Venous Thromboembolism Prophylaxis

Last updated: August 7, 2017

CMS Measure ID: CMS108v5
Version: 5
NQF Number: 0371
Measure Description:

This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission

Initial Patient Population:

Patients age 18 and older discharged during the measurement period from hospital inpatient acute care with a length of stay less than or equal to 120 days, without a diagnosis of venous thromboembolism (VTE) or obstetrics

Denominator Statement:

All patients in the initial population

Denominator Exclusions:
  • Patients who have a length of stay less than 2 days
  • Patients with comfort measures documented anytime between arrival and the day after hospital admission
  • Patients with comfort measures documented by the day after surgery end date for surgeries that start the day of or the day after hospital admission
  • 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 equal to one day
  • Patients with a principal diagnosis of mental disorders or stroke
  • Patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries
Numerator Statement:

Patients who received VTE prophylaxis:

  • the day of or the day after hospital admission
  • the day of or the day after surgery end date for surgeries that end the day of or the day after hospital admission

Patients who have documentation of a reason why no VTE prophylaxis was given:

  • between arrival and hospital admission
  • the day of or the day after hospital admission
  • the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)
Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Domain: Patient Safety
Short Name: VTE1
Next Version: Venous Thromboembolism Prophylaxis
Previous Version: Venous Thromboembolism Prophylaxis
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

When low dose unfractionated heparin is not administered due to medical reasons, the intended administration route is subcutaneous

Addendum Notes: Value Set content updated

Specifications

Release Notes

Header

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Measure Lead

  • Removed guidance related to the intent of the logic related to IV heparin. This guidance is no longer needed due to updates to the content of the unfractionated heparin value set.

    Section: Guidance

    Source: Measure Lead

  • 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.

    Section: Guidance

    Source: Measure Lead

Logic

  • Replaced 'Diagnosis, Active: XXX (ordinality: Principal)' datatype with 'Encounter, Performed: XXX (principal diagnosis: XXX)' datatype to conform with QDM 4.2 changes and provide more accurate logic.

    Section: Denominator Exclusions

    Source: QDM Standards

  • Replaced Mental Disorders value set (OID 2.16.840.1.113883.3.117.1.7.1.262) with Mental Health Diagnoses value set (OID 2.16.840.1.113883.3.464.1003.105.12.1004) to harmonize across measures.

    Section: Denominator Exclusions

    Source: Harmonization Review

  • Added logic to expand allowable timing for VTE and obstetrics diagnoses to the ED visit. This allows patients who are diagnosed with a VTE or obstetrics diagnosed in the ED to be excluded from the initial population.

    Section: Initial Population

    Source: JIRA (CQM-581)

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

    Section: Initial Population

    Source: QDM Standards

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

    Section: Initial Population

    Source: Measure Lead

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

    Section: Numerator

    Source: QDM Standards

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

    Section: Numerator

    Source: QDM Standards

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

    Section: QDM Data Elements

    Source: QDM Standards

  • Added new attribute 'principal diagnosis' to 'Encounter, performed' datatype to conform to QDM 4.2 changes and provide more accurate logic. Removed QDM data element Attribute: 'Ordinality: Principal' using 'Principal SNOMEDCT Value Set (2.16.840.1.113883.3.1.7.1.14.)’ to conform to QDM 4.2. changes and provide more accurate logic.

    Section: QDM Data Elements

    Source: QDM Standards

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

    Section: QDM Data Elements

    Source: QDM Standards

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

    Section: QDM Data Elements

    Source: QDM Standards

  • Value set Mental Disorders (2.16.840.1.113883.3.117.1.7.1.262): Removed Mental Disorders.

    Section: QDM Data Elements

    Source: Harmonization Review

  • Value set Mental Health Diagnoses (2.16.840.1.113883.3.464.1003.105.12.1004): Added Mental Health Diagnoses.

    Section: QDM Data Elements

    Source: Harmonization Review

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

    Section: QDM Variables

    Source: QDM Standards

Value Set

  • Value set Direct Thrombin Inhibitor (2.16.840.1.113883.3.117.1.7.1.205): Deleted 1 RXNORM code (200322).

    Section: None

    Source: None

  • Value set General or Neuraxial Anesthesia (2.16.840.1.113883.3.666.5.1743): Added 3 SNOMEDCT codes (50697003, 74527005, 82776005).

    Section: None

    Source: None

  • Value set General Surgery (2.16.840.1.113883.3.117.1.7.1.255): Removed ICD9CM extensional value set (2.16.840.1.113883.3.117.1.7.1.362) including 214 codes.

    Section: None

    Source: None

  • Value set Gynecological Surgery (2.16.840.1.113883.3.117.1.7.1.257): Removed ICD9CM extensional value set (2.16.840.1.113883.3.117.1.7.1.312) including 21 codes.

    Section: None

    Source: None

  • Value set Hip Fracture Surgery (2.16.840.1.113883.3.117.1.7.1.258): Removed ICD9CM extensional value set (2.16.840.1.113883.3.117.1.7.1.324) including 1 code.

    Section: None

    Source: None

  • Value set Hip Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.259): Removed ICD9CM extensional value set (2.16.840.1.113883.3.117.1.7.1.320) including 11 codes.

    Section: None

    Source: None

  • Value set Injectable Factor Xa Inhibitor for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.211): Deleted 2 RXNORM codes (349308, 545076).

    Section: None

    Source: None

  • Value set Intermittent pneumatic compression devices (IPC) (2.16.840.1.113883.3.117.1.7.1.214): Added 2 SNOMEDCT codes (469317002, 469365001).

    Section: None

    Source: None

  • Value set Intracranial Neurosurgery (2.16.840.1.113883.3.117.1.7.1.260): Removed ICD9CM extensional value set (2.16.840.1.113883.3.117.1.7.1.345) including 13 codes.

    Section: None

    Source: None

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Added 3 SNOMEDCT codes (230701008, 307363008, 426107000) and deleted 5 SNOMEDCT codes (233964008, 288723005, 300920004, 64586002, 71444005). Deleted 18 ICD10CM codes.

    Section: None

    Source: None

  • Value set Knee Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.261): Removed ICD9CM extensional value set (2.16.840.1.113883.3.117.1.7.1.316) including 7 codes.

    Section: None

    Source: None

  • Value set Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39): Added 4 RXNORM codes (1658634, 1658637, 1659260, 1659263) and deleted 2 RXNORM codes (1361568, 1362837).

    Section: None

    Source: None

  • Value set Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219): Deleted 3 RXNORM codes (854258, 978717, 978761).

    Section: None

    Source: None

  • Value set Medical Reason (2.16.840.1.113883.3.117.1.7.1.473): Deleted 1 SNOMEDCT code (161590003).

    Section: None

    Source: None

  • Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Deleted 5 SNOMEDCT codes (200015003, 200016002, 200026009, 308551004, 405235009). Removed ICD9CM extensional value set (2.16.840.1.113883.3.117.1.7.1.272) including 828 codes.

    Section: None

    Source: None

  • Value set Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment (2.16.840.1.113883.3.117.1.7.1.134): Added 3 RXNORM codes (1599543, 1599551, 1599555).

    Section: None

    Source: None

  • Value set Unfractionated Heparin (2.16.840.1.113883.3.117.1.7.1.218): Added 4 RXNORM codes (1658717, 1658720, 1659195, 1659197) and deleted 9 RXNORM codes (1361048, 1361226, 1361568, 1361574, 1361577, 1361613, 1361615, 1362831, 1362837).

    Section: None

    Source: None

  • Value set Urological Surgery (2.16.840.1.113883.3.117.1.7.1.272): Removed ICD9CM extensional value set (2.16.840.1.113883.3.117.1.7.1.332) including 31 codes.

    Section: None

    Source: None

  • Value set Hemorrhagic Stroke (2.16.840.1.113883.3.117.1.7.1.212): Added 1 ICD10CM code (I60.2) and deleted 3 ICD10CM codes (I60.20, I60.21, I60.22).

    Section: None

    Source: ICD-10 Addendum

  • Value set Hip Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.259): Added 8 ICD10PCS codes (0SPA0JZ, 0SPE0JZ, 0SPR0JZ, 0SPS0JZ, 0SWA0JZ, 0SWE0JZ, 0SWR0JZ, 0SWS0JZ).

    Section: None

    Source: ICD-10 Addendum

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Added 18 ICD10CM codes.

    Section: None

    Source: ICD-10 Addendum

  • Value set Knee Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.261): Added 18 ICD10PCS codes.

    Section: None

    Source: ICD-10 Addendum

  • Value set Mental Health Diagnoses (2.16.840.1.113883.3.464.1003.105.12.1004): Added 13 ICD10CM codes.

    Section: None

    Source: ICD-10 Addendum

  • Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Added 67 ICD10CM codes.

    Section: None

    Source: ICD-10 Addendum

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