Maternity Care Primary C-Section Rate Specifications 2014 (07/01/2013 to 06/30/2014 Dates of Service)

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1 Summary of Changes Denominator Changes: Two additions were made to the denominator criteria. The denominator was changed to include patients who had: a vertex position delivery AND a term pregnancy of greater or equal to 37 weeks gestation Please review the denominator section to review all criteria. Eligible Clinics: Any clinic that is part of a medical group in which the medical group has providers who perform cesarean deliveries will be eligible to report data for this measure. Description Methodology Rationale Measurement Period Denominator A measure of the percentage of cesarean deliveries for nulliparous births. Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are either extracted from an EMR system or abstracted through medical record review. Full population data is required. Safe and healthy pregnancies and births are a primary goal for society and particularly for expectant mothers and their families, healthcare providers, and payers. While most births are positive experiences with healthy outcomes, childbirth also brings substantial risks for both the mother and the infant. For consumers, Minnesota lacks publicly reported maternity measures to aid and inform decision making. Several other states have public reporting for maternity care measures, most commonly cesarean section (C-section) and vaginal birth after C-section delivery (VBAC) rates due to the high volume, high costs and increased morbidity associated with C-section procedures. Recently, new clinical guidelines offering more direction regarding the care and management of pregnant women and childbirth have been released along with new quality measures that can be used to highlight variation and underscore appropriate maternal care. Measurement period will be a fixed 12-month period: 07/01/2013 to 06/30/2014. Patients who meet each of the following criteria is included in the measure denominator: Female patient was nulliparous and of any age. Patient had a single liveborn delivery. Patient had vertex position delivery of a term (greater or equal to 37 weeks gestation) baby via a vaginal or cesarean birth. Patient had at least one prenatal care visit with an eligible provider in an eligible specialty in the medical group prior to the onset of labor. Page 1

2 Patient was delivered by an eligible provider in an eligible specialty who had a delivery date during the measurement period (07/01/2013 to 06/30/2014). Eligible clinics: All clinics that are part of a medical group in which the medical group has providers who perform cesarean section procedures. Eligible specialties: Family Medicine, General Practice, Obstetrics/Gynecology, Perinatology. Eligible providers: Medical Doctor (MD), Doctor of Osteopathy (DO), Certified Nurse Midwives (CMS), and Certified Professional Midwives (CPM). Recommendations to identify nulliparous, singleton, liveborn deliveries: 1. Nulliparous female patients: Nulliparous women are defined as women whose pregnancy is at least at 20 weeks gestational age and who have not previously had a pregnancy of at least 20 weeks gestational age in the past. Medical groups / clinics will need to track and supply information about nulliparity either through medical codes or in the medical record. Identification of nulliparous deliveries can be accomplished by using one of the following suggested methods: a. Create a field in an electronic medical record or chart to indicate nulliparity. b. ICD-9 codes that medical groups / clinics may use to identify nulliparous women if used consistently for all deliveries (see Table 1). Those ICD-9 codes are: V22.0 Supervision of normal first pregnancy. V23.81 Other high-risk pregnancy; Elderly primigravida. V23.83 Other high-risk pregnancy: Young primigravida. c. Use the enumeration of a female s obstetrical history where parity (P) = 0 (zero). 2. Singleton liveborn deliveries: Defined as a delivery with one liveborn baby. Identification of singleton liveborn deliveries can be accomplished by using one of the following suggested methods: a. ICD-9 code V27.0 (single liveborn; see Table 2). b. Create a field in an electronic medical record or chart to indicate single, liveborn. 3. Identification of deliveries and type of delivery: Type of delivery defined as vaginal or cesarean section delivery. Identification of type of delivery can be accomplished by using one of the Page 2

3 following suggested methods: a. CPT procedure codes (see Table 3): routine care with vaginal delivery vaginal delivery only vaginal delivery only including postpartum care routine care with cesarean delivery cesarean delivery only cesarean delivery only including postpartum care. b. Create a field in an electronic medical record or chart that indicates type of delivery. c. Select ICD-9 codes indicating that a delivery occurred. Please refer to the data collection guide for a list of suggested codes to be used to identify patients. Exclusions Patient had pregnancy with multiple gestations (ICD-9 codes , V27.2-V27.7; see Table 4). Patient had pregnancy with a stillborn (ICD-9 codes , V27.1; see Table 4). Patient had delivery with a non-vertex fetal position (ICD-9 codes , , ; see Table 5). Numerator The number of live, singleton, vertex position, term (greater or equal to 37 weeks gestation) newborns who were delivered via cesarean section. When no prenatal care is provided by the medical group/clinic, the C-section delivery is not included in the numerator calculation for the C-section rate. (Additional instructions on how to identify and provide this information are in the data collection guide.) s Used to Identify Patients who Meet Inclusion Criteria Please use the tables below and the tables located in the Data Collection Guide Appendices to identify patients who meet inclusion criteria. Table 1: s for Identifying Nulliparity V22.0 Supervision of normal first pregnancy V23.81 Other high-risk pregnancy; Elderly primigravida V23.83 Other high-risk pregnancy: Young primigravida Page 3

4 Table 2: s for Identifying Single Liveborn V27.0 Single liveborn Table 3: CPT Procedure s for Identifying Deliveries and Delivery Type CPT Procedure CPT Procedure Description Routine care with vaginal delivery Vaginal delivery only Vaginal delivery only including postpartum care Routine care with cesarean delivery Cesarean delivery only Cesarean delivery only including postpartum care s Used to Identify Patients who Meet Exclusion Criteria Table 4: s for Identifying Stillborn and Multiple Gestation Births V27.1 Outcome of delivery, single stillborn V27.2 Outcome of delivery, twins, both liveborn V27.3 Outcome of delivery, twins, one liveborn and one stillborn V27.4 Outcome of delivery, twins, both stillborn V27.5 Outcome of delivery, other multiple birth, all liveborn V27.6 Outcome of delivery, other multiple birth, some liveborn V27.7 Outcome of delivery, other multiple birth, all stillborn Twin pregnancy, unspecified as to episode of care or not applicable Twin pregnancy, delivered, with or without Twin pregnancy, antepartum condition or Triplet pregnancy, unspecified as to episode of care or not applicable Triplet pregnancy, delivered, with or without Triplet pregnancy, antepartum condition or Quadruplet pregnancy, unspecified as to episode of care or not applicable Page 4

5 Maternity Care Primary C-Section Rate Specifications Quadruplet pregnancy, delivered, with or without mention of antepartum condition Quadruplet pregnancy, antepartum condition or Twin pregnancy with fetal loss and retention of one fetus, unspecified as to episode of care or not applicable Twin pregnancy with fetal loss and retention of one fetus, delivered, with or without Twin pregnancy with fetal loss and retention of one fetus, antepartum condition or Triplet pregnancy with fetal loss and retention of one or more fetus(es), unspecified as to episode of care or not applicable Triplet pregnancy with fetal loss and retention of one or more fetus(es), delivered, with or without Triplet pregnancy with fetal loss and retention of one or more fetus(es), antepartum condition or Quadruplet pregnancy with fetal loss and retention of one or more fetus(es), unspecified as to episode of care or not applicable Quadruplet pregnancy with fetal loss and retention of one or more fetus(es), delivered, with or without Quadruplet pregnancy with fetal loss and retention of one or more fetus(es), antepartum condition or Other multiple pregnancy with fetal loss and retention of one or more fetus(es), unspecified as to episode of care or not applicable Other multiple pregnancy with fetal loss and retention of one or more fetus(es), delivered, with or without Other multiple pregnancy with fetal loss and retention of one or more fetus(es), antepartum condition or Multiple gestation following (elective) fetal reduction, unspecified as to episode of care or not applicable Multiple gestation following (elective) fetal reduction, delivered, with or without Multiple gestation following (elective) fetal reduction, antepartum condition or Other specified multiple gestation, unspecified as to episode of care or not applicable Page 5

6 Maternity Care Primary C-Section Rate Specifications Other specified multiple gestation, delivered, with or without mention of antepartum condition Other specified multiple gestation, antepartum condition or Unspecified multiple gestation, unspecified as to episode of care or not applicable Unspecified multiple gestation, delivered, with or without mention of antepartum condition Unspecified multiple gestation, antepartum condition or Intrauterine death, affecting management of mother, unspecified as to episode of care or not applicable Intrauterine death, affecting management of mother, delivered, with or without Intrauterine death, affecting management of mother, antepartum condition or Table 5: ICD-9 Procedure s for Identifying Non-Vertex Fetal Positions s Breech presentation without mention of version; unspecified as to episode of care or not applicable Breech presentation without mention of version; delivered, with or within Breech presentation without mention of version; antepartum condition or Transverse or oblique presentation; unspecified as to episode of care or not applicable Transverse or oblique presentation; delivered, with or within mention of antepartum condition Transverse or oblique presentation; antepartum condition or Face or brow presentation; unspecified as to episode of care or not applicable Face or brow presentation; delivered, with or within mention of antepartum condition Face or brow presentation; antepartum condition or Other specified malposition or malpresentation; unspecified as to episode of care or not applicable Page 6

7 s Maternity Care Primary C-Section Rate Specifications Other specified malposition or malpresentation; delivered, with or within Other specified malposition or malpresentation; antepartum condition or Breech extraction, without mention of indication Page 7

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