Venous Thromboembolism Prophylaxis

Last updated: May 3, 2018

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:
Previous Version:
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

Notes: Value Set content updated Jan 2017 and Sept 2017, TRNs updated Oct 2017

Specifications

Release Notes

Header

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: 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.

    Measure Section: Guidance

    Source of Change: 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.

    Measure Section: Guidance

    Source of Change: 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.

    Measure Section: Denominator Exclusions

    Source of Change: 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.

    Measure Section: Denominator Exclusions

    Source of Change: 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.

    Measure Section: Initial Population

    Source of Change: JIRA (CQM-581)

  • 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

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

    Measure Section: Numerator

    Source of Change: QDM Standards

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

    Measure Section: Numerator

    Source of Change: QDM Standards

  • 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

  • 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.

    Measure Section: QDM Data Elements

    Source of Change: QDM Standards

  • 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

  • Replaced datatypes 'Diagnosis, Inactive'; 'Diagnosis, Resolved' 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 Mental Disorders (2.16.840.1.113883.3.117.1.7.1.262): Removed Mental Disorders.

    Measure Section: QDM Data Elements

    Source of Change: Harmonization Review

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

    Measure Section: QDM Data Elements

    Source of Change: Harmonization Review

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

    Measure Section: QDM Variables

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

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

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

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

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

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

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

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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).

    Measure Section: QDM Data Elements

    Source of Change: 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).

    Measure Section: QDM Data Elements

    Source of Change: ICD-10 Addendum

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

    Measure Section: QDM Data Elements

    Source of Change: ICD-10 Addendum

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

    Measure Section: QDM Data Elements

    Source of Change: ICD-10 Addendum

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

    Measure Section: QDM Data Elements

    Source of Change: ICD-10 Addendum

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

    Measure Section: QDM Data Elements

    Source of Change: ICD-10 Addendum

  • Value set Glycoprotein IIb/IIIa Inhibitors (2.16.840.1.113762.1.4.1045.41): Added 5 RXNORM codes (1736470, 1736477, 1737466, 1737471, 1813035) and deleted 3 RXNORM codes (200326, 200348, 205253).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Direct Thrombin Inhibitor (2.16.840.1.113883.3.117.1.7.1.205): Added 3 RXNORM codes (1804735, 1804737, 1804738) and deleted 1 RXNORM code (1110708).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set General Surgery (2.16.840.1.113883.3.117.1.7.1.255): Deleted 48 ICD10PCS codes. Deleted 1 SNOMEDCT code (45608007).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Intracranial Neurosurgery (2.16.840.1.113883.3.117.1.7.1.260): Deleted 4 ICD10PCS codes (0N9200Z, 0N920ZZ, 0N9800Z, 0N980ZZ).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Obstetrics VTE (2.16.840.1.113883.3.117.1.7.1.264): Deleted 35 ICD9CM codes.

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Venous Thromboembolism (2.16.840.1.113883.3.117.1.7.1.279): Deleted 14 ICD9CM codes.

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Patient Refusal (2.16.840.1.113883.3.117.1.7.1.93): Added 3 SNOMEDCT codes (183946001, 183956002, 609589008).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set General or Neuraxial Anesthesia (2.16.840.1.113883.3.666.5.1743): Deleted 6 ICD10PCS codes (3E0F7DZ, 3E0F8DZ, 3E0R3CZ, 3E0S3CZ, 3E0T3CZ, 3E0X3CZ).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Hemorrhagic Stroke (2.16.840.1.113883.3.117.1.7.1.212): Deleted 2 ICD9CM codes (430, 431).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Deleted 12 ICD9CM codes.

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Added 78 ICD10CM codes and deleted 12 ICD10CM codes. Added 4 SNOMEDCT codes (459166009, 459167000, 713575004, 713576003) and deleted 6 SNOMEDCT codes (199094009, 200074009, 200080001, 237088009, 237246007, 66064007).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Mental Health Diagnoses (2.16.840.1.113883.3.464.1003.105.12.1004): Added 247 SNOMEDCT codes and deleted 23 SNOMEDCT codes. Added 1 ICD10CM code (F50.82) and deleted 13 ICD10CM codes.

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

External Resources