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Venous Thromboembolism Prophylaxis

Compare Versions of: "Venous Thromboembolism Prophylaxis"

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

Compare 2026 version to

Table Options
Measure Information 2026 Reporting Period
Title Venous Thromboembolism Prophylaxis
CMS eCQM ID CMS108v14
Short Name

VTE-1

CBE ID* Not Applicable
Measure Steward The Joint Commission
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 end the day after hospital...

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Measure Scoring Proportion measure
Measure Type Process
Stratification

None

Risk Adjustment

None

Rationale

The estimated annual incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), ranges from 350,000 to 600,000 (Maynard, 2016). According to the Centers for Disease Control and Prevention (CDC) 2020 statistics, 1-2 per 1,000...

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Clinical Recommendation Statement

Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for acutely ill hospitalized patients at high risk for developing a deep vein thrombosis or dying from a pulmonary embolism. Screening all patients is the only evidence-based practice...

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Improvement Notation

Increased score indicates improvement

Definition

None

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 medical doctor, advanced...

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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 that ends during the measurement period

Denominator

Equals 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...

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Numerator

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 after hospital admission)

Inpatient hospitalizations for patients who have...

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Numerator Exclusions

None

Denominator Exceptions

None

Next Version No Version Available
Previous Version

Header

TRN

Measure Section

Source of Change

Updated 'eCQM Identifier (Measure Authoring Tool)' field to 'CMS ID' based on tooling update.

CMS ID

Standards/Technical Update

Updated the eCQM version number.

eCQM Version Number

Annual Update

Updated measurement period to reflect exact dates of reporting.

Measurement Period

Standards/Technical Update

Updated the Description to better align with updates to the Numerator statement.

Description

Measure Lead

Updated copyright.

Copyright

Annual Update

Updated disclaimer.

Disclaimer

Annual Update

Updated Improvement Notation field to read 'Increased score indicates improvement' based on tooling update to promote alignment across measures.

Improvement Notation

Standards/Technical Update

Added new guidance clarifying when Oral Factor Xa medications are acceptable to count toward the Numerator for better alignment with logic.

Guidance

Test Case Review

Removed reference to the 'Surgical Care Improvement Project (SCIP)' when describing selected surgery types qualifying for the Denominator Exclusions and added guidance to clarify the specific surgeries included in 'Selected Surgery' logic definition in the Guidance field.

Guidance

Measure Lead

Added clarification that patient refusal is the only reason for no pharmacological and no mechanical VTE prophylaxis that may be documented by a nurse.

Guidance

Measure Lead

Added guidance noting that there is not a specific risk assessment model or tool that is required to determine VTE risk for this measure.

Guidance

ONC Project Tracking System (JIRA): CQM-7034

Removed reference to the 'Surgical Care Improvement Project (SCIP)' when describing selected surgery types qualifying for the Denominator Exclusions and added guidance to clarify the specific surgeries included in 'Selected Surgery' logic definition in the Guidance field.

Denominator Exclusions

Measure Lead

Updated the description of surgery timing constraints to better align with the measure intent and logic definitions.

Denominator Exclusions

Measure Lead

Updated the description of surgery timing constraints to better align with the measure intent and logic definitions.

Numerator

Measure Lead

Updated Numerator Exclusions field to read 'None' instead of 'Not Applicable' when no exclusions present to promote alignment across header fields.

Numerator Exclusions

Standards/Technical Update

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

Multiple Sections

Annual Update

Updated references and measure header to reflect current evidence and new or updated literature.

Multiple Sections

Measure Lead

Logic

TRN

Measure Section

Source of Change

Updated definition names and alias for clarification and to better align with the removal of 'SCIP' in the Denominator Exclusions narrative section.

Denominator Exclusions

Measure Lead

Updated the version number of the TJC Overall Library to v9.0.000.

Definitions

Annual Update

Updated the version number of the VTE Library to v9.0.000.

Definitions

Annual Update

Updated the version number of the Global Shared Library to v9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM'.

Definitions

Annual Update

Updated definition names and alias for clarification and to better align with the removal of 'SCIP' in the Denominator Exclusions narrative section.

Definitions

Measure Lead

Updated the CQL library name from 'CMS108-v13-0-000-QDM-5-6.cql' to 'CMS108VTEProphylaxis-14.2.000.cql' based on recommendation by technical experts.

Definitions

Standards/Technical Update

Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

Definitions

Standards/Technical Update

Relocated the timing condition function, VTE.FromDayOfStartOfHospitalizationToDayAfterAdmission, from shared VTE Library directly to the measure logic because the function is no longer shared with VTE-2.

Functions

Measure Lead

Updated the version number of the Global Shared Library to v9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM'.

Functions

Annual Update

Updated the version number of the TJC Overall Library to v9.0.000.

Functions

Annual Update

Updated the version number of the VTE Library to v9.0.000.

Functions

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.

TRN

Measure Section

Source of Change

Replaced value set used for Sex Supplemental Data Element (SDE) ONC Administrative Sex (2.16.840.1.113762.1.4.1) with value set Federal Administrative Sex (2.16.840.1.113762.1.4.1021.121) based on updated standards.

Terminology

Standards/Technical Update

Value set Atrial Fibrillation or Flutter (2.16.840.1.113883.3.117.1.7.1.202): Deleted 1 SNOMED CT code (195080001) based on terminology update.

Terminology

Annual Update

Value set General Surgery (2.16.840.1.113883.3.117.1.7.1.255): Added 4 SNOMED CT codes (176006006, 36432003, 1299162005, 274026006) based on terminology update. Deleted 14 SNOMED CT codes based on terminology update.

Terminology

Annual Update

Value set Hip Fracture Surgery (2.16.840.1.113883.3.117.1.7.1.258): Added 1 SNOMED CT code (119614000) based on terminology update. Deleted 1 SNOMED CT code (265745003) based on terminology update. Added 24 ICD-10-PCS codes based on terminology update.

Terminology

Annual Update

Value set Hip Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.259): Added 3 SNOMED CT codes (1290059002, 43660001, 69625007) based on terminology update. Deleted 12 SNOMED CT codes based on terminology update.

Terminology

Annual Update

Value set Intracranial Neurosurgery (2.16.840.1.113883.3.117.1.7.1.260): Added 9 SNOMED CT codes (273990004, 1287541008, 1296603004, 1296604005, 1296605006, 1296606007, 1296607003, 1296608008, 1296626006) based on terminology update. Deleted 8 SNOMED CT codes (19994000, 21205002, 243570009, 27968003, 34719005, 51991009, 79272003, 80460006) based on terminology update.

Terminology

Annual Update

Value set Knee Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.261): Deleted 2 SNOMED CT codes (179344006, 179351002) based on terminology update.

Terminology

Annual Update

Value set Mental Health Diagnoses (2.16.840.1.113883.3.464.1003.105.12.1004): Added 8 SNOMED CT codes (1339031006, 128293007, 19886006, 405790001, 67698009, 763626009, 80193009, 86110000) based on terminology update. Deleted 18 SNOMED CT codes based on terminology update. Added 27 ICD-10-CM codes based on terminology update.

Terminology

Annual Update

Value set Obstetrical or Pregnancy Related Conditions (2.16.840.1.113883.3.117.1.7.1.263): Added 9 SNOMED CT codes (10755381000119108, 1258895002, 1287713006, 156222001, 16316801000119102, 199248002, 270500004, 7870007, 95121000119108) based on terminology update. Deleted 10 SNOMED CT codes (10812081000119108, 198878009, 199205008, 199870008, 199881006, 199890004, 199901007, 200051005, 63662002, 86196005) based on terminology update.

Terminology

Annual Update

Value set Patient Refusal (2.16.840.1.113883.3.117.1.7.1.93): Added 1 SNOMED CT code (1296859006) based on terminology update. Deleted 1 SNOMED CT code (105480006) based on terminology update.

Terminology

Annual Update

Value set Urological Surgery (2.16.840.1.113883.3.117.1.7.1.272): Added 2 SNOMED CT codes (176025009, 40173000) based on terminology update. Deleted 1 SNOMED CT code (57212002) based on terminology update.

Terminology

Annual Update

Value set Venous Thromboembolism (2.16.840.1.113883.3.117.1.7.1.279): Added 4 ICD-10-CM codes (I26.03, I26.04, I26.95, I26.96) based on terminology update. Added 26 SNOMED CT codes based on terminology update.

Terminology

Annual Update

Last Updated: May 06, 2025