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CMS Measure ID:
Version:
7
NQF Number:
480
Performance/Reporting Period
2019
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 estimated gestational age at birth.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Assessment. The intent of this data element is to identify estimated gestational age at birth.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes that identify estimated gestational age at birth.
Exclusion Criteria: Excludes codes that do not meet the inclusion criteria.

Constrained to codes in the Assessment, Performed: Estimated Gestational Age at Birth value set (2.16.840.1.113762.1.4.1045.47)

QDM Datatype and Definition (QDM Version 5.3)

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.

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

Timing: The time the assessment is completed; Author dateTime.

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: Excludes codes that do not meet the inclusion criteria.

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 5.3)

Diagnoses

Coded diagnoses/problems addressed during the encounter. The diagnoses attribute is intended to capture ALL diagnoses, including principal diagnosis. Use of the Encounter, Performed: diagnoses attribute and the Diagnosis datatype is redundant for relating the diagnosis to the Encounter, Performed. The Encounter, Performed: diagnoses 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 prevalence period, 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.
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 5.3)

Diagnoses

Coded diagnoses/problems addressed during the encounter. The diagnoses attribute is intended to capture ALL diagnoses, including principal diagnosis. Use of the Encounter, Performed: diagnoses attribute and the Diagnosis datatype is redundant for relating the diagnosis to the Encounter, Performed. The Encounter, Performed: diagnoses 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 prevalence period, 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.
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: Excludes codes that do not meet the inclusion criteria.

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

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

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 Diagnosis: Single Live Born Newborn Born in Hospital value set (2.16.840.1.113883.3.117.1.7.1.26)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

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 where 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 5.3)

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 5.3)

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 5.3)

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.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a neonatal intensive care unit (NICU) location.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Location. The intent of this data element is to identify the NICU.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes that identify the NICU.
Exclusion Criteria: No exclusions.

Constrained to codes in the Facility Locations: Neonatal Intensive Care Unit (NICU) value set (2.16.840.1.113883.3.117.1.7.1.75)

QDM Attribute and Definition (QDM Version 5.3)

Facility Locations

The particular locations in a facility in which the diagnostic study or encounter occurs or occurred. Examples include, but are not limited to, intensive care units (ICUs), non- ICUs, burn critical-care unit, neonatal ICU, and respiratory-care unit. Each Encounter, Performed may have 1 or more locations. For example, a patient treated in multiple locations during an individual encounter might be expressed as: Encounter, Performed: Inpatient Admission, ICU (location period), Non-ICU Admission (location period), Rehab (location period). Facility Locations (plural) is used for Encounter, Performed since there may be more than one facility location used in any given encounter.
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent whether the patient is Hispanic or not; ethnicity category defined by the Centers for Disease Control and Prevention and National Center for Health Statistics.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Ethnicity.
Inclusion Criteria: Includes only relevant concepts associated with ethnicity defined as Hispanic or Latino, or Not Hispanic or Latino.
Exclusion Criteria: No exclusions.

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 5.3)

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: This value set contains concepts that represent categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Payer.
Inclusion Criteria: Includes only relevant concepts associated with payer codes in the code system.
Exclusion Criteria: No exclusions.

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 5.3)

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 Relevant Period 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: This value set contains concepts that represent the general race category reported by the patient - subject may have more than one; defined by the Centers for Disease Control and Prevention and National Center for Health Statistics.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Race.
Inclusion Criteria: Includes only relevant concepts associated with the following race categories: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, Other Race, White.
Exclusion Criteria: No exclusions.

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 5.3)

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: This value set contains concepts that represent gender identity restricted to only male and female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Sex.
Inclusion Criteria: Includes relevant concepts associated with gender concepts for male and female only.
Exclusion Criteria: Excludes 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 5.3)

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: Excludes codes that do not meet the inclusion criteria.

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 5.3)

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.

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

Timing: The Relevant Period addresses:

  • startTime -the time the procedure begins,
  • stopTime -the time the procedure is completed

NOTE:

  1. 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.
  2. The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
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 5.3)

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: The Relevant Period addresses:

  • startTime - when a single substance administration event starts (e.g., the initiation of an intravenous infusion, or administering the substance orally or topically to a patient);
  • stopTime - when a single substance administration event ends (e.g., the end time of the intravenous infusion, or the administration of a substance orally or topically is completed - for oral or topical administration, the start and stop times are the same)

 

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.

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 5.3)

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: The Relevant Period addresses:

  • startTime - when a single substance administration event starts (e.g., the initiation of an intravenous infusion, or administering the substance orally or topically to a patient);
  • stopTime - when a single substance administration event ends (e.g., the end time of the intravenous infusion, or the administration of a substance orally or topically is completed - for oral or topical administration, the start and stop times are the same)