2024 Reporting PeriodCMS1028v2PC-07

]]>Not ApplicablePatients with severe obstetric complications which occur during the inpatient delivery hospitalization

]]>For this measure, specifications are modeled after the nationally available and adopted CDC definition for Severe Maternal Morbidity (SMM) with the addition of maternal mortality. At times, we may refer to the CDC indicators of morbidity as SMM, but the outcome of the measure, which includes morbidity and mortality, is referred to as Severe Obstetric Complications (SOC).

]]>Inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure with a discharge date that ends during the measurement period

]]>Inpatient hospitalizations for patients with severe obstetric complications (not present on admission that occur during the current delivery encounter) including the following:

- Severe maternal morbidity diagnoses (see list below)

- Severe maternal morbidity procedures (see list below)

- Discharge disposition of expired

Please note that present on admission codes may be those entered by coding staff, extracted from billing/claims data.

Severe Maternal Morbidity Diagnoses:

- Cardiac

Acute heart failure

Acute myocardial infarction

Aortic aneurysm

Cardiac arrest/ventricular fibrillation

Heart failure/arrest during procedure or surgery

- Hemorrhage

Disseminated intravascular coagulation

Shock

- Renal

Acute renal failure

- Respiratory

Adult respiratory distress syndrome

Pulmonary edema

- Sepsis

- Other OB

Air and thrombotic embolism

Amniotic fluid embolism

Eclampsia

Severe anesthesia complications

- Other Medical

Puerperal cerebrovascular disorder

Sickle cell disease with crisis

Severe Maternal Morbidity Procedures:

- Blood transfusion

- Conversion of cardiac rhythm

- Hysterectomy

- Temporary tracheostomy

- Ventilation

]]>Not applicable

]]>Inpatient hospitalizations for patients delivering stillborn or live birth with >= 20 weeks, 0 days gestation completed

]]>Inpatient hospitalizations for patients with confirmed diagnosis of COVID with COVID-related respiratory condition or patients with confirmed diagnosis of COVID with COVID-related respiratory procedure

]]>None

]]>The Joint Commission]]>Proportion]]>Outcome]]>Improvement noted as a decrease in the rate

]]>The United States (US) experiences higher rates of maternal morbidity and mortality than most other developed countries. These rates have continued to trend upward in recent decades (CDC, n.d.). Research indicates that the overall rate of severe maternal morbidity (SMM) increased by almost 200% between 1993 and 2014 to 144 per 10,000 delivery hospitalizations (CDC, n.d.), with more than 25,000 women per year experiencing obstetric complications (U.S. Department of Health and Human Services, 2020). Recent maternal mortality data from 2018 reveal that 658 women in the US died from maternal causes, resulting in a rate of 17.4 deaths per 100,000 live births, with 77% of the deaths attributed to direct obstetric causes like hemorrhage, preeclampsia, obstetric embolism, and other complications (Hoyert & Minino, 2018). 144 per 10,000 women hospitalized for delivery have experienced SMM, including hemorrhage, embolism, hypertension, stroke, and other serious complications (CDC,2020). Racial and ethnic disparities for Black women and Hispanic women are at a significantly higher risk for developing these complications than are Non-Hispanic White women (Leonard et al., 2019). Increasing rates of SMM are resulting in increased healthcare costs, longer hospitalization stays and impacts on a woman's health.

There is limited national evaluation of hospitals' performance on maternal morbidity and mortality although SMM is widely used at the population level. SMM is linked to maternal mortality, varies significantly among hospitals, and has significant racial/ethnic and urban/rural disparities. SMM is a cost driver for both Medicaid and commercial plans. This measure is important as it will assist in the discovery and understanding of SMM patterns which can lead to improvements in the safety and quality of maternal care necessary to reduce SMM rates.

]]>Stratum1: Delivery hospitalizations with severe obstetric complications excluding hospitalizations where transfusion was the only severe obstetric complication.

Additionally, this measure will be stratified by race and ethnicity after measure submission.

]]>The Severe Obstetric Complications Risk Adjustment Methodology Report is available on the eCQI Resource Center (https://ecqi.healthit.gov).

Pre-existing conditions and variables must be present on admission. Please note that present on admission codes may be those entered by coding staff, extracted from billing/claims data.

- Anemia

- Asthma

- Autoimmune Disease

- Bariatric Surgery

- Bleeding disorder

- Cardiac Disease

- Gastrointestinal Disease

- Gestational Diabetes

- HIV

- Housing Instability

- Hypertension

- Maternal Age (derived from birthdate)

- Mental Health Disorder

- Morbid Obesity

- Multiple Pregnancy

- Neuromuscular Disease

- Other Pre-eclampsia

- Placenta Previa

- Placental Abruption

- Placental Accreta Spectrum

- Pre-existing Diabetes

- Preterm Birth

- Previous Cesarean

- Pulmonary Hypertension

- Renal Disease

- Severe Pre-eclampsia

- Substance Abuse

- Thyrotoxicosis

- Long-term Anticoagulant Use

- Obstetric VTE

Lab and Physical Exam Results:

Report the first resulted value 24 hours prior to start of encounter and before time of delivery in UCUM units specified:

- Heart rate: {beats}/min

- Systolic blood pressure: mm[Hg]

- White blood cell count: 10*3/uL

- Hematocrit: %

Note regarding submission of risk variable data: The risk variable definitions are included in the specifications and risk variable data should be sent with eCQM data in the QRDA1 file. Specific risk variable templates are not needed in the QRDA1 files.

]]>Healthy People 2030 Measure (MICH-05): Reduce severe maternal complications identified during delivery hospitalizations

The American College of Obstetricians and Gynecologists (the College) and the Society for Maternal-Fetal Medicine (SMFM) recommend identifying potential cases of severe maternal morbidity for further review, with a focus on outcomes and complications, and consider this an important step toward promoting safe obstetric care.

]]>

This is a risk adjusted measure: 

There are known issues for CMS1028v2. See issues EKI-23, EKI-43, and EKI-44 on the ONC eCQM Known Issues Dashboard for details.

]]>2025 Reporting PeriodCMS1028v3PC-07

]]>Not ApplicablePatients with severe obstetric complications that occur during the inpatient delivery hospitalization

]]>For this measure, specifications are modeled after the nationally available and adopted CDC definition for Severe Maternal Morbidity (SMM) with the addition of maternal mortality. At times, we may refer to the CDC indicators of morbidity as SMM, but the outcome of the measure, which includes morbidity and mortality, is referred to as Severe Obstetric Complications (SOC).

]]>Inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure with a discharge date that ends during the measurement period

]]>Two numerator populations are defined for this measure:

1. All Severe Obstetric Complications (SOC).

2. SOC excluding encounters where transfusion was the only SOC.

Inpatient hospitalizations for patients with severe obstetric complications (not present on admission that occur during the current delivery encounter) including the following:

- Severe maternal morbidity diagnoses (see list below)

- Severe maternal morbidity procedures (see list below)

- Discharge disposition of expired

Please note that present on admission codes may be extracted from billing/claims data that was entered by coding staff.

Severe Maternal Morbidity Diagnoses:

- Cardiac

Acute heart failure

Acute myocardial infarction

Aortic aneurysm

Cardiac arrest/ventricular fibrillation

Heart failure/arrest during procedure or surgery

- Hemorrhage

Disseminated intravascular coagulation

Shock

- Renal

Acute renal failure

- Respiratory

Adult respiratory distress syndrome

Pulmonary edema

- Sepsis

- Other OB

Air and thrombotic embolism

Amniotic fluid embolism

Eclampsia

Severe anesthesia complications

- Other Medical

Puerperal cerebrovascular disorder

Sickle cell disease with crisis

Severe Maternal Morbidity Procedures:

- Blood transfusion

- Conversion of cardiac rhythm

- Hysterectomy

- Temporary tracheostomy

- Ventilation

]]>Inpatient hospitalizations with blood transfusion or hysterectomy with a diagnosis of placenta percreta or placenta increta and no additional severe obstetrical complications.

]]>Inpatient hospitalizations for patients delivering stillborn or live birth with >= 20 weeks, 0 days gestation completed

]]>Inpatient hospitalizations for patients with confirmed diagnosis of COVID with COVID-related respiratory condition or patients with confirmed diagnosis of COVID with COVID-related respiratory procedure during the encounter

]]>None

]]>The Joint Commission]]>Proportion]]>Outcome]]>Improvement noted as a decrease in the rate

]]>The United States (US) experiences higher rates of maternal morbidity and mortality than most other developed countries. These rates have continued to trend upward in recent decades (CDC, 2021). Research indicates that the overall rate of severe maternal morbidity (SMM) increased by almost 200% between 1993 and 2014 to 144 per 10,000 delivery hospitalizations (CDC, 2021), with more than 25,000 women per year experiencing obstetric complications (U.S. Department of Health and Human Services, 2020). Recent maternal mortality data from 2018 reveal that 658 women in the US died from maternal causes, resulting in a rate of 17.4 deaths per 100,000 live births, with 77% of the deaths attributed to direct obstetric causes like hemorrhage, preeclampsia, obstetric embolism, and other complications (Hoyert & Minino, 2018). 144 per 10,000 women hospitalized for delivery have experienced SMM, including hemorrhage, embolism, hypertension, stroke, and other serious complications (CDC, 2021). Racial and ethnic disparities exist: Black women and Hispanic women are at a significantly higher risk for developing these complications than are Non-Hispanic White women (Leonard, Main, Scott, Profit, & Carmichael, 2019). Increasing rates of SMM are resulting in increased healthcare costs, longer hospitalization stays and impacts on a woman's health (Callaghan, Creanga, & Kuklina, 2012).

There is limited national evaluation of hospitals' performance on maternal morbidity and mortality although SMM is widely used at the population level. SMM is linked to maternal mortality, varies significantly among hospitals, and has significant racial/ethnic and urban/rural disparities. SMM is a cost driver for both Medicaid and commercial plans. This measure is important as it will assist in the discovery and understanding of SMM patterns that can lead to improvements in the safety and quality of maternal care necessary to reduce SMM rates.

]]>This measure will be stratified by race/ethnicity and payer after measure submission

]]>The Severe Obstetric Complications Risk Adjustment Methodology Report is available on the eCQI Resource Center (https://ecqi.healthit.gov).

Pre-existing conditions and variables must be present on admission. Please note that present on admission codes may be extracted from billing/claims data that was entered by coding staff (Leonard, Kennedy, Carmichael, Lyell, & Main, 2020; Main, Leonard, & Menard, 2020).

- Anemia (includes sickle cell disease)

- Asthma

- Autoimmune Disease

- Bariatric Surgery

- Bleeding Disorder

- Cardiac Disease

- Economic Housing Instability

- Gastrointestinal Disease

- Gestational Diabetes

- HIV

- Hypertension

- Long-term Anticoagulant Use

- Maternal Age (derived from birthdate)

- Mental Health Disorder

- Morbid Obesity

- Multiple Pregnancy

- Neuromuscular Disease

- Obstetric VTE

- Other Pre-eclampsia

- Placenta Previa

- Placental Abruption

- Placental Accreta Spectrum

- Pre-existing Diabetes

- Preterm Birth

- Previous Cesarean

- Pulmonary Hypertension

- Renal Disease

- Severe Pre-eclampsia

- Substance Abuse

- Thyrotoxicosis

Lab and Physical Exam Results:

Report the first resulted value 24 hours prior to start of encounter and before time of delivery in UCUM units specified:

- Heart rate: {beats}/min

- Systolic blood pressure: mm[Hg]

- Hematocrit: %

- White blood cell count: 10*3/uL

Note regarding submission of risk variable data: The risk variable definitions are included in the specifications and risk variable data should be sent with eCQM data in the QRDA1 file. Specific risk variable templates are not needed in the QRDA1 files.

]]>Healthy People 2030 Measure (MICH-05): Reduce severe maternal complications identified during delivery hospitalizations (U.S. Department of Health and Human Services, n.d.).

The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine recommend identifying potential cases of severe maternal morbidity for further review, with a focus on outcomes and complications, and consider this an important step toward promoting safe obstetric care (American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine, Kilpatrick, & Ecker, 2016).

]]>

This is a risk adjusted measure:

There are known issues for CMS1028v3. See issue EKI-43 and EKI-44 on the ONC eCQM Known Issues Dashboard for details.

]]>2026 Reporting PeriodCMS1028v4PC-07

]]>Not ApplicablePatients with severe obstetric complications that occur during the inpatient delivery hospitalization

]]>For this measure, specifications are modeled after the nationally available and adopted CDC definition for Severe Maternal Morbidity (SMM) with the addition of maternal mortality. At times, we may refer to the CDC indicators of morbidity as SMM, but the outcome of the measure, which includes morbidity and mortality, is referred to as Severe Obstetric Complications (SOC).

]]>Population Criteria 1, Initial Population: Inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure with a discharge date that ends during the measurement period Population Criteria 2, Initial Population: Same initial population as Population Criteria 1.

]]>Population Criteria 1, Numerator: All Severe Obstetric Complications (SOC).

Inpatient hospitalizations for patients with severe obstetric complications (not present on admission that occur during the current delivery encounter) including the following:

- Severe maternal morbidity diagnoses (see list below)

- Severe maternal morbidity procedures (see list below)

- Discharge disposition of expired

Please note that present on admission codes may be extracted from billing/claims data that was entered by coding staff.

Severe Maternal Morbidity Diagnoses:

- Cardiac

Acute heart failure

Acute myocardial infarction

Aortic aneurysm

Cardiac arrest/ventricular fibrillation

Heart failure/arrest during procedure or surgery

- Hemorrhage

Disseminated intravascular coagulation

Shock

- Renal

Acute renal failure

- Respiratory

Adult respiratory distress syndrome

Pulmonary edema

- Sepsis

- Other OB

Air and thrombotic embolism

Amniotic fluid embolism

Eclampsia

Severe anesthesia complications

- Other Medical

Puerperal cerebrovascular disorder

Sickle cell disease with crisis

Severe Maternal Morbidity Procedures:

- Blood transfusion

- Conversion of cardiac rhythm

- Hysterectomy

- Temporary tracheostomy

- Ventilation

Population Criteria 2, Numerator: Delivery encounters with SOC excluding encounters where transfusion was the only SOC.

Inpatient hospitalizations for patients with severe obstetric complications (not present on admission that occur during the current delivery encounter) including the following:

- Severe maternal morbidity diagnoses (see list below)

- Severe maternal morbidity procedures (see list below)

- Discharge disposition of expired

Please note that present on admission codes may be extracted from billing/claims data that was entered by coding staff.

Severe Maternal Morbidity Diagnoses:

- Cardiac

Acute heart failure

Acute myocardial infarction

Aortic aneurysm

Cardiac arrest/ventricular fibrillation

Heart failure/arrest during procedure or surgery

- Hemorrhage

Disseminated intravascular coagulation

Shock

- Renal

Acute renal failure

- Respiratory

Adult respiratory distress syndrome

Pulmonary edema

- Sepsis

- Other OB

Air and thrombotic embolism

Amniotic fluid embolism

Eclampsia

Severe anesthesia complications

- Other Medical

Puerperal cerebrovascular disorder

Sickle cell disease with crisis

Severe Maternal Morbidity Procedures:

- Blood transfusion

- Conversion of cardiac rhythm

- Hysterectomy

- Temporary tracheostomy

- Ventilation

]]>Population Criteria 1, Numerator Exclusion: Inpatient hospitalizations with blood transfusion or hysterectomy with a diagnosis of placenta percreta or placenta increta and no additional severe obstetrical complications

Population Criteria 2, Numerator Exclusion: Inpatient hospitalizations with SOC excluding encounters where transfusion was the only SOC, with a hysterectomy or blood transfusion with a diagnosis of placenta percreta or placenta increta and no additional severe obstetrical complications

]]>Population Criteria 1, Denominator: Inpatient hospitalizations for patients delivering stillborn or live birth with >= 20 weeks, 0 days gestation completed

Population Criteria 2, Denominator: Same denominator population as Population Criteria 1.

]]>None

]]>None

]]>The Joint Commission]]>Proportion]]>Outcome]]>Decreased score indicates improvement

]]>The United States (US) experiences higher rates of maternal morbidity and mortality than most other developed countries. The Centers for Disease Control and Prevention (CDC) (2021) report that these rates have continued to trend upward in recent decades. Research indicates that the overall rate of severe maternal morbidity (SMM) increased by almost 200% between 1993 and 2014 to 144 per 10,000 delivery hospitalizations (CDC, 2021), with more than 25,000 women per year experiencing obstetric complications (U.S. Department of Health and Human Services, 2020). Recent maternal mortality data from 2018 reveal that 658 women in the US died from maternal causes, resulting in a rate of 17.4 deaths per 100,000 live births, with 77% of the deaths attributed to direct obstetric causes like hemorrhage, preeclampsia, obstetric embolism, and other complications (Hoyert & Minino, 2020). 144 per 10,000 women hospitalized for delivery have experienced SMM, including hemorrhage, embolism, hypertension, stroke, and other serious complications (CDC, 2021). Racial and ethnic disparities exist: Black women and Hispanic women are at a significantly higher risk for developing these complications than are Non-Hispanic White women (Leonard, Main, Scott, Profit, & Carmichael, 2019). Increasing rates of SMM are resulting in increased healthcare costs, longer hospitalization stays and impacts on a woman's health (Callaghan, Creanga, & Kuklina, 2012).

There is limited national evaluation of hospitals' performance on maternal morbidity and mortality although SMM is widely used at the population level. SMM is linked to maternal mortality, varies significantly among hospitals, and has significant racial/ethnic and urban/rural disparities. SMM is a cost driver for both Medicaid and commercial plans. This measure is important as it will assist in the discovery and understanding of SMM patterns that can lead to improvements in the safety and quality of maternal care necessary to reduce SMM rates.

]]>None

]]>The Severe Obstetric Complications Risk Adjustment Methodology Report is available on this eCQI Resource Center.

Pre-existing conditions and variables must be present on admission. Please note that present on admission codes may be extracted from billing/claims data that was entered by coding staff (Leonard, Kennedy, Carmichael, Lyell, & Main, 2020; Main, Leonard, & Menard, 2020).

- Anemia (includes sickle cell disease)

- Asthma

- Autoimmune Disease

- Bariatric Surgery

- Bleeding Disorder

- Cardiac Disease

- Economic Housing Instability

- Gastrointestinal Disease

- Gestational Diabetes

- HIV

- Hypertension

- Long-term Anticoagulant Use

- Maternal Age (derived from birthdate)

- Mental Health Disorder

- Morbid Obesity

- Multiple Pregnancy

- Neuromuscular Disease

- Obstetric VTE

- Other Pre-eclampsia

- Placenta Previa

- Placental Abruption

- Placental Accreta Spectrum

- Pre-existing Diabetes

- Preterm Birth

- Previous Cesarean

- Pulmonary Hypertension

- Renal Disease

- Severe Pre-eclampsia

- Substance Abuse

- Thyrotoxicosis

Lab and Physical Exam Results:

Report the first resulted value 24 hours prior to start of encounter and before time of delivery in UCUM units specified:

- Heart rate: {beats}/min

- Systolic blood pressure: mm[Hg]

- Hematocrit: %

- White blood cell count: 10*3/uL

Note regarding submission of risk variable data: The risk variable definitions are included in the specifications and risk variable data should be sent with eCQM data in the QRDA I file. Specific risk variable templates are not needed in the QRDA I files.

]]>Healthy People 2030 Measure (MICH-05): Reduce severe maternal complications identified during delivery hospitalizations (U.S. Department of Health and Human Services, n.d.).

The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine recommend identifying potential cases of severe maternal morbidity for further review, with a focus on outcomes and complications, and consider this an important step toward promoting safe obstetric care (American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine, Kilpatrick, & Ecker, 2016).

]]>

This is a risk adjusted measure:

There are known issues for CMS1028v4. See issues EKI-43 and EKI-44 on the ONC eCQM Known Issues Dashboard for details.

]]>