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Exclusive Breast Milk Feeding

eCQMs for 2022 Reporting Period

General eCQM Information

CMS Measure ID CMS9v10
Short Name PC-05
NQF Number 0480e
Measure 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.

Initial Population Inpatient hospitalizations for single newborns who were born in the hospital that ends during the measurement period, and with either of the following conditions: - An estimated gestational age at birth of >= 37 weeks - Birth weight >= 3000 grams without an estimated gestational age at birth
Denominator Statement

Initial Population

Denominator Exclusions

Inpatient hospitalizations for newborns who were with any of the following conditions:

• admitted to the Neonatal Intensive Care Unit (NICU)

• transferred to an acute care facility, or other health care facility

• expired during the hospitalization

• a length of stay greater than 120 days that ends during the measurement period

• a diagnosis of galactosemia

• subject to parenteral nutrition

Numerator Statement

Inpatient hospitalizations for newborns who were fed breast milk only since birth

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Measure Steward The Joint Commission
Measure Scoring Proportion
Measure Type Process
Improvement Notation

Improvement noted as an increase in the rate

Guidance

A discharge to a designated cancer center or children's hospital should be captured as a discharge to an acute care facility.

Data shows that the majority of newborns with gestational age 37 weeks or more have a birth weight 3000 grams or more. Birth weight 3000 grams or more is a proxy to capture term newborns without gestational age recorded in EHR system. Only one birth weight value should be recorded. In cases where there is conflicting data, use the document recording the birth weight closest to the time of delivery.

If dextrose or glucose 40% gel is given, it is considered a medication not a feeding. This should be reflected as such in the newborn's EHR documentation.

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.

Meaningful Measure Care is Personalized and Aligned with Patient's Goals
Previous Version

Release Notes

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • Added a period '.' to 'Measure specifications are in the Public Domain' in Copyright section to align with current guidelines.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Added clarifying language to the guidance section of episode-based measures to define the episode.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added guidance to consider 40% dextrose or glucose gel as a medication to better align with the measure intent.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added guidance to use birth weight closest to delivery when there are multiple birth weights documented for consistency with measure intent.

    Measure Section: Guidance

    Source of Change: ONC Project Tracking System (Jira): CQM-4012

  • Removed guidance for calculation of gestational age based on ReVITALize guidelines because it is not consistent with current measure logic.

    Measure Section: Guidance

    Source of Change: Measure Lead

Logic

  • ​Revised the unit of 'Gestational age--at birth' from 'wk' to 'weeks' to more accurately reflect the way it is documented within an EHR.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Added 'day of' to the 'Single Live Term Newborn Encounter During Measurement Period' definition to align with a change to the Global.'Inpatient Encounter' definition.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Created a new CQL library 'PCNewborn' to facilitate sharing the same Initial Population definitions across all newborn measures.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Added 'Intensive Care Unit' facility location to capture all relevant denominator exclusion cases for newborns admitted to an intensive care unit.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (Jira): CQM-4044

  • Added 'Medication, Administered' data type to express a denominator exclusion for newborn administered Total Parenteral Nutrition.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

    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.

  • Added value set Intensive Care Unit (2.16.840.1.113762.1.4.1029.206) based on new or changed coding guidelines.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Added value set Total Parenteral Nutrition (2.16.840.1.113762.1.4.1110.54) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 08, 2021