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Severe Obstetric Complications

Compare Versions of: "Severe Obstetric Complications"

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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 No Version Available
Previous Version No Version Available
Notes

*This is a risk adjusted measure.

Risk Adjustment Methodology Report: Severe Obstetric Complications Methodology Report

*This is a risk adjusted measure. Risk Adjustment Methodology Report: Severe Obstetric Complications Methodology Report

**There is a known issue on CMS1028v2. See issue EKI-23 on the ONC eCQM Known Issues Dashboard for details.

Header

  • Updated grammar, wording, and/or formatting to improve readability and consistency.

    Measure Section: Description

    Source of Change: Annual Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Added link to the Risk Methodology Report to aid implementation.

    Measure Section: Risk Adjustment

    Source of Change: Measure Lead

  • Clarified Lab and Physical Exam Results to improve readability.

    Measure Section: Risk Adjustment

    Source of Change: Measure Lead

  • Updated risk adjustment variable description from 'BMI>=40' to 'Morbid Obesity' as ICD-10 coding guidelines indicate BMI codes are not to be assigned for pregnant patients.

    Measure Section: Risk Adjustment

    Source of Change: Measure Lead

  • Added guidance to clarify patients may now be qualified for the denominator based on gestational age diagnosis codes when neither calculated or reported gestational age is available.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added guidance to clarify where present on admission information may be sourced.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Added logic to denominator criteria to capture patients with specified weeks gestation based on diagnosis codes when neither calculated or reported gestational age is available.

    Measure Section: Denominator

    Source of Change: Measure Lead

  • Updated definition name to 'Risk Variable Morbid Obesity' to reflect change in value set as ICD-10 coding guidelines indicate BMI codes are not to be assigned for pregnant patients.

    Measure Section: Definitions

    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: Definitions

    Source of Change: Standards/Technical Update

  • Updated the version number of the PC Maternal Library to v3.0.000.

    Measure Section: Definitions

    Source of Change: Annual Update

  • Removed 'Truncate.Time' function and added 'as DateTime' to Estimated Delivery Date result to simplify logic and allow hospitals to submit data as date only or as date/time.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Updated the version number of the PC Maternal Library to v3.0.000.

    Measure Section: Functions

    Source of Change: Annual 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.

  • Added value set 20 to 42 Plus Weeks Gestation (2.16.840.1.113762.1.4.1110.67) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set (2.16.840.1.113883.3.117.1.7.1.271): Renamed to Acute or Persistent Asthma based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Anemia (2.16.840.1.113762.1.4.1029.323): Added 4 ICD-10-CM codes (D59.30, D59.31, D59.32, D59.39) based on terminology update. Deleted 1 ICD-10-CM code (D59.3) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Bleeding Disorder (2.16.840.1.113762.1.4.1029.287): Added 10 ICD-10-CM codes (D68.00, D68.01, D68.020, D68.021, D68.022, D68.023, D68.029, D68.03, D68.04, D68.09) based on terminology update. Deleted 1 ICD-10-CM code (D68.0) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Blood Transfusion (2.16.840.1.113762.1.4.1029.213): Added 19 SNOMED CT codes based on terminology update. Added 20 ICD-10-PCS codes based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Cardiac Disease (2.16.840.1.113762.1.4.1029.341): Added 30 ICD-10-CM codes based on terminology update. Deleted 5 ICD-10-CM codes (I47.2, I31.3, I34.8, Q21.1, Q21.2) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Economic Housing Instability (2.16.840.1.113762.1.4.1029.292): Added 3 ICD-10-CM codes (Z59.82, Z59.86, Z59.87) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Gastrointestinal Disease (2.16.840.1.113762.1.4.1029.338): Added 1 ICD-10-CM code (K76.82) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Hematocrit lab test (2.16.840.1.113762.1.4.1045.114): Added 1 LOINC code (48703-3) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set (2.16.840.1.113762.1.4.1029.272): Renamed to HIV in Pregnancy Childbirth and Puerperium based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Mental Health Disorder (2.16.840.1.113762.1.4.1029.314): Added 5 ICD-10-CM codes (F32.A, F06.70, F06.71, F43.81, F43.89) based on terminology update. Deleted 1 ICD-10-CM code (F43.8) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113762.1.4.1029.329): Renamed to Mild or Moderate Preeclampsia based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113762.1.4.1029.290): Renamed to Morbid or Severe Obesity based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Neuromuscular Disease (2.16.840.1.113762.1.4.1029.308): Added 2 ICD-10-CM codes (G40.833, G40.834) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Previous Cesarean (2.16.840.1.113762.1.4.1029.278): Added 1 ICD-10-CM code (O34.218) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Renal Disease (2.16.840.1.113762.1.4.1029.335): Added 7 ICD-10-CM codes (N03.A, N04.A, N05.A, N07.A, N18.30, N18.31, N18.32) based on terminology update. Deleted 1 ICD-10-CM code (N18.3) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Respiratory Support Procedures Related to COVID 19 (2.16.840.1.113762.1.4.1029.379): Deleted 1 ICD-10-PCS code (5A0522C) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Severe Maternal Morbidity Diagnoses (2.16.840.1.113762.1.4.1029.255): Added 44 ICD-10-CM codes based on terminology update. Deleted 1 ICD-10-CM code (O72.3) based on review by technical experts, SMEs, and/or public feedback. Deleted 8 ICD-10-CM codes (I71.1, I71.5, I63.8, I71.01, I71.2, I71.3, I71.4, I71.6) based on terminology update.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Severe Maternal Morbidity Procedures (2.16.840.1.113762.1.4.1029.256): Added 61 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Substance Abuse (2.16.840.1.113762.1.4.1029.320): Added 21 ICD-10-CM codes based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113762.1.4.1029.363): Renamed to Venous Thromboembolism in Pregnancy based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set White blood cells count lab test (2.16.840.1.113762.1.4.1045.129): Added 2 LOINC codes (12227-5, 92635-2) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jan 22, 2024