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Severe Obstetric Complications

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

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

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 Exceptions

None

Measure 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.

MIPS Quality ID
Meaningful Measure Safety
Next Version No Version Available
Previous Version No Version Available

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Measure Information 2023 Reporting Period
Title Severe Obstetric Complications
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

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
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 Exceptions

None

Measure 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.

Meaningful Measure Safety
Next Version No Version Available
Previous Version No Version Available
Last Updated: Aug 29, 2022