Healthy Term Newborn

Last updated: May 4, 2017

CMS Measure ID: CMS185v4
Version: 4
NQF Number: 0716
Measure Description:

Percent of term singleton live births (excluding those with diagnoses originating in the fetal period) who DO NOT have significant complications during birth or the nursery care.

Initial Patient Population:

All patients who are single liveborn term newborns born in a hosptital.

Measure Population:

Not applicable

Measure Observations:

Not applicable

Denominator Statement:

The denominator is composed of singleton, term (>=37 weeks), inborn, livebirths in their birth admission. The denominator further has eliminated fetal conditions likely to be present before labor. Maternal and obstetrical conditions (eg hypertension, prior cesarean, malpresentation) are not excluded unless evidence of fetal effect prior to labor (eg IUGR/SGA).

Denominator Exclusions:

Denominator exclusions: multiple gestations, preterm, congenital anomalies or fetuses affected by selected maternal conditions.

Numerator Statement:

The absence of conditions or procedures reflecting morbidity that happened during birth and nursery care to an otherwise normal infant.

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: Centers for Medicare & Medicaid Services
Domain: Patient Safety
Next Version: Healthy Term Newborn
Previous Version: Healthy Term Newborn
Measure Score: Proportion
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

CMS suggests eligible hospitals participating in the Medicare & Medicaid EHR Incentive Programs not select CMS185/NQF0716: Healthy Term Newborn as one of their additional electronic clinical quality measures (eCQMs) for meaningful use. The measure steward is making substantial changes to this measure and is working with NQF on endorsement of the revised measure. CMS will review the changes to this measure and assess its feasibility for future implementation.

The very first step for this measure, identifying all term singleton infants can be surprisingly challenging. Some hospitals do not do a good job of using the proper v-codes or DRGs so that clinical information such as birthweight and gestational age need to be used in the first step.

The logic phrase AND: Occurrence A of Encounter, Performed: Inpatient Encounter (reason: 'Birth') intends to capture admission type of newborn for the encounter. Where this information is available in existing EHR structured fields (eg data that is fed to UB-04, field location 14), it can be used to map the criterion specified in the logic.

The logic phrase AND: Diagnosis, Active: Liveborn Born In Hospital starts during Occurrence A of Encounter, Performed: Inpatient Encounter intends to capture the point of origin for the inpatient admission. Where this information is available in existing EHR structured fields (eg data that is fed to UB-04, field location 15), it can be used to map the criterion specified in the logic.

Specifications

Release Notes

Header

  • eMeasure version number incremented.
  • Copyright updated.
  • Disclaimer updated.
  • CMS suggests eligible hospitals participating in the Medicare & Medicaid EHR Incentive Programs not select CMS185/NQF0716: Healthy Term Newborn as one of their additional electronic clinical quality measures (eCQMs) for meaningful use. The measure steward is making substantial changes to this measure and is working with NQF on endorsement of the revised measure. CMS will review the changes to this measure and assess its feasibility for future implementation.

Logic

  • Changed data type of 'Result' or 'Finding' to 'Performed'.
  • Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions or 'satisfies any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
  • Introduced occurrencing on variables to enforce that the same instance of a clinical event is used throughout the measure when the logic within the variable does not limit the event to a single instance, e.g., FIRST or MOST RECENT.
  • Introduced the 'Intersection of' operator to specify the selection of the data sets common to all individual statements underneath the 'Intersection of'.
  • Introduced variable $EncounterInpatient to allow re-use of logical expressions and reduce redundancy/complexity.
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.

Value Sets

  • Value Set Birth Trauma or Injuries Group (OID 2.16.840.1.113883.3.666.5.1567): Deleted 1 SNOMED code (302934007) and added 2 SNOMED codes (410730009, 699699005).
  • Value Set Congenital Anomalies Group (OID 2.16.840.1.113883.3.666.5.1570): Deleted 16 SNOMED codes and added 4 SNOMED codes.
  • Value set Congenital or Infantile Cerebral Palsy Group (OID 2.16.840.1.113883.3.666.5.1580): Deleted 8 SNOMED codes (1178005, 192957004, 206187005, 230772000, 275466008, 275467004, 275469001, 371119007) and added 4 SNOMED codes (230773005, 278512001, 48721008, 58193001).
  • Value set Discharge to Acute Care Facility (OID 2.16.840.1.113883.3.117.1.7.1.87): Deleted 1 SNOMED code (306699001) and added 2 SNOMED codes (306703003, 434781000124105). Updated value set name from Discharge to Another Hospital to Discharge to Acute Care Facility.
  • Value set Hyperbilirubinemia Group (OID 2.16.840.1.113883.3.666.5.1593): Deleted 1 ICD10CM code (P55.1), 1 ICD9CM code (773.1), and 2 SNOMED codes (111469006, 32858009). Added 1 ICD10CM code (P59.9), ICD9CM codes (774.30, 774.6), and 7 SNOMED codes (17140000,276549000, 281610001, 281611002,281612009, 387712008, 69347004).
  • Value set Hypoxia or Asphyxia Group (OID 2.16.840.1.113883.3.666.5.1577): Deleted 1 SNOMED code (206187005).
  • Value set Infection Group (OID 2.16.840.1.113883.3.666.5.1590): Deleted 3 SNOMED codes (105592009, 211420008, 41229001) and added 2 SNOMED codes (403000003, 91302008).
  • Value set Laryngeal Stenosis Group (OID 2.16.840.1.113883.3.666.5.1576): Added 1 ICD10CM code (J38.6).
  • Value set Shock and Complications Group (OID 2.16.840.1.113883.3.666.5.1581): Deleted 3 SNOMED codes (105592009, 211420008, 41229001) and added 2 SNOMED codes (403000003, 91302008).
  • Value set Social Reasons Group (OID 2.16.840.1.113883.3.666.5.1595): Deleted 1 ICD10CM code (Z75.5), 1 ICD9CM code (V60.5), and 7 SNOMED codes (105387008, 105389006, 183431002, 306206005, 306238000, 306240005, 309630000).
  • Value sets were updated to remove category codes.
  • Value sets were updated to remove non-human disorders.

External Resources