Exclusive Breast Milk Feeding

Last updated: July 12, 2017

CMS Measure ID: CMS9v4
Version: 4
NQF Number: 0480
Measure Description:

PC-05 Exclusive breast milk feeding during the newborn's entire hospitalization.

PC-05a Exclusive breast milk feeding during the newborn's entire hospitalization considering mother's choice.

Initial Patient Population:

Single term newborns born in the hospital who did not have a diagnosis of galactosemia, were not subject to parenteral nutrition, and had a length of stay less than or equal to 120 days.

Measure Population:

Not applicable

Measure Observations:

Not applicable

Denominator Statement:

PC-05 Single term newborns discharged from the hospital.

PC-05a Single term newborns discharged from the hospital.

Denominator Exclusions:

PC-05 Newborns who were admitted to the Neonatal Intensive Care Unit (NICU), who were transferred to an acute care facility, or who expired during the hospitalization.

PC-05a Newborns who were admitted to the Neonatal Intensive Care Unit (NICU), who were transferred to an acute care facility, who expired during the hospitalization, or whose mothers chose not to exclusively breast feed.

Numerator Statement:

PC-05 Newborns who were fed breast milk only since birth.

PC-05a Newborns who were fed breast milk only since birth.

Numerator Exclusions:

Not applicable

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Domain: Effective Clinical Care
Short Name: BF
Next Version: Exclusive Breast Milk Feeding
Previous Version: Exclusive Breast Milk Feeding
Measure Score: Proportion
Improvement Notation:

Improvement noted as an increase in the rate

Guidance:

A discharge to a designated cancer center or children's hospital should be captured as a discharge to an acute care facility.

The unit of measurement for this measure is an inpatient episode of care. Each distinct hospitalization should be reported, regardless of whether the same patient is admitted for inpatient care more than once during the measurement period. In addition, the eMeasure logic intends to represent events within or surrounding a single occurrence of an inpatient hospitalization.

Specifications

Release Notes

Header

  • Copyright updated.
  • eMeasure version number incremented.
  • eMeasure version number incremented from 4.0.000 to 4.1.000.

Logic

  • Changed data type of 'Result' or 'Finding' to 'Performed'.
  • Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions or 'satisfies any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
  • Introduced occurrencing on variables to enforce that the same instance of a clinical event is used throughout the measure when the logic within the variable does not limit the event to a single instance, e.g., FIRST or MOST RECENT.
  • Introduced the 'Intersection of' operator to specify the selection of the data sets common to all individual statements underneath the 'Intersection of'.
  • Introduced variable $EncounterInpatient to allow re-use of logical expressions and reduce redundancy/complexity.
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced timing relationship 'during' with 'starts during' where both a start datetime and an end datetime associated with a particular QDM element are not critical to fulfill the measure intent.
  • Revised timing constraint for 'Physical Exam, Performed: Estimated Gestational Age at Birth' to occur any time during the hospitalization, in the initial population logic.
  • The representation of the concept of birth date/time in the Denominator Exclusions logic was revised to use the 'Patient Characteristic, Birthdate' QDM datatype, in order align with other measures.
  • The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.

Value Sets

  • Value set Discharge to Acute Care Facility (OID 2.16.840.1.113883.3.117.1.7.1.87): Deleted 1 SNOMED code (306699001) and added 2 SNOMED codes (306703003, 434781000124105). Updated value set name from Discharge to Another Hospital to Discharge to Acute Care Facility.
  • Value set Galactosemia (OID 2.16.840.1.113883.3.117.1.7.1.35): Added 2 ICD10CM (E74.20, E74.29).
  • Value set Parenteral Nutrition (OID 2.16.840.1.113883.3.117.1.7.1.38): Updated value set name from Parenteral Infusion to Parenteral Nutrition and added 3 ICD10PCS codes (3E0336Z, 3E0536Z, 3E0636Z).

XML

  • This measure contains multiple Population Criteria sections. The earlier version of this measure contained mismatches between the applicable Population Criteria human readable narrative sections and their associated computer-readable sections in the XML file. This issue has been corrected.

External Resources