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Exclusive Breast Milk Feeding

eCQMs for 2021 Reporting Period

Specifications
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General eCQM Information

CMS Measure ID CMS9v9
Short Name PC-05
NQF Number 0480e
Measure Description

PC-05 Exclusive breast milk feeding during the newborn's entire hospitalization.

The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization.

Initial Population Inpatient hospitalizations for single newborns who were born in the hospital that ends during the measurement period, and with either of the following conditions: - An estimated gestational age at birth of >= 37 weeks - Birth weight >= 3000 grams without an estimated gestational age at birth
Denominator Statement

Initial Population

Denominator Exclusions

Inpatient hospitalizations for newborns who were with any of the following conditions:

• admitted to the Neonatal Intensive Care Unit (NICU)

• transferred to an acute care facility, or other health care facility

• expired during the hospitalization

• a length of stay greater than 120 days that ends during the measurement period

• a diagnosis of galactosemia

• subject to parenteral nutrition

Numerator Statement

Inpatient hospitalizations for newborns who were fed breast milk only since birth

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Measure Steward The Joint Commission
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

Improvement noted as an increase in the rate

Guidance

A discharge to a designated cancer center or children's hospital should be captured as a discharge to an acute care facility.

It is acceptable to calculate Gestational Age using the American College of Obstetricians and Gynecologists ReVITALize guidelines, which define Gestational Age as calculated using the best obstetrical Estimated Due Date (EDD) based on the formula:

Gestational Age= (280-(EDD-Reference Date))/7

where Reference Date is the date on which you are trying to determine gestational age. For PC-05, Reference Date is the Birth Date.

Note however that the calculation may yield a non-whole number and gestational age should be rounded off to the nearest completed week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.

Data shows that the majority of newborns with gestational age 37 weeks or more have a birth weight 3000 grams or more. Birth weight 3000 grams or more is a proxy to capture term newborns without gestational age recorded in EHR system.

This eCQM is an episode-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

Meaningful Measure Care is Personalized and Aligned with Patient's Goals
Previous Version
Release Notes

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated link to reference.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Revised the Guidance to reflect the rationale for adding birth weight to capture term newborns.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Revised the initial population and denominator exclusions to align with eCQM PC-06, Unexpected Complications in Term Newborns.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Revised the initial population and denominator exclusions to align with eCQM PC-06, Unexpected Complications in Term Newborns.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Logic

  • Moved the criteria of length of stay (LOS), diagnosis of galactosemia and subject to parenteral nutrition from initial population to denominator exclusions.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Added birth weight criteria to the initial population as an alternative to estimated gestational age at birth.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Moved the criteria of length of stay (LOS), diagnosis of galactosemia and subject to parenteral nutrition from initial population to denominator exclusions.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Added birth weight criteria to the initial population as an alternative to estimated gestational age at birth.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Moved the criteria of length of stay (LOS), diagnosis of galactosemia and subject to parenteral nutrition from initial population to denominator exclusions.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Added birth weight criteria to the initial population as an alternative to estimated gestational age at birth.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Moved the criteria of length of stay (LOS), diagnosis of galactosemia and subject to parenteral nutrition from initial population to denominator exclusion.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added birth weight criteria to the initial population as an alternative to estimated gestational age at birth.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replaced 'weeks' with the UCUM code ‘wk’ to be consistent with HL7 standards.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • QDM v5.5 standards update: Modified 'Encounter, Performed' diagnosis attribute to reference diagnosis codes in value sets specified in the logic.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Parenteral Nutrition (2.16.840.1.113883.3.117.1.7.1.38): Deleted 1 SNOMED CT code (304055007) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Birth Weight (2.16.840.1.113762.1.4.1029.194): Added Birth Weight based on change in measure requirements, using birth weight to capture term newborns whose the estimated gestational age at birth information is missing.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: Jun 24, 2020