| Measure Information | 2023 Reporting Period |
|---|---|
| CMS eCQM ID | CMS1028v1 |
| Short Name | PC-07 |
| NQF Number | Not Applicable |
| Description |
Patients with severe obstetric complications which occur during the inpatient delivery hospitalization. |
| Initial Population |
Inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure with a discharge date that ends during the measurement period |
| Numerator |
Inpatient hospitalizations for patients with severe obstetric complications (not present on admission that occur during the current delivery encounter) including the following: - Severe maternal morbidity diagnoses (see list below) - Severe maternal morbidity procedures (see list below) - Discharge disposition of expired Severe Maternal Morbidity Diagnoses: - Cardiac Acute heart failure Acute myocardial infarction Aortic aneurysm Cardiac arrest/ventricular fibrillation Heart failure/arrest during procedure or surgery - Hemorrhage Disseminated intravascular coagulation Shock - Renal Acute renal failure - Respiratory Adult respiratory distress syndrome Pulmonary edema - Sepsis - Other OB Air and thrombotic embolism Amniotic fluid embolism Eclampsia Severe anesthesia complications - Other Medical Puerperal cerebrovascular disorder Sickle cell disease with crisis Severe Maternal Morbidity Procedures: - Blood transfusion - Conversion of cardiac rhythm - Hysterectomy - Temporary tracheostomy - Ventilation |
| Numerator Exclusions |
Not applicable |
| Denominator |
Inpatient hospitalizations for patients delivering stillborn or live birth with >= 20 weeks, 0 days gestation completed |
| Denominator Exclusions |
Inpatient hospitalizations for patients with confirmed diagnosis of COVID with COVID-related respiratory condition or patients with confirmed diagnosis of COVID with COVID-related respiratory procedure |
| Denominator Exceptions |
None |
| Steward | The Joint Commission |
| Measure Scoring | Proportion measure |
| Measure Type | Outcome measure |
| Improvement Notation |
Improvement noted as a decrease in the rate. |
| Guidance |
In the case of multiple births, map the first delivery date/time (Baby A) as the delivery date/time for the encounter. This measure allows for 2 approaches to determine estimated gestational age (EGA) in the following order of precedence: 1. The EGA is calculated using the American College of Obstetricians and Gynecologists ReVITALize guidelines.* 2. The EGA is obtained from a discrete field in the electronic health record. This option is only used when the calculated EGA is not available. Wherever gestational age is mentioned, relative to the delivery, the intent is to capture the last estimated gestational age prior to or at the time of delivery.
*ACOG ReVITALize Guidelines for Calculating Gestational Age:
Gestational Age = (280-(EDD minus Reference Date))/7 --Estimated Due Date (EDD): The best obstetrical Estimated Due Date is determined by last menstrual period if confirmed by early ultrasound or no ultrasound performed, or early ultrasound if no known last menstrual period or the ultrasound is not consistent with last menstrual period, or known date of fertilization (eg, assisted reproductive technology) --Reference Date is the date on which you are trying to determine gestational age. For purposes of this eCQM, Reference Date would be the Date of Delivery. Note however 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. 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. |
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| Previous Version | No Version Available |
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| Measure Information | 2023 Reporting Period | 2024 Reporting Period |
|---|---|---|
| Title | Severe Obstetric Complications | Severe Obstetric Complications |
| CMS eCQM ID | CMS1028v1 | CMS1028v2 |
| Short Name | PC-07 | PC-07 |
| NQF Number | Not Applicable | Not Applicable |
| Description |
Patients with severe obstetric complications which occur during the inpatient delivery hospitalization. |
Patients with severe obstetric complications which occur during the inpatient delivery hospitalization |
| Initial Population |
Inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure with a discharge date that ends during the measurement period |
Inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure with a discharge date that ends during the measurement period |
| Denominator |
Inpatient hospitalizations for patients delivering stillborn or live birth with >= 20 weeks, 0 days gestation completed |
Inpatient hospitalizations for patients delivering stillborn or live birth with >= 20 weeks, 0 days gestation completed |
| Denominator Exclusions | Inpatient hospitalizations for patients with confirmed diagnosis of COVID with COVID-related respiratory condition or patients with confirmed diagnosis of COVID with COVID-related respiratory procedure | Inpatient hospitalizations for patients with confirmed diagnosis of COVID with COVID-related respiratory condition or patients with confirmed diagnosis of COVID with COVID-related respiratory procedure |
| Numerator |
Inpatient hospitalizations for patients with severe obstetric complications (not present on admission that occur during the current delivery encounter) including the following: - Severe maternal morbidity diagnoses (see list below) - Severe maternal morbidity procedures (see list below) - Discharge disposition of expired Severe Maternal Morbidity Diagnoses: - Cardiac Acute heart failure Acute myocardial infarction Aortic aneurysm Cardiac arrest/ventricular fibrillation Heart failure/arrest during procedure or surgery - Hemorrhage Disseminated intravascular coagulation Shock - Renal Acute renal failure - Respiratory Adult respiratory distress syndrome Pulmonary edema - Sepsis - Other OB Air and thrombotic embolism Amniotic fluid embolism Eclampsia Severe anesthesia complications - Other Medical Puerperal cerebrovascular disorder Sickle cell disease with crisis Severe Maternal Morbidity Procedures: - Blood transfusion - Conversion of cardiac rhythm - Hysterectomy - Temporary tracheostomy - Ventilation |
Inpatient hospitalizations for patients with severe obstetric complications (not present on admission that occur during the current delivery encounter) including the following: - Severe maternal morbidity diagnoses (see list below) - Severe maternal morbidity procedures (see list below) - Discharge disposition of expired Please note that present on admission codes may be those entered by coding staff, extracted from billing/claims data. Severe Maternal Morbidity Diagnoses: - Cardiac Acute heart failure Acute myocardial infarction Aortic aneurysm Cardiac arrest/ventricular fibrillation Heart failure/arrest during procedure or surgery - Hemorrhage Disseminated intravascular coagulation Shock - Renal Acute renal failure - Respiratory Adult respiratory distress syndrome Pulmonary edema - Sepsis - Other OB Air and thrombotic embolism Amniotic fluid embolism Eclampsia Severe anesthesia complications - Other Medical Puerperal cerebrovascular disorder Sickle cell disease with crisis Severe Maternal Morbidity Procedures: - Blood transfusion - Conversion of cardiac rhythm - Hysterectomy - Temporary tracheostomy - Ventilation |
| Numerator Exclusions |
Not applicable |
Not applicable |
| Denominator Exceptions |
None |
None |
| Measure Steward | The Joint Commission | The Joint Commission |
| Measure Scoring | Proportion measure | Proportion measure |
| Measure Type | Outcome measure | Outcome measure |
| Improvement Notation |
Improvement noted as a decrease in the rate. |
Improvement noted as a decrease in the rate |
| Guidance |
In the case of multiple births, map the first delivery date/time (Baby A) as the delivery date/time for the encounter. This measure allows for 2 approaches to determine estimated gestational age (EGA) in the following order of precedence: 1. The EGA is calculated using the American College of Obstetricians and Gynecologists ReVITALize guidelines.* 2. The EGA is obtained from a discrete field in the electronic health record. This option is only used when the calculated EGA is not available. Wherever gestational age is mentioned, relative to the delivery, the intent is to capture the last estimated gestational age prior to or at the time of delivery.
*ACOG ReVITALize Guidelines for Calculating Gestational Age:
Gestational Age = (280-(EDD minus Reference Date))/7 --Estimated Due Date (EDD): The best obstetrical Estimated Due Date is determined by last menstrual period if confirmed by early ultrasound or no ultrasound performed, or early ultrasound if no known last menstrual period or the ultrasound is not consistent with last menstrual period, or known date of fertilization (eg, assisted reproductive technology) --Reference Date is the date on which you are trying to determine gestational age. For purposes of this eCQM, Reference Date would be the Date of Delivery. Note however 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. 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. |
In the case of multiple births, map the first delivery date/time (Baby A) as the delivery date/time for the encounter. This measure allows for 3 approaches to determine gestational age (GA) in the following order of precedence: 1. The GA is calculated using the American College of Obstetricians and Gynecologists ReVITALize guidelines.* 2. The GA is obtained from a discrete field in the electronic health record. This option is only used when the calculated GA is not available. 3. The GA is based on ICD10 or SNOMED codes indicative of weeks gestation. This option is only used when results from items #1 and #2 (see above) are not available. Wherever gestational age is mentioned, relative to the delivery, the intent is to capture the last estimated gestational age prior to or at the time of delivery.
*ACOG ReVITALize Guidelines for Calculating Gestational Age:
Gestational Age = (280-(Estimated Due Date minus Reference Date))/7 --Estimated Due Date (EDD): The best obstetrical EDD is determined by last menstrual period if confirmed by early ultrasound or no ultrasound performed, or early ultrasound if no known last menstrual period or the ultrasound is not consistent with last menstrual period, or known date of fertilization (e.g., assisted reproductive technology) --Reference Date is the date on which you are trying to determine gestational age. For purposes of this eCQM, Reference Date would be the Date of Delivery. Note however 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. 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. |
| Next Version | CMS1028v2 | No Version Available |
| Previous Version | No Version Available |
*This is a risk adjusted measure.
Risk Adjustment Methodology Report: Severe Obstetric Complications Methodology Report