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Venous Thromboembolism Prophylaxis

Measure Information 2023 Reporting Period
CMS Measure ID CMS108v11
Short Name VTE-1
NQF Number Not Applicable
Measure Description

This measure assesses the number of patients who received Venous Thromboembolism (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 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

* 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

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
Measure Type Process measure
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."

The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home.

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 Preventive Care
Next Version No Version Available
Previous Version

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Measure Information 2021 Reporting Period 2022 Reporting Period 2023 Reporting Period
CMS Measure ID CMS108v9 CMS108v10 CMS108v11
Short Name VTE-1 VTE-1 VTE-1
NQF Number Not Applicable Not Applicable Not Applicable
Measure Description

This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission

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

This measure assesses the number of patients who received Venous Thromboembolism (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

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

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

Inpatient hospitalizations for all patients in the initial population

Initial population

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 * 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 * Inpatient hospitalizations for patients who have a length of stay less than 2 days* 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* 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
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)

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)

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

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 rate

Improvement noted as an increase in rate

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.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

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.

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."

The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home.

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 Preventive Care Preventive Care Preventive Care
Next Version CMS108v10 CMS108v11 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

  • Changed 'VTE Prophylaxis' to 'VTE prophylaxis' to align with typographical standard.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated guidance to indicate patients in Acute Hospital Care at Home programs are included in the denominator population.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • 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

  • Revised the denominator exclusions narrative to list exclusions in the same order as the logic for improved readability.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Standardized use of parentheses in numerator statement.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Updated grammar and punctuation to improve readability.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Replaced reference to Global.ToDate with identical function named TJC.TruncateTime because Global.ToDate was retired.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Replaced 'Device, Applied' with 'Procedure, Performed' datatype to align with QDM v5.6 updates and created 3 new value sets with SNOMED CT codes to align with terminology recommendations by QDM datatype.

    Measure Section: Numerator

    Source of Change: Standards/Technical Update

  • Updated definition name to align with logic content.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Replaced age calculation from BirthDate with CQL function AgeInYearsAt in the TJCOverall and VTE libraries.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replaced Global.ToDate() with TJC.TruncateTime() in the function of FromDayOfStartOfHospitalizationToDayAfterAdmission and FromDayOfStartOfHospitalizationToDayAfterFirstICU.

    Measure Section: Functions

    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 timing precision in definitions using the functions TJC.'CalendarDayOfOrDayAfter' and VTE.'FromDayOfStartOfHospitalizationToDayAfterFirstICU' from datetime to date by adding 'day of' to align with the measure intent.

    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

  • Updated the version number of the TJC Overall Library to v6.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated the version number of the VTE Library to v6.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated definition names to reflect the removal of the 'Device, Applied' datatype.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

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

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.

    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 Urological Surgery (2.16.840.1.113883.3.117.1.7.1.272): Deleted 3 SNOMED CT codes (289754003, 290691008, 89528006) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment (2.16.840.1.113883.3.117.1.7.1.134): Deleted 5 RxNorm codes (1114198, 1232082, 1232086, 1549682, 2059015) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Obstetrics VTE (2.16.840.1.113883.3.117.1.7.1.264): Deleted 5 SNOMED CT codes (200237000, 200238005, 280966008, 63795001, 84216001) 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): Deleted 62 SNOMED CT codes based on terminology update. Deleted 50 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Hip Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.259): Deleted 1 SNOMED CT code (397956004) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Graduated compression stockings (GCS) (2.16.840.1.113883.3.117.1.7.1.256): Deleted 12 SNOMED CT codes based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Added value set Application of Venous Foot Pumps (VFP) (2.16.840.1.113762.1.4.1110.64) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Medical Reason (2.16.840.1.113883.3.117.1.7.1.473): Deleted 1 SNOMED CT code (397745006) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Rivaroxaban for VTE Prophylaxis (2.16.840.1.113762.1.4.1110.50): Added 1 RxNorm code (2588062) 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 3 ICD-10-CM codes (F32.A, T40.712A, T40.722A) based on terminology update. Deleted 1 ICD-10-CM code (T40.7X2A) based on terminology update. Deleted 4 SNOMED CT codes (162722001, 3503000, 391099000, 50878001) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Added value set Application of Intermittent Pneumatic Compression Devices (IPC) (2.16.840.1.113762.1.4.1110.65) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Added value set Application of Graduated Compression Stockings (GCS) (2.16.840.1.113762.1.4.1110.66) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Venous Thromboembolism (2.16.840.1.113883.3.117.1.7.1.279): Deleted 2 SNOMED CT codes (195394007, 266267005) 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 2 SNOMED CT codes (238212008, 28933001) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: May 04, 2022