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Venous Thromboembolism Prophylaxis

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Measure Information 2021 Reporting Period
CMS Measure ID CMS108v9
Short Name VTE-1
NQF Number Not Applicable
Measure Description

This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission
Initial Population

Inpatient hospitalizations for patients age 18 and older, discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period
Denominator Statement

Inpatient hospitalizations for all patients in the initial population
Denominator Exclusions

* Inpatient hospitalizations for patients who have a length of stay less than 2 days

* Inpatient hospitalizations for patients with comfort measures documented anytime between the day of arrival and the day after hospital admission

* Inpatient hospitalizations for patients with comfort measures documented by the day after surgery end date for surgeries that start the day of or the day after hospital admission

* Inpatient hospitalizations for patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day

* Inpatient hospitalizations for patients with a principal diagnosis of mental disorders or stroke

* Inpatient hospitalizations for patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries
Numerator Statement

Inpatient hospitalizations for patients who received VTE prophylaxis:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date for surgeries that end the day of or the day after hospital admission

Inpatient hospitalizations for patients who have documentation of a reason why no VTE prophylaxis was given:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)
Numerator Exclusions

Not Applicable
Denominator Exceptions

None
Measure Steward The Joint Commission
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

Improvement noted as an increase in rate
Guidance

When low dose unfractionated heparin is administered for VTE Prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous.

Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed."

This eCQM is an episode-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.
Meaningful Measure Preventive Care
Next Version
CMS108v10
Previous Version No Version Available

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Measure Information 2021 Reporting Period 2022 Reporting Period 2023 Reporting Period
Name Venous Thromboembolism Prophylaxis Venous Thromboembolism Prophylaxis Venous Thromboembolism Prophylaxis
CMS Measure ID CMS108v9 CMS108v10 CMS108v11
Short Name VTE-1 VTE-1 VTE-1
NQF Number Not Applicable Not Applicable Not Applicable
Measure Description

This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission

This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given between the day of arrival to the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission

This measure assesses the number of patients who received Venous Thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given between the day of arrival to the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission
Initial Population

Inpatient hospitalizations for patients age 18 and older, discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period

Inpatient hospitalizations for patients age 18 and older, discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period

Inpatient hospitalizations for patients age 18 and older, discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period
Denominator Statement

Inpatient hospitalizations for all patients in the initial population

Initial population

Initial population
Denominator Exclusions * Inpatient hospitalizations for patients who have a length of stay less than 2 days * Inpatient hospitalizations for patients with comfort measures documented anytime between the day of arrival and the day after hospital admission * Inpatient hospitalizations for patients with comfort measures documented by the day after surgery end date for surgeries that start the day of or the day after hospital admission * Inpatient hospitalizations for patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day * Inpatient hospitalizations for patients with a principal diagnosis of mental disorders or stroke * Inpatient hospitalizations for patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries * Inpatient hospitalizations for patients who have a length of stay less than 2 days * Inpatient hospitalizations for patients with comfort measures documented anytime between the day of arrival and the day after hospital admission * Inpatient hospitalizations for patients with comfort measures documented by the day after surgery end date for surgeries that start the day of or the day after hospital admission * Inpatient hospitalizations for patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day * Inpatient hospitalizations for patients with a principal diagnosis of mental disorders or stroke * Inpatient hospitalizations for patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries * Inpatient hospitalizations for patients who have a length of stay less than 2 days* Inpatient hospitalizations for patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day* Inpatient hospitalizations for patients with a principal diagnosis of mental disorders or stroke* Inpatient hospitalizations for patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries* Inpatient hospitalizations for patients with comfort measures documented anytime between the day of arrival and the day after hospital admission* Inpatient hospitalizations for patients with comfort measures documented by the day after surgery end date for surgeries that start the day of or the day after hospital admission
Numerator Statement

Inpatient hospitalizations for patients who received VTE prophylaxis:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date for surgeries that end the day of or the day after hospital admission

Inpatient hospitalizations for patients who have documentation of a reason why no VTE prophylaxis was given:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)

Inpatient hospitalizations for patients who received VTE prophylaxis:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date for surgeries that end the day of or the day after hospital admission

Inpatient hospitalizations for patients who have documentation of a reason why no VTE prophylaxis was given:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)

Inpatient hospitalizations for patients who received VTE prophylaxis:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)

Inpatient hospitalizations for patients who have documentation of a reason why no VTE prophylaxis was given:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)
Numerator Exclusions

Not Applicable

Not Applicable

Not Applicable
Denominator Exceptions

None

None

None
Measure Steward The Joint Commission The Joint Commission The Joint Commission
Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type Process measure Process measure Process measure
Improvement Notation

Improvement noted as an increase in rate

Improvement noted as an increase in rate

Improvement noted as an increase in rate
Guidance

When low dose unfractionated heparin is administered for VTE Prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous.

Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed."

This eCQM is an episode-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

When low dose unfractionated heparin is administered for VTE Prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous.

Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed."

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

When low dose unfractionated heparin is administered for VTE prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous.

Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed."

The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.
Meaningful Measure Preventive Care Preventive Care Preventive Care
Next Version CMS108v10 CMS108v11 No Version Available
Previous Version No Version Available
CMS108v9
CMS108v10
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CMS108v9.html 107.55 KB
CMS108v9.zip 127.4 KB
CMS108v9-TRN.xlsx 23.2 KB

Data Element Repository

Value Sets
Value Sets to be used with CMS108v9

Release Notes

CMS108v9-TRN.xlsx

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Updated due to clinical practice.

    Measure Section: Numerator

    Source of Change: ONC Project Tracking System (Jira): CQM-2832

Logic

  • QDM v5.5 standards update: Replaced 'Assessment, Performed' attribute 'authorDatetime' with 'relevantDatetime' and added a new variable in various logic locations.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Renamed the ​'In Low Risk for VTE or On Anticoagulant' definition and revised logic for clarification consistent with the Clinical Quality Language (CQL) Style Guide.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added 'Rivaroxaban and Betroxban for VTE Prophylaxis' to definitions due to US Food and Drug Administration (FDA) approval of Rivaroxaban and Betrixaban for VTE prophylaxis.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Expanded VTE prophylaxis timeframe to allow interventions in the ED or Observation setting prior to admission to count toward the numerator.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (Jira): CQM-2832

  • Followed CQL Style Guide to be consistent when defining SCIP acronym.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • CQL Library version update: Updated version number of the TJC_Overall Library (TJC_Overall-4.4.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • CQL Library version update: Updated version number of the VTEICU Library (VTEICU-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • QDM v5.5 standards update: Modified 'Encounter, Performed' diagnosis attribute to reference diagnosis codes in value sets specified in the logic.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39): Added 1 RxNorm code (2121591) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Unfractionated Heparin (2.16.840.1.113883.3.117.1.7.1.218): Deleted 1 RxNorm code (1658720) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set General Surgery (2.16.840.1.113883.3.117.1.7.1.255): Added 2 SNOMED CT codes (47208000, 81561002) and deleted 7 SNOMED CT codes (14037006, 274029004, 275016006, 277578005, 426267007, 87389009, 89646009) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Gynecological Surgery (2.16.840.1.113883.3.117.1.7.1.257): Added 1 SNOMED CT code (784191009) and deleted 1 SNOMED CT code (236890000) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Intracranial Neurosurgery (2.16.840.1.113883.3.117.1.7.1.260): Deleted 1 SNOMED CT code (230892001) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Venous Thromboembolism (2.16.840.1.113883.3.117.1.7.1.279): Added 3 ICD-10-CM codes (I26.93, I26.94, I28.9) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Hip Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.259): Deleted 3 SNOMED CT codes (29969002, 33788003, 425443008) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Knee Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.261): Added 1 SNOMED CT code (609588000) and deleted 3 SNOMED CT codes (430698003, 443543000, 443658004) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Added 17 SNOMED CT codes and deleted 27 SNOMED CT codes based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Added 1 SNOMED CT code (422504002) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Observation Services (2.16.840.1.113762.1.4.1111.143): Deleted 2 SNOMED CT codes (448851000124103, 76464004) based on clinical/coding expert feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Rivaroxaban and Betrixaban for VTE Prophylaxis (2.16.840.1.113762.1.4.1110.50): Added Rivaroxaban and Betrixaban for VTE Prophylaxis due to FDA approval of Rivaroxaban and Betrixaban for VTE prophylaxis.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Principal (2.16.840.1.113883.3.117.1.7.1.14): Removed Principal due to QDM v5.5 standards updates.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Atrial Fibrillation/Flutter Value Set (2.16.840.1.113883.3.117.1.7.1.202): Removed 2 ICD-10-CM codes (I48.1, I48.2) and added 4 ICD-10-CM codes (I48.11, I48.19, I48.20, I48.21) based on terminology update.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (Jira): CQM-3827

Last Updated: May 04, 2022