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CMS Measure ID:
Version:
7
NQF Number:
1354
Performance/Reporting Period
2019
Description:

This measure assesses the proportion of births that have been screened for hearing loss before hospital discharge

Data Elements contained within the eCQM + Expand all

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent diagnoses that are commonly used in the inpatient setting for newborn live born, and born in hospital.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype or attribute related to Diagnosis. The intent of this data element is to identify patients who have active diagnosis of live birth newborn born in hospital.
Inclusion Criteria: Includes only relevant concepts associated with diagnosis of live birth newborn born in hospital. This value set Includes ICD-10-CM and SNOMED CT value sets.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnoses: Live Birth Newborn Born In Hospital value set (2.16.840.1.113762.1.4.1046.6)

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 are commonly used in the inpatient setting for newborn live born, and born in hospital.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype or attribute related to Diagnosis. The intent of this data element is to identify patients who have active diagnosis of live birth newborn born in hospital.
Inclusion Criteria: Includes only relevant concepts associated with diagnosis of live birth newborn born in hospital. This value set Includes ICD-10-CM and SNOMED CT value sets.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Live Birth Newborn Born in Hospital value set (2.16.840.1.113762.1.4.1046.6)

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 procedures or evaluations for newborn hearing screening conducted on left ear.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Diagnostic Study, Performed. The intent of this data element is to identify patients who have received newborn hearing screening of the left ear.
Inclusion Criteria: Includes only relevant concepts associated with LOINC code for newborn hearing screen of the left ear.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnostic Study, Performed: Newborn Hearing Screen Left value set (2.16.840.1.114222.4.1.214079.1.1.3)

QDM Datatype and Definition (QDM Version 5.3)

Diagnostic Study, Performed

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

Timing: The Relevant Period addresses:

  • startTime – when the diagnostic study is initiated
  • stopTime – when the diagnostic study is completed

Examples:

  • Initiation of a treadmill stress test to the time the treadmill stress test has completed
  • Initiation of the ultrasound study until completion of the ultrasound study

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures or evaluations for newborn hearing screening conducted on right ear.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Diagnostic Study, Performed. The intent of this data element is to identify patients who have received newborn hearing screening of the right ear.
Inclusion Criteria: Includes only relevant concepts associated with LOINC codes for newborn hearing screen of the right ear.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnostic Study, Performed: Newborn Hearing Screen Right value set (2.16.840.1.114222.4.1.214079.1.1.4)

QDM Datatype and Definition (QDM Version 5.3)

Diagnostic Study, Performed

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

Timing: The Relevant Period addresses:

  • startTime – when the diagnostic study is initiated
  • stopTime – when the diagnostic study is completed

Examples:

  • Initiation of a treadmill stress test to the time the treadmill stress test has completed
  • Initiation of the ultrasound study until completion of the ultrasound study

 

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 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 contains concepts that represent findings that indicate the normal findings on hearing examination or referral is needed.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Result. The intent of this data element is to identify patients who received a newborn hearing screening with result of pass or refer.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing concepts associated with normal finding on hearing examination and referral.
Exclusion Criteria: No exclusions.

Constrained to codes in the Result: Pass Or Refer value set (2.16.840.1.114222.4.1.214079.1.1.6)

QDM Attribute and Definition (QDM Version 5.3)

Result

The final consequences or data collected from the datatype. Results can be used in four ways, to express: (1) That a result is present in the electronic record but any entry is acceptable. (2) A numerical result is reported directly as a value. Values may be integers or decimal numbers without units, or as a quantity with a value and units. Examples: 100 mg/dL for a lab test, 140 mmHg for blood pressure, as a percentage (actually a quantity with % as units), as a ratio (e.g., 1:4, 1:80). (3) A result that matches one of a specific set of coded concepts in a value set or a code that matches a direct reference code. (4) A result as a dateTime (Assessment, Performed and components). Note: Measures use Clinical Quality Language (CQL) logic to express the mathematical operators to constrain desired results to those above or below a certain threshold.