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CMS Measure ID: CMS9v9    Performance/Reporting Period: 2021    Version: 9    NQF Number: 0480e
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.

Data Elements contained within the eCQM + Expand all

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent codes for newborn's birth weight.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Assessment category. The intent of this data element is to identify newborn's birth weight.
Inclusion Criteria: Includes only relevant concepts associated with LOINC codes that identify newborn's birth weight.
Exclusion Criteria: No exclusions.

Constrained to codes in the Assessment, Performed: Birth Weight value set (2.16.840.1.113762.1.4.1029.194)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Assessment, Performed

Data elements that meet criteria using this datatype should document completion of the assessment indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references timing for an assessment that occurs at a single point in time.
  • relevant Period references a start and stop time for an assessment that occurs over a time interval
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.

Direct Reference Code

Constrained to 'Gestational age--at birth' LOINC code

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Assessment, Performed

Data elements that meet criteria using this datatype should document completion of the assessment indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references timing for an assessment that occurs at a single point in time.
  • relevant Period references a start and stop time for an assessment that occurs over a time interval
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent diagnoses that represent galactosemia.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnosis. The intent of this data element is to identify galactosemia.
Inclusion Criteria: Includes only relevant concepts associated with ICD-10-CM and SNOMED CT codes that identify galactosemia.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnoses: Galactosemia value set (2.16.840.1.113883.3.117.1.7.1.35)

QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

Diagnoses

Coded diagnoses/problems addressed during the encounter. The diagnoses attribute has three components:

  • diagnosis (code)
  • presentOnAdmissionIndicator (code)
  • rank (positive integer)

To reference an encounter diagnosis, the expression must include the diagnosis code component. The other components are optional. The expression should only include the presentOnAdmissionIndicator if it is necessary to reference present on admission and should only include the rank if it is necessary to reference principal diagnosis.

The "Encounter, Performed" diagnosis attribute is intended to capture ALL diagnoses, including the principal diagnosis, i.e., all diagnoses addressed during the encounter represented by the diagnosis (code) used in the expression.The presentOnAdmissionIndicator (code) allows the eCQM developer to include criteria about whether each specific "Encounter, Performed" diagnosis was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition for information about using the "Encounter, Performed" diagnosis attribute.

The "Encounter, Performed" diagnosis (rank) replaces the principal diagnosis attribute. To reference a principal diagnosis, eCQM developers should express the "Encounter, Performed" diagnosis with a diagnosis (code) and a rank of 1. See definition of rank attribute.

With an "Encounter, Performed" diagnosis, there is no dependency on the timing of the diagnosis in relation to the encounter.

  • Use of the "Encounter, Performed": diagnoses attribute component and the "Diagnosis" datatype is redundant for relating the diagnosis to the "Encounter, Performed". The "Encounter, Performed": diagnoses component syntax is preferred.
  • Referencing the same diagnosis using "Encounter, Performed" (diagnoses attribute) and "Diagnosis" (datatype) should only occur if the measure must define a specified length of a prevalencePeriod, e.g.,
    • The measure must assure that the diagnoses
      • have been present for at least some defined time period before the encounter, and
      • were addressed during the "Encounter, Performed"
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent types of delivery that represent the single live birth.
Data Element Scope: This value set may use the Quality Data Model (QDM) category or attribute related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with identifying single live born newborn.
Exclusion Criteria: Excludes codes indicating the birth took place outside of the hospital.

Constrained to codes in the Diagnoses: Single Live Born Newborn Born In Hospital value set (2.16.840.1.113883.3.117.1.7.1.26)

QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

Diagnoses

Coded diagnoses/problems addressed during the encounter. The diagnoses attribute has three components:

  • diagnosis (code)
  • presentOnAdmissionIndicator (code)
  • rank (positive integer)

To reference an encounter diagnosis, the expression must include the diagnosis code component. The other components are optional. The expression should only include the presentOnAdmissionIndicator if it is necessary to reference present on admission and should only include the rank if it is necessary to reference principal diagnosis.

The "Encounter, Performed" diagnosis attribute is intended to capture ALL diagnoses, including the principal diagnosis, i.e., all diagnoses addressed during the encounter represented by the diagnosis (code) used in the expression.The presentOnAdmissionIndicator (code) allows the eCQM developer to include criteria about whether each specific "Encounter, Performed" diagnosis was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition for information about using the "Encounter, Performed" diagnosis attribute.

The "Encounter, Performed" diagnosis (rank) replaces the principal diagnosis attribute. To reference a principal diagnosis, eCQM developers should express the "Encounter, Performed" diagnosis with a diagnosis (code) and a rank of 1. See definition of rank attribute.

With an "Encounter, Performed" diagnosis, there is no dependency on the timing of the diagnosis in relation to the encounter.

  • Use of the "Encounter, Performed": diagnoses attribute component and the "Diagnosis" datatype is redundant for relating the diagnosis to the "Encounter, Performed". The "Encounter, Performed": diagnoses component syntax is preferred.
  • Referencing the same diagnosis using "Encounter, Performed" (diagnoses attribute) and "Diagnosis" (datatype) should only occur if the measure must define a specified length of a prevalencePeriod, e.g.,
    • The measure must assure that the diagnoses
      • have been present for at least some defined time period before the encounter, and
      • were addressed during the "Encounter, Performed"
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the discharge of a patient to an acute care facility.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Discharge Disposition. The intent of this data element is to identify the final place or setting to which the patient was discharged on the day of discharge from a particular inpatient encounter. This particular value set intends to identify patients who were discharged to an acute care facility.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing short-term acute care hospitals, including specialty hospitals.
Exclusion Criteria: No exclusions.

Constrained to codes in the Discharge Disposition: Discharge To Acute Care Facility value set (2.16.840.1.113883.3.117.1.7.1.87)

QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

Discharge Disposition

The disposition, or location to which the patient is transferred at the time of hospital discharge.
Value Set Description from VSAC
Clinical Focus: This set of values contains SNOMEDCT codes for for environments of care representing post-acute and psychiatric settings.
Data Element Scope: This value set may use Quality Data Model (QDM) category related to Encounter. The intent of this data element is to identify an admission source or discharge disposition of an other health care facility.
Inclusion Criteria: Includes codes representing extended care facilities, intermediate care facilities, LTACHs, nursing homes, skilled nursing facilities, veterans homes, and psychiatric hospitals.
Exclusion Criteria: Exclude codes representing acute inpatient and outpatient environments of care.

Constrained to codes in the Discharge Disposition: Other Health Care Facility value set (2.16.840.1.113762.1.4.1029.67)

QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

Discharge Disposition

The disposition, or location to which the patient is transferred at the time of hospital discharge.
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a patient who has died in the hospital.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Discharge Disposition. The intent of this data element is to identify the discharge status of patient expired as an attribute of the inpatient encounter.
Inclusion Criteria: Includes only relevant concepts associated with codes for a patient who had died in the hospital. Codes used are to be SNOMED CT codes only.
Exclusion Criteria: No exclusions.

Constrained to codes in the Discharge Disposition: Patient Expired value set (2.16.840.1.113883.3.117.1.7.1.309)

QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

Discharge Disposition

The disposition, or location to which the patient is transferred at the time of hospital discharge.
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the most common inpatient encounter types.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter. The intent of this data element is to identify patients who have had an inpatient encounter.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing inpatient encounter.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Encounter Inpatient value set (2.16.840.1.113883.3.666.5.307)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

  • negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent neonatal intensive care units (NICU).
Data Element Scope: This value set may use Quality Data Model (QDM) datatype related to Encounter, Performed, or attribute related to Location. The intent of this data element is to identify patients in intensive care units.
Inclusion Criteria: Includes only relevant concepts associated with neonatal intensive care units (NICU). This is a grouping of HSLOC and SNOMEDCT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Facility Locations: Neonatal Intensive Care Unit (NICU) value set (2.16.840.1.113762.1.4.1029.205)

QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

Facility Locations

The particular locations in a facility in which the diagnostic study or encounter occurs or occurred. Examples include intensive care units (ICUs), nonICUs, burn critical care unit, neonatal ICU, and respiratory care unit. Each "Encounter, Performed" may have one or more locations. For example, a patient treated in multiple locations during an individual encounter might be expressed as:
  • "Encounter, Performed": Inpatient Admission, facility locations
    • ICU (locationPeriod)
    • Non-ICU Admission (locationPeriod)
    • Rehab (locationPeriod)
Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Patient Characteristic, Ethnicity: Ethnicity value set (2.16.840.1.114222.4.11.837)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Patient Characteristic, Ethnicity

Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set.

Timing: Ethnicity does not have a specific timing. Measures using "Patient Characteristic, Ethnicity" should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
Data Element Scope: @code in CCDA r2.1 template Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] DYNAMIC
Inclusion Criteria: All codes in the code system
Exclusion Criteria: none

Constrained to codes in the Patient Characteristic, Payer: Payer value set (2.16.840.1.114222.4.11.3591)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Patient Characteristic, Payer

Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set.

Timing:

The relevantPeriod addresses:

  • startTime – the first day of insurance coverage with the referenced payer.
  • stopTime – the last day of insurance coverage with the referenced payer.
Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Patient Characteristic, Race: Race value set (2.16.840.1.114222.4.11.836)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Patient Characteristic, Race

Data elements that meet criteria using this datatype should document the patient’s race.

Timing: Race does not have a specific timing. Measures using "Patient Characteristic, Race" should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: Gender
Inclusion Criteria: Male and Female only.
Exclusion Criteria: Any gender identity that is not male or female.

Constrained to codes in the Patient Characteristic, Sex: ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Patient Characteristic, Sex

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.

Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent parenteral infusion procedures.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure. The intent of this data element is to identify parenteral infusion procedures.
Inclusion Criteria: Includes only relevant concepts associated with ICD-10-PCS and SNOMED CT codes that identify parenteral infusion.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: Parenteral Nutrition value set (2.16.840.1.113883.3.117.1.7.1.38)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Procedure, Performed

Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.

Two QDM Known Issues has been identified related to this datatype.

  • To see the QDM Known Issue related to QDM Procedure, Performed completion time, please click here.
  • To see the QDM Known Issue related to Differentiating Elective Vs Emergent or Urgent Procedures, please click here.

Timing:

  • relevant dateTime references the time the procedure is performed when the procedure occurs at a single point in time.
  • relevantPeriod references a start and stop time for a procedure that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the procedure begins.
    • stopTime - The time the procedure ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes:

  • Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  • The incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
  • negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
  • For clarification, see Appendix 6.6 with 2020 guidance about differentiating between successful and unsuccessful procedures.
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent breast milk.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Substance. The intent of this data element is to identify breast milk.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes that identify breast milk.
Exclusion Criteria: No exclusions.

Constrained to codes in the Substance, Administered: Breast Milk value set (2.16.840.1.113883.3.117.1.7.1.30)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Substance, Administered

Data elements that meet criteria using this datatype should document that the substance indicated by the QDM category and its corresponding value set was actually given to the patient.

Timing:

  • relevant dateTime references the time the substance is administered if it was given or taken at a single point in time.
  • relevantPeriod references a start and stop time for substance administration if the administration event occurred over a time interval.
  • The relevantPeriod addresses:
    • startTime - when a single substance administration event starts (e.g., the initiation of an intravenous infusion).
    • stopTime - when a single substance administration event ends (e.g., the end time of the intravenous infusion).
  • author dateTime references the time the substance administration was recorded and applies only when the record has no reference to the time the substance administration occurred and only the recorded time is available.

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent dietary intake other than breast milk.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Substance. The intent of this data element is to identify dietary intake other than breast milk.
Inclusion Criteria: Includes only relevant SNOMED CT concepts associated that identify dietary intake other than breast milk.
Exclusion Criteria: Excludes codes that represent breast milk or Sweet-ease and Glocuse 40% gel.

Constrained to codes in the Substance, Administered: Dietary Intake Other than Breast Milk value set (2.16.840.1.113883.3.117.1.7.1.27)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Substance, Administered

Data elements that meet criteria using this datatype should document that the substance indicated by the QDM category and its corresponding value set was actually given to the patient.

Timing:

  • relevant dateTime references the time the substance is administered if it was given or taken at a single point in time.
  • relevantPeriod references a start and stop time for substance administration if the administration event occurred over a time interval.
  • The relevantPeriod addresses:
    • startTime - when a single substance administration event starts (e.g., the initiation of an intravenous infusion).
    • stopTime - when a single substance administration event ends (e.g., the end time of the intravenous infusion).
  • author dateTime references the time the substance administration was recorded and applies only when the record has no reference to the time the substance administration occurred and only the recorded time is available.