NIPPLE-DEL W P/P BREAST ABSCESS-DELIVERED BREAST ABSCESS-DEL W P/P MASTITIS-DELIVERED MASTITIS-DELIV W P/P BREAST INFECT NEC-DELIV BREAST INF NEC-DEL W P/P BREAST INFECT NOS-DELIV BREAST INF NOS-DEL W P/P RETRACTED NIPPLE-DELIVER RETRACT NIPPLE-DEL W P/P CRACKED NIPPLE-DELIVERED CRACKED NIPPLE-DEL W P/P BREAST ENGORGE-DELIVERED BREAST ENGORGE-DEL W P/P BREAST DIS NEC-DELIVERED BREAST DIS NEC-DEL W P/P LACTATION FAIL-DELIVERED LACTATION FAIL-DEL W P/P SUPPR LACTATION-DELIVER SUPPR LACTAT-DEL W P/P GALACTORRHEA-DELIVERED GALACTORRHEA-DEL W P/P Page 12 of 15

13 LACTATION DIS NEC-DELIV LACTAT DIS NEC-DEL W P/P LACTATION DIS NOS-DELIV LACTAT DIS NOS-DEL W P/P Table Number 11.05: Medical Induction of Labor INDUCT LABOR-RUPT MEMB 73.1 SURG INDUCT LABOR NEC 73.4 MEDICAL INDUCTION LABOR Table Number 11.06: Cesarean Section 74.0 CLASSCIAL C-SECTION 74.1 LOW CERVICAL C-SECTION 74.2 EXTRAPERITONEAL C-SECTION 74.4 CESAREAN SECTION NEC CESAREAN SECTION NOS Table Number : Planned Cesarean Section in Labor SPON LABR W PLAN C/S-DEL LBR W PLAN C/S-DEL W P/P Table Number 11.07: Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation 042 HUMAN IMMUNO VIRUS DIS PLACENTA PREVIA-DELIVER PLACENTA PREV HEM-DELIV PREM SEPAR PLACEN-DELIV COAG DEF HEMORR-DELIVER ANTEPARTUM HEM NEC-DELIV ANTEPARTUM HEM NOS-DELIV ESSEN HYPERTEN-DELIVERED ESSEN HYPERTEN-DEL W P/P RENAL HYPERTEN PG-DELIV RENAL HYPERTEN-DEL P/P OLD HYPERTEN NEC-DELIVER Page 13 of 15

14 OLD HYPERTEN-DELIV W P/P TRANS HYPERTEN-DELIVERED TRANS HYPERTEN-DEL W P/P MILD/NOS PREECLAMP-DELIV MILD PREECLAMP-DEL W P/P SEVERE PREECLAMP-DELIVER SEV PREECLAMP-DEL W P/P ECLAMPSIA-DELIVERED ECLAMPSIA-DELIV W P/P TOX W OLD HYPERTEN-DELIV TOX W OLD HYP-DEL W P/P HYPERTENS NOS-DELIVERED HYPERTENS NOS-DEL W P/P POST TERM PREG-DEL RENAL DIS NOS-DELIVERED RENAL DIS NOS-DEL W P/P LIVER/BIL TRCT DISR-DEL DIABETES-DELIVERED CONGEN CV DIS-DELIVERED CONGEN CV DIS-DEL W P/P CV DIS NEC PREG-DELIVER CV DIS NEC-DELIVER W P/P ABN GLUCOSE TOLER-DELIV ABN GLUCOSE-DELIV W P/P COAGULATION DEF-DELIV COAGULATN DEF-DEL W P/P TWIN PREGNANCY-DELIVERED TRIPLET PREGNANCY-DELIV QUADRUPLET PREG-DELIVER TWINS W FETAL LOSS-DEL TRIPLETS W FET LOSS-DEL QUADS W FETAL LOSS-DEL MULT GES W FET LOSS-DEL MULT GEST-FET REDUCT DEL MULTI GESTAT NEC-DELIVER MULT GESTATION NOS-DELIV UNSTABLE LIE-DELIVERED MULT GEST MALPRES-DELIV FETAL CNS MALFORM-DELIV Page 14 of 15

15 FETAL CHROMOSO ABN-DELIV FET DAMG D/T VIRUS-DELIV FET DAMG D/T DIS-DELIVER FET DAMAG D/T DRUG-DELIV RADIAT FETAL DAMAG-DELIV FETAL ABNORM NEC-UNSPEC FETAL-MATERNAL HEM-DELIV RH ISOIMMUNIZAT-DELIVER ABO ISOIMMUNIZAT-DELIVER FETAL DISTRESS-DELIVERED INTRAUTER DEATH-DELIVER POOR FETAL GROWTH-DELIV POLYHYDRAMNIOS-DELIVERED OLIGOHYDRAMNIOS-DELIVER PREM RUPT MEMBRAN-DELIV PROLONG RUPT MEMB-DELIV AMNIOTIC INFECTION-DELIV ABN FTL HRT RATE/RHY-DEL VASA PREVIA-DELIVERED V08 ASYMP HIV INFECTN STATUS V23.5 PREG W POOR REPRODUCT HX V27.1 DELIVER-SINGLE STILLBORN Tables 11.01, 11.02, 11.03, 11.04, 11.05, 11.06, , and were copied from the Specifications Manual for The Joint Commission National Quality Measures (v2013b), Copied 12/16/2013 Information used to complete this educational packet was taken from the Specifications Manual for The Joint Commission National Quality Measures (v2013b), Copied 12/16/2013 This material was prepared by FMQAI, the Medicare Quality Improvement Organization for Florida, and Health Services Advisory Group of California, Inc., the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication Nos. FL-10SOW-2014FLC and CA-10SOW C Page 15 of 15