eCQM Title

Hearing Screening Prior To Hospital Discharge

eCQM Identifier (Measure Authoring Tool) 31 eCQM Version number 7.5.000
NQF Number 1354 GUID 0924fbae-3fdb-4d0a-aab7-9f354e699fde
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward CDC National Center on Birth Defects and Developmental Disabilities
Measure Developer CDC Early Hearing Detection and Intervention Program
Endorsed By National Quality Forum
This measure assesses the proportion of births that have been screened for hearing loss before hospital discharge
Measure specifications are in the Public Domain.

This material contains SNOMED Clinical Terms (R) (SNOMED CT(C)) copyright 2004-2017 International Health Terminology Standards Development Organization. All rights reserved.

LOINC (R) is a registered trademark of the Regenstrief Institute.
These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty. CMS has contracted with Mathematica Policy Research and its subcontractors, Lantana and Telligen, for the continued maintenance of this electronic measure.
Measure Scoring Proportion
Measure Type Process
Risk Adjustment
Rate Aggregation
Birthing facility staff should review the effectiveness and timeliness of screening relative to nursery discharge. Benchmarks set within the EHCP may trigger hospital or jurisdictional compliance activities, such as re-writing of procedural guidelines or re-training of screening staff.
Clinical Recommendation Statement
Improvement Notation
Improvement noted as an increase in rate
HRSA Title V Block Grant MCHB Performance Measure: Percentage of newborns who have been screened for hearing before hospital discharge.
U.S. Preventive Services Task Force ( Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. Joint Committee on Infant Hearing. Pediatrics 2007;120;898-921 (
Complete hearing screening is defined as having both ears screened during the inpatient encounter.

The Medical Reasons value set (OID 2.16.840.1.114222.4.1.214079.1.1.7) includes SNOMED codes to capture medical contraindications, surgical contraindications, and not indicated because there is a reason to withhold a certain medical procedure/treatment because it could harm a patient. A comprehensive list of codes for these conditions is not available because the judgement is often subjective. This value set is not intended to be used for other reasons a screening was not performed, such as parent refusal, technical failure, or a missed procedure.
Transmission Format
Initial Population
Live birth encounters at a hospital or birthing facility where the newborn was discharged with hospital stays <= 120 days that ends during the measurement period
Denominator is equal to the Initial Population
Denominator Exclusions
A live birth encounter where the newborn expires prior to discharge and has not received a complete hearing screening
A live birth encounter where a complete newborn hearing screening is performed prior to discharge or the newborn is not screened due to medical reasons
Numerator Exclusions
Not applicable
Denominator Exceptions
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Table of Contents

Population Criteria




Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables

Measure Set
Early Hearing Detection and Intervention (EHDI)