Exclusive Breast Milk Feeding

Measure Information	2023 Reporting Period
Title	Exclusive Breast Milk Feeding
CMS eCQM ID	CMS9v11
Short Name	PC-05
CBE ID*	0480e
Measure Steward	The Joint Commission
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.
Measure Scoring	Proportion measure
Measure Type	Process
Stratification	*See CMS9v11.html
Risk Adjustment	*See CMS9v11.html
Rationale	*See CMS9v11.html
Clinical Recommendation Statement	*See CMS9v11.html
Improvement Notation	Improvement noted as an increase in the rate
Definition	*See CMS9v11.html
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. Show more > 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. Show less
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 Show more > 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 Show less
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 Show more > 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 Show less
Numerator	Inpatient hospitalizations for newborns who were fed breast milk only since birth
Numerator Exclusions	Not Applicable
Denominator Exceptions	None
Next Version	No Version Available
Previous Version	No Version Available

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Specifications

Additional Resources for CMS9v11

CMS9v11-TRN.xlsx

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

Compare Versions of: "Exclusive Breast Milk Feeding"

Additional Resources for CMS9v11

Header

Logic

Value set

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