Exclusive Breast Milk Feeding

Last updated: May 3, 2018

CMS Measure ID: CMS9v5
Version: 5
NQF Number: 0480
Measure Description:

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

Initial Patient Population:

Single newborns with an estimated gestational age at birth of >=37 weeks who are born in the hospital and 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

Denominator Statement:

Initial Population

Denominator Exclusions:

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

Numerator Statement:

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:
Previous Version:
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.

It is acceptable to calculate Gestational Age using the American College of Obstetricians and Gynecologists ReVITALize guidelines, which define Gestational Age as calculated using the best obstetrical Estimated Due Date (EDD) based on the formula:

Gestational Age= (280-(EDD-Reference Date))/7

where Reference Date is the date on which you are trying to determine gestational age. For PC-05, Reference Date is the Birth Date.

Note however that 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.

Notes: Value Set content updated Sept 2017

Specifications

Release Notes

Header

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Removed language to related to the PC-05a population which has been removed from the measure.

    Measure Section: Denominator

    Source of Change: JIRA (CQM-1691)

  • ​Removed language to related to the PC-05a population which has been removed from the measure.

    Measure Section: Denominator Exclusions

    Source of Change: JIRA (CQM-1691)

  • ​Removed language to related to the PC-05a population which has been removed from the measure.

    Measure Section: Description

    Source of Change: JIRA (CQM-1691)

  • Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • ​Removed language to related to the PC-05a population which has been removed from the measure.

    Measure Section: Guidance

    Source of Change: JIRA (CQM-1691)

  • Added guidance to support calculation of gestational age based on best obstetrical estimated due date (EDD).

    Measure Section: Guidance

    Source of Change: JIRA (CQM-1897)

  • Removed unit of measurement language from Guidance. HQMF now has a header field, 'measure item count', where the unit of measurement can be identified in a computable fashion.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • ​Removed language to related to the PC-05a population which has been removed from the measure.

    Measure Section: Numerator

    Source of Change: JIRA (CQM-1691)

Logic

  • Added new attribute 'diagnosis' to 'Encounter, performed' datatype to conform to QDM 4.2 changes and provide more accurate logic.

    Measure Section: Initial Population

    Source of Change: QDM Standards

  • Introduced the operator 'Intersection of' to condense logic and reduce complexity.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Introduced the operator 'Union of' to condense logic and reduce complexity.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Replaced datatypes 'Diagnosis, Active; with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Measure Section: Initial Population

    Source of Change: QDM Standards

  • ​Removed PC-05a population to align with updates to the chart-abstracted measure.

    Measure Section: Measure Population

    Source of Change: JIRA (CQM-1691)

  • Added new attribute 'diagnosis' to 'Encounter, performed' datatype to conform to QDM 4.2 changes and provide more accurate logic.

    Measure Section: QDM Data Elements

    Source of Change: QDM Standards

  • Removed 'Communication: From Patient to Provider: Feeding Intention Breast' using 'Feeding Intention Breast SNOMEDCT Value Set (2.16.849.1.113762.1.4.1045.29). The data element was used in the numerator of PC-05a. The data element is no longer needed as the PC-05a population has been removed from the measure.

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1691)

  • Replaced datatypes 'Diagnosis, Active; with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Measure Section: QDM Data Elements

    Source of Change: QDM Standards

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 Single Live Born Newborn Born in Hospital (2.16.840.1.113883.3.117.1.7.1.26): Deleted 2 ICD9CM codes (V30.00, V30.01).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Galactosemia (2.16.840.1.113883.3.117.1.7.1.35): Deleted 1 ICD9CM code (271.1).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Parenteral Nutrition (2.16.840.1.113883.3.117.1.7.1.38): Deleted 1 ICD9CM code (99.15).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

External Resources