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Venous Thromboembolism Prophylaxis

eCQMs for 2022 Reporting Period

General eCQM Information

CMS Measure ID CMS108v10
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 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
Denominator Statement

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 Type Process
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. 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 Preventive Care
Previous Version

Release Notes

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • Revised the measure description for consistency with the numerator statement.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Corrected a misspelling.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

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

    Measure Section: Guidance

    Source of Change: Measure Lead

  • ​Revised the denominator statement for consistency with other measures where the denominator is the initial population.

    Measure Section: Denominator

    Source of Change: Measure Lead

Logic

  • Created a library named 'VTE' for an Initial Population definition that is shared by both VTE-1 and VTE-2 measures.

    Measure Section: Initial Population

    Source of Change: Annual Update

  • Updated Global.'Inpatient Encounter' definition by adding 'day of' to ensure all cases within the measurement period are captured and evaluated in the initial population.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replace relevantDatetime with Global.'EarliestOf'() for assessment performed datatype to decrease implementation burden due to variable use of timing attributes for the same QDM datatypes used across measures.

    Measure Section: Multiple Sections

    Source of Change: ONC Project Tracking System (Jira): CQM-3873

  • 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

  • Updated VTEICU CQL Library to version 5.2.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated TJC_Overall CQL Library to version 5.2.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

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 Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment (2.16.840.1.113883.3.117.1.7.1.134): Deleted 2 RxNorm codes (1927856, 1927864) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219): Deleted 1 RxNorm code (978713) 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): Deleted 7 SNOMED CT codes (173743009, 173744003, 174309007, 235280006, 239989009, 287794009, 287861004) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Obstetrics VTE (2.16.840.1.113883.3.117.1.7.1.264): Deleted 2 SNOMED CT codes (200302000, 663008) 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): Deleted 1 ICD-10-CM code (I28.9) and 2 SNOMED CT codes (276494008, 413956008) 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 3 ICD-10-CM codes (O99.891, O99.892, O99.893) based on terminology update. Deleted 36 SNOMED CT codes and 1 ICD-10-CM code (O99.89) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Mental Health Diagnoses (2.16.840.1.113883.3.464.1003.105.12.1004): Added 54 SNOMED CT codes and 780 ICD-10-CM codes based on review by technical experts, SMEs, and/or public feedback. Deleted 25 SNOMED CT codes and 5 ICD-10-CM codes (F32.8, F34.8, F42, F50.8, F53) based on terminology update.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (Jira): CQM-4028

  • Renamed value set Rivaroxaban for VTE Prophylaxis (2.16.840.1.113762.1.4.1110.50) based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Rivaroxaban for VTE Prophylaxis (2.16.840.1.113762.1.4.1110.50): Deleted 2 RxNorm codes (1927856, 1927864) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: Jul 08, 2021