Back to top
Top

Exclusive Breast Milk Feeding

Measure Information 2023 Reporting Period
CMS eCQM ID CMS9v11
Short Name PC-05
NQF Number 0480e
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

Initial Population

Denominator Exclusions

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

• admitted to the Neonatal Intensive Care Unit (NICU) or transferred to a regular intensive care unit (ICU)

• 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

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
Measure Type Process measure
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 show 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 start of encounter.

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 5.6. Please refer to the QDM page for more information on the QDM.

MIPS Quality ID
Meaningful Measure Care is Personalized and Aligned with Patient’s Goals
Next Version No Version Available
Previous Version

Compare eCQM Versions

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

Filter Measure By
Download
Measure Information 2021 Reporting Period 2022 Reporting Period 2023 Reporting Period
Title Exclusive Breast Milk Feeding Exclusive Breast Milk Feeding Exclusive Breast Milk Feeding
CMS eCQM ID CMS9v9 CMS9v10 CMS9v11
Short Name PC-05 PC-05 PC-05
NQF Number 0480e 0480e 0480e
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.

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.

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

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

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

Initial Population

Initial Population

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 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 Inpatient hospitalizations for newborns who were with any of the following conditions: • admitted to the Neonatal Intensive Care Unit (NICU) or transferred to a regular intensive care unit (ICU) • 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

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

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

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

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 the rate

Improvement noted as an increase in the rate

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.

It is acceptable to calculate Gestational Age using the American College of Obstetricians and Gynecologists ReVITALize guidelines, which define Gestational Age as calculated using the best obstetrical Estimated Due Date (EDD) based on the formula:

Gestational Age= (280-(EDD-Reference Date))/7

where Reference Date is the date on which you are trying to determine gestational age. For PC-05, Reference Date is the Birth Date.

Note however that the calculation may yield a non-whole number and gestational age should be rounded off to the nearest completed week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.

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.

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.

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.

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

Data show 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 start of encounter.

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 5.6. Please refer to the QDM page for more information on the QDM.

Meaningful Measure Care is Personalized and Aligned with Patient's Goals Care is Personalized and Aligned with Patient's Goals Care is Personalized and Aligned with Patient’s Goals
Next Version CMS9v10 CMS9v11 No Version Available
Previous Version No Version Available

Release Notes

Header

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated rationale with more current evidence.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Standards/Technical Update

  • Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.

    Measure Section: Guidance

    Source of Change: Standards/Technical Update

  • Updated grammar and punctuation to improve readability.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated guidance to reflect logic to improve clarity and understanding of measure intent to capture birthweight.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Update the denominator exclusions narrative to include reference to ICU to align with the logic and intent.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Logic

  • Changed alias name from 'SingleLiveBirthEncounter' to 'SingleLiveBornEncounter' in PCNewborn Library to align with the CQL Style Guide and to provide clarity.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Updated the definition name to simplify and align with the logic and intent.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Changed the definition name in PCNewborn library To 'PCNewborn.Single Live Term Newborn Encounter Ends During Measurement Period' to align with logic intent.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated the version number of the PC Newborn Library to v2.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Changed 'With' to 'with' in the definition names to align with CQL Style Guide.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • 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/Technical Update

  • Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical 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 Neonatal Intensive Care Unit (NICU) (2.16.840.1.113762.1.4.1029.205): Added 1 HSLOC code (1269-0) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: Aug 29, 2022