Perinatal Care (PC) Core Measures: Updates for Fall 2015 Webinar Question and Answer Session

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1 Updates for Fall 2015 and Answer Session Should we continue submitting the PC-5a data until October? ACOG definition of full term is weeks. What is the rationale for including 37 & 38 weeks in the denominator of PC 05? Are NB's treated x 48hrs with ABX excluded? Yes. PC-05 is evaluating healthy term newborns. The ACOG definition of term is: Greater than or equal to 37 weeks and 0 days using best EDD. It is divided into the following categories: Early Term - 37 weeks and 0 days through 38 weeks and 6 days Full Term - 39 weeks and 0 days through 40 weeks and 6 days Late Term - 41 weeks and 0 days through 41 weeks and 6 days Post Term - Greater than or equal to 42 weeks and 0 days This is an incomplete question. We assume this question is about the data element Bloodstream Infection Present on Admission. If so, you would answer "no" if the course of IV antibiotics started within the first 48 hours after admission lasted less than 7 days. Are you using a standard for PROM vs SROM - how long do you wait for labor to ensue before you consider an SROM a PROM? The ACOG definition is: Spontaneous rupture of membranes that occurs before the onset of labor. The clinician must document this as spontaneous rupture of membranes (SROM) and that labor did not begin at the time of SROM. Breastfeeding gestational age <37weeks...is this 36.6 and less? Can you please review the current guidelines regarding a mother that has a documented history of transabdominal cerclage (placed just prior to pregnancy) and if it would meet exclusion criteria for early elective delivery, after extensively reviewing the possible reasons justifying early elective delivery we could not locate this code. Yes, only term newborns who have reached 37 completed weeks of gestation are included in the denominator for PC-05. There is no code for a "prior" procedure. This appears in the data element Prior Uterine Surgery.

2 Updates for Fall 2015 and Answer Session If a mother is induced with cervidil and there is no additional methods of induction used, it is coded as which is not on the list of acceptable codes for induction. The ICD-9-CM procedure code for is "other genitourinary installation", not cervidil placement. Cervidil is a form of medical induction which is used to ripen the cervix. It is not used for any other purpose other than to induce labor. Comment: Given the rising rate of substance abuse, which was previously listed as maternal contraindication, we believe it is >2% and not a rare event. We would recommend that an organization track the maternal medical contraindications to understand their population. Are breast pump inductions included in the induction methods? Could JCAHO please acknowledge today and in their future presentations that there are both Physicians AND Nurse-Midwives as birth attendants. The Midwifery model of care is a key strategy for normal birth as evident by the UK, Nordic evidence. Nurse Midwives are mandated Medicaid service providers and are Meaningful Use Providers. Thank you. All hospitals are encouraged to review cases which do not pass any of the PC measures, in order to determine why the case did not pass. As stated during the presentation, PC-05 was revised so that it is similar in construct to PC-02: Cesarean Birth which also does not exclude any cases due to medical reasons. The change to PC-05 was necessary in order to reduce the burden of data abstraction and to align with the ecqm version of the measure which cannot model these exclusions. No, we are not aware of an ICD-10-PCS Procedure Code for induction based on nipple stimulation with a breast pump. Certified nurses midwives are already referenced as advanced clinicians throughout the PC specifications manual.

3 Updates for Fall 2015 and Answer Session Do signs/symptoms AND suspected sepsis have to be documented within that initial 48 hours to be excluded...or can the documentation just say "suspected sepsis"? PC-04 When will 2014 Joint Commission Rates for the measures be available for comparison? Do we have to use the same data we currently report? Our N size is really low. Its only a sample. Do you have any reference or suggestion of physicians seeing and evaluating their patients within a week prior to induction? Does term single newborn include 37 0/7 to 37 6/7 for PC 05? During the recent NQF MAP (Measure Applications Partnership) process, PC-02 was considered to be under development and was not available to recommend for inclusion in federal measure sets. Is this measure now available for this purpose? If not, when will it be available? Documentation of R/O sepsis alone for high risk newborns should not be used to answer yes to Bloodstream Infection Present on Admission. You should be looking for supporting documentation that there is a suspected sepsis present at birth or arrival (if a transfer-in) based on presenting symptoms, not R/O sepsis. This needs to be documented within 48 hours of admission. The advanced clinician should be documenting that the patient is showing clinical symptoms of sepsis, i.e., body temperature changes, respiratory difficulty, diarrhea, hypoglycemia, reduced movements, reduced sucking, seizures, bradycardia, swollen/distended abdomen, vomiting and/or jaundice. And they must also have been started on a course of antibiotics within the first 48 hours after admission which lasted for 7 days or longer. The Joint Commission Annual Report on Quality and Safety will be posted with the PC composite rates in the fall of In the meantime, you can check your hospital's performance against other hospitals by viewing the quarterly ORYX report posted to your extranet site with The Joint Commission. Yes, the same data used for ORYX submission may be used for certification submission. Sampling is optional, so you can review all cases if your N is small. Hospitals are encouraged to use Vital Records reports, delivery logs and other clinical information systems to help them identify the appropriate cases. We are unsure of your question as it relates to hospital performance for the PC measures. Term newborns are at least 37 weeks and 0 days completed gestation or greater at the time of delivery. The Joint Commission is working with contractors to CMS to retool PC-02 into an ecqm. Once this is completed, it will be revisited by the MAP.

4 Updates for Fall 2015 and Answer Session For BSI abstractions, do the abstractors have The presence of the POA with the billing code is the responsibility of the coder, not the the responsibility of ensuring the BSI POA is abstractor. You will need to work with your coding department if you are noticing accurate? discrepancies. For PC-01, placenta accreta/percreta is not Cases with this diagnosis made prior to delivery are recommended to be delivered prior to listed on Table 11.07; can this be reviewed for 37 weeks of completed gestation; therefore, this condition is not listed as exclusion for the future inclusion, as these cases are measure population. diagnosed prenatally (hopefully!) but not always associated with a Previa (which is excludable), and delivered prior to 39 weeks. Has PC-05a been completely eliminated? Also, have the exclusions of mom HIV positive and adopted babies been removed from PC-05? Can there be a PC-04 OFI if there is no positive blood culture? If you have a positive blood culture on day of admit/birth is this considered POA? How is parenteral nutrition defined in PCO5? How is the 'n' determined when doing the data abstraction? Our data is abstracted elsewhere. PC-05a will be retired effective with 10/1/15 discharges. All maternal medical conditions will also be removed from PC-05 effective with 10/1/15 discharges. As stated during the presentation, there may be some cases which are coded with an infection code from Table or due to documentation of other infections, i.e., NEC, urosepsis, etc. which would cause the case to fail. This is the reason the new data element Bloodstream Infection Confirmed has been added for an additional check beginning with manual V2015B to confirm the source. Yes, this is an example of one of the diagnostic tests used to confirm the bloodstream infection was present on admission. Parenteral nutrition is defined with codes found on Table in Appendix A of the specifications manual. Your performance measurement systems vendor will provide you with a sample for all of the PC measures which may be sampled. If you do not have a vendor, please refer to the Specifications Manual for Joint Commission National Quality Measures (v2015a1) for information on the initial patient population selection and sampling procedures.

5 Updates for Fall 2015 and Answer Session I did have a TJC support rep tell me that I could use the Ballard score of the infant on an UTD no prenatal care mom last year when UTD caused a fallout. Is this correct? You are looking for documentation of a numeric value between 1 and 50 documented in the medical record in order to answer the question about gestational age. A full term demise (for example) would be counted as zero parity? Doesn't this defeat the purpose of counting parity with regards to consideration for a previous delivery and how that affects subsequent deliveries? As stated during the presentation, parity is being renamed to the number of previous live births in order to allow for the capture of this data in an automated fashion from Vital Records reports. This change was made based on recommendations from the PC Technical Advisory Panel, since the incidence of a first birth stillborn is extremely rare. Our lactation consultants after birth when they do their assessment ask the question about the mother's initial feeding plan, they do not rely on documentation (which is not always accurate) in the chart from L&D. Is this not acceptable? As a follow up to my last question, and I know the measure is being retired, but how is there supposed to be documentation in the newborn record dated and timed before the first feeding, when the newborn EHR is only just created at the birth? This is nearly logistically impossible. Yes, provided the discussion of the risks of formula feeding and benefits of breast milk feeding along with the mother's decision documented is performed prior to the first feeding. It is acceptable to hold the initial feeding plan discussion of the risks of formula feeding and benefits of breast milk feeding along with the mother's decision PRIOR to the birth of the newborn. A copy of the discussion and decision which is timed and dated prior to the first feeding can be placed in the newborn's medical record once it is created in order to meet this requirement. If the RN held the discussion there must also be documentation from the advanced clinician that they are aware of the formula feeding decision at ANYTIME during the hospitalization. I see that the PC-02 Rate is 25.9% - What is the JC goal for PC-02? Thanks. There has been no goal established for PC-02.

6 Updates for Fall 2015 and Answer Session I would like further discussion on the reason for adding the data element bloodstream infection confirmed. If chorioamnionitis is documented on the pathology report of the placenta but not before delivery can that be used for a reason for not initiating antenatal steroids? This data element was added to be used for cases having an infection code on either Table or in order to determine in the infection was health care-associated or due to another medical condition. There should be documentation that the condition was "suspected" prior to delivery in order to use this diagnosis as an implied reason. If Pitocin is given to augment labor at less than 39 weeks, does that count as an induction? If the H & P states R/O sepsis and the DC summary states baby did have sepsis, can we mark yes to the element BSI present on admission? If we are providing level II care & do not have a NICU, do we answer yes to NICU? If we are using standardized terminology, "hyperstimulation" should be abandoned and replaced by "tachysystole." It not only occurs with oxytocin, but with cervical ripening agents and also with spontaneous labor. This measure should reflect this, don't you think? No. The coder should not be applying a medical induction of labor code 73.4 for cases when Pitocin is used to augment labor. This can be used only if the H & P states that the sepsis was present within the first 48 hours after admission. A NICU is defined as a hospital unit providing critical care services which is organized with personnel and equipment to provide continuous life support and comprehensive care for extremely high-risk newborn infants and those with complex and critical illness (source: American Academy of Pediatrics). Names of NICUs may vary from hospital to hospital. Level designations and capabilities also vary from region to region and cannot be used alone to determine if the nursery is a NICU. We are aware of this terminology; however, the term "hyperstimulation" does not appear anywhere in the specifications manual. Future presentations will be revised to use this term.

7 Updates for Fall 2015 and Answer Session I am a bit confused as to why we don't count "latent" or "prodromal" labor as labor but "regular contractions with or without cervical change" is counted as labor. There is a great deal of evidence regarding latent labor that has been published recently reflecting that change in what can be (incorrectly) diagnosed as "prolonged labor." This seems like an unclear aspect of the measure. In regards to defining induction, is a ripening agent included in that criteria? If so, why? In the rare situation where the infant meets all criteria but mother needs to supplement with donor human milk, can we still count that as exclusive? Is RN documentation of gestational age at delivery acceptable or does it need to be provider documentation? Is Stripping of membranes in the physician office with immediate admission to L&D considered induction? Is the initial review announced to the Hospital? Is there a link for the Perinatal Toolkit the speaker spoke about when answering the hardstop policy development? Is this measure (or why is it not) risk-adjusted to the maternal level of care (e.g. RPCs...)? The decision to exclude both latent labor and prodromal labor is based on recommendations from the PC Technical Advisory Panel and the ACOG definition: Latent phase from the onset of labor to the onset of the active phase; therefore, latent is not the same as active labor. Yes, a ripening agent is only used for the purposes of preparing the cervix to be favorable for delivery and as a precursor to labor induction. Yes, donor milk is acceptable. RN documentation can be used at the time of delivery. PC-01 does not address any procedure which takes place prior to hospitalization. Yes. Initial certification programs will receive a 30 day notice once their review has been scheduled. The toolkit to reduce elective deliveries prior to 39 weeks is available at: or We cannot answer the question, since we do not know which measure is being addressed.

8 Updates for Fall 2015 and Answer Session How about HIV? It does not make any sense to include stillbirths, as this indicates a higher risk, where NTSV is supposed to be lowest risk. And Nulliparous means NO previous birth! Once you submit your data, what is required to receive certification? PC-05 Specific requirements for documentation of conversation regarding maternal intent documented in the baby's chart prior to the first feed, still required? PC-01? If patient received appropriate care and there is just no documentation of GA. - we should not check UTD? What should we put? PC-04 - What if we have a Blood Culture on admission negative with 7 days or longer of antibiotics? Would this be acceptable? We cannot answer the question, since we do not know which measure is being addressed. As stated during the presentation, parity is being renamed to the number of previous live births in order to allow for the capture of this data in an automated fashion from Vital Records reports. This change was made based on recommendations from the PC Technical Advisory Panel, since the incidence of a first birth stillborn is extremely rare. The Joint Commission will schedule and conduct an on-site review of your program. You will receive a preliminary report of any findings of non-compliance before the reviewer leaves your organization. The report is then reviewed by our Standards Interpretation Group to assure the findings are appropriate. You will receive a written report from TJC indicating any finding that needs to be addressed and corrected prior to a certification decision. Please refer to The Joint Commission Review Guide for detailed information as it relates to this process. Yes, this documentation must continue until 10/1/15 discharges at which time PC-05a will be retired. If there is no documentation of a numeric value between 1 and 50 for gestational age, you must select UTD regardless of whether prenatal care was documented or not. With that said, you will need to work with your clinicians to make sure gestational age is documented in the medical record closest to the time of delivery. Cases with UTD are removed from the measure which could adversely impact your denominator size. A smaller denominator with resultant numerator cases could cause your rate to be much higher than it would be if all denominator cases have gestational age documented in order to include the cases. Generally speaking there must also be documentation that the patient was septic as the reason for continuing the antibiotics for 7 days or longer. In some cases the course of antibiotics could be administered for reasons other than a bloodstream infection.

9 Updates for Fall 2015 and Answer Session The 7 days antibiotics or longer is this effective as of today? or October 2015? Thank you in advance. This is for BSI. PC05 - When the mother is ready for discharge and the baby has to stay due to elevated Bili, we are finding it challenging to keep mother with the baby so she can breast feed. Is there anything out there to assist with reimbursement for the mother to keep her with the baby? Please clarify for PC-01 - if there is documentation of SROM and no labor would this case be excluded? Only PROM is on the exclusion list so does PROM need to be clearly documented or does SROM suffice? PC-05 - What is the effective date for maternal medical reasons no longer considered an exclusion? Recently, we had a PC-01 fall out. Patient was a 38 wk patient with a history of previous C-section. Patient presented to labor and delivery with incisional pain (signs of uterine rupture). No u/s was done. MD performed C- section and clinical evidence was correct. Patient had a uterine window. Why did this patient fall out? MD insists u/s is not proper indicator for uterine rupture/window. Yes, this guidance applies now to all cases when trying to make that determination. The Joint Commission appreciates your decision to support mothers who want to feed breast milk exclusively; however, we are an accrediting organization and are not involved in reimbursement. These mothers should be given a breast pump to express breast milk for the staff to use to feed the newborn. PROM with no commencement of labor should be clearly documented, so that the appropriate code can be applied. This begins with manual V2015B effective with 10/1/15 discharges. The history of a uterine window can be documented as a result of an ultrasound finding or presence noted during a prior surgery. Based on the information provided, it appears the documentation did not support this finding as described.

10 Updates for Fall 2015 and Answer Session So we cannot exclude those patients that come in to deliver and say up front that they do not want to breastfeed at all? Thank you for the great presentation. When will the Perinatal Care Core Measure Composite overall rating appear on Quality Check? Currently, there are rates posted, but the overall measure that other measures are rated as "Plus","Check" or "Minus"? This PC measure has always admitted that the list of allowable reasons to deliver at <39 weeks for NOT all inclusive. Understanding that there are medical indications that would still lead to abstraction as a fallout. However, now this is a value based purchasing measure with a threshold of 3.1% and a benchmark of 0.0%. How do we reach 0.0% when there are multiple medical reasons to induce at less than 39 weeks that (even though are well documented) are not allowable as reasons for early delivery? To clarify, does the physician have to document "labor" in order to check "yes" to labor? Will documentations of cervical change suffice effective 10/1/15? We are interested in specific information regarding the benefits and requirements for Perinatal Care Certification process. Is a future webinar planned? Effective with 10/1/15 PC-05a will be retired. PC-05 will continue to evaluate the hospital's overall exclusive breast milk feeding rate only. Current data shows over half of all hospitals are at less than 50% for PC-05 which is the important population health measure that hospitals should be focusing their attention. The composite rates do not appear in Quality Check. These appear in The Joint Commission's Annual Report on Quality and Safety which will be published in the fall of There are no plans at this time to change the displays on Quality Check. Any concerns about the inclusion of PC-01 in the VBP program should be directed to CMS at: Baus, Kristie A. (CMS/CCSQ) [email protected], Hayden, Megan R. (CMS/OFM) [email protected] and/or Nakano, Karen T. (CMS/CCSQ) [email protected]. Yes, documentation that the patient was in labor should be taken at face value in order to answer "yes" to labor. The addition of regular contractions with or without cervical change as an additional way to answer "yes" to labor takes effect with 10/1/15 discharges. A general webinar regarding the perinatal certification program was held on April 28, The recording of the webinar is available on The Joint Commission's Certification Website. You can also contact the Business Development Department at TJC by calling who can provide to you additional information regarding the program.

11 Updates for Fall 2015 and Answer Session We had 3 cases this past year with justifiable early elective delivery but did not fall into 11.07, including one case with a recommendation by a Perinatologist. We realize these are fairly rare but it is still frustrating that we "failed" when in fact we were providing the best care for Mother and baby. The cases did have codes on table Why not use for Early elective delivery? We have an older maternal population at our facility. Many of our OBs are uncomfortable waiting until 39 weeks on mothers with advanced maternal age due to risk of stillbirth. Is there any discussion of adding maternal age as an exclusion in the future? What have other facilities used to encourage a higher level of review for a "hard stop" policy? What is the hierarchy pertaining to gestational age? Will TJC be aligning with CMS and start accepting the electronic versions of PC-01 and PC-05? The purpose of Table is to identify cases for the initial patient population; therefore, not all complications of pregnancy require an early term elective delivery. The codes on Table are based on initial testing of the measure and recommendations from the PC Technical Advisory Panel. No. The codes on Table are based on initial testing of the measure and recommendations from the PC Technical Advisory Panel. We suggest you review the toolkit in order to reduce elective deliveries prior to 39 weeks. It is available at: or for additional information. The priority order is: Delivery room record, Operating room record, History and physical, Prenatal forms, Admission clinician progress notes and Discharge summary. The Joint Commission has already begun accepting ecqms for both PC-01 and PC-05 for These selections are available on your extranet site.

12 Updates for Fall 2015 and Answer Session When clarifying gestational age - do we go by Gestational age documented at the time of delivery should be used. the gestational age assessment after delivery or by prenatal record dates? Would you please expand on the BSI. Will Beginning with manual V2015B effective with 10/1/15 discharges, the new data element there be questions the abstractors will have to Bloodstream Infection Confirmed will be used to confirm the source of infection at the time of answer? BSI confirmed, in the future? discharge.