Venous Thromboembolism Prophylaxis

Last updated: October 25, 2017

CMS Measure ID: CMS108v6
Version: 6
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 from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period

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
Short Name: VTE1
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 Sept 2017, TRNs updated Oct 2017

Specifications

Release Notes

Header

  • Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Added 'Patients age 18 and older discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period' to the Initial Population narrative statement to better align with the logic.

    Measure Section: Initial Population

    Source of Change: JIRA (CQM-2520)

Logic

  • Replaced 'Unfractionated Heparin for VTE prophylaxis ingredient specific' value set with 'Low Dose Unfractionated Heparin for VTE Prophylaxis' semantic clinical drug value set to ease implementation burden.

    Measure Section: Numerator (QDM Variable)

    Source of Change: JIRA (CQM-1835)

  • Replaced 'Low Molecular Weight Heparin for VTE prophylaxis ingredient specific' value set with 'Low Molecular Weight Heparin for VTE Prophylaxis' semantic clinical drug value set to ease implementation burden.

    Measure Section: Numerator (QDM Variable)

    Source of Change: JIRA (CQM-1835)

  • Replaced 'Injectable factor Xa inhibitor for VTE prophylaxis ingredient specific' value set with 'Injectable factor Xa inhibitor for VTE Prophylaxis' semantic clinical drug value set to ease implementation burden.

    Measure Section: Numerator (QDM Variable)

    Source of Change: JIRA (CQM-1835)

  • Replaced 'Warfarin-only ingredient specific' value set with 'Warfarin' semantic clinical drug value set to ease implementation burden.

    Measure Section: Numerator (QDM Variable)

    Source of Change: JIRA (CQM-1835)

  • Replaced temporal operator 'starts after start of' with 'starts after or concurrent with start of' to allow for concurrent data capture.

    Measure Section: Denominator Exclusions

    Source of Change: JIRA (CQM-2125)

  • Replaced temporal operator 'starts after end of' with 'starts after or concurrent with end of' to allow for concurrent data capture.

    Measure Section: Denominator Exclusions

    Source of Change: JIRA (CQM-2125)

  • Replaced temporal operator 'ends after start of' with 'ends after or concurrent with start of' to allow for concurrent data capture.

    Measure Section: Denominator Exclusions

    Source of Change: JIRA (CQM-2125)

  • Replaced temporal operator 'starts after start of' with 'starts after or concurrent with start of' to allow for concurrent data capture.

    Measure Section: Numerator

    Source of Change: JIRA (CQM-2125)

  • Replaced temporal operator 'starts after end of' with 'starts after or concurrent with end of' to allow for concurrent data capture.

    Measure Section: Numerator

    Source of Change: JIRA (CQM-2125)

  • Replaced temporal operator 'ends after start of' with 'ends after or concurrent with start of' to allow for concurrent data capture.

    Measure Section: Numerator

    Source of Change: JIRA (CQM-2125)

  • Replaced 'Risk Category Assessment' datatype with 'Assessment, Performed' datatype to conform with QDM 4.3 changes.

    Measure Section: Numerator

    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.

  • Replaced Warfarin-only ingredient specific value set (2.16.840.1.113762.1.4.1021.10) with Warfarin (2.16.840.1.113883.3.117.1.7.1.232) value set.

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1835)

  • Replaced Injectable factor Xa inhibitor for VTE prophylaxis ingredient specific value set (2.16.840.1.113762.1.4.1021.11) with Injectable factor Xa inhibitor for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.211) value set.

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1835)

  • Replaced Low Molecular Weight Heparin for VTE prophylaxis ingredient specific value set (2.16.840.1.113762.1.4.1021.12) with Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219) value set.

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1835)

  • Replaced Unfractionated Heparin for VTE prophylaxis ingredient specific value set (2.16.840.1.113762.1.4.1021.13) with Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39) value set.

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1835)

  • 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: Annual Update

  • 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: Annual Update

  • 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: Annual Update

  • 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: Annual Update

  • 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: Annual Update

  • 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: Annual Update

  • 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: Annual Update

  • Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Added 78 ICD10CM codes and deleted 8 ICD10CM codes (O00.0, O00.1, O00.2, O00.8, O00.9, O33.7, O34.21, O70.2). Added 4 SNOMEDCT codes (459166009, 459167000, 713575004, 713576003) and deleted 4 SNOMEDCT codes (200074009, 200080001, 237088009, 237246007).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Mental Health Diagnoses (2.16.840.1.113883.3.464.1003.105.12.1004): Added 180 SNOMEDCT codes and deleted 22 SNOMEDCT codes. Deleted 365 ICD9CM codes. Deleted 13 ICD10CM codes.

    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): Deleted 48 ICD10PCS codes. Deleted 1 SNOMEDCT code (45608007).

    Measure Section: QDM Data Elements

    Source of Change: 2018 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: 2018 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: 2018 Addendum

  • Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Deleted 4 ICD10CM codes (O00.10, O00.11, O00.20, O00.21). Deleted 2 SNOMEDCT codes (199094009, 66064007).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • Value set Mental Health Diagnoses (2.16.840.1.113883.3.464.1003.105.12.1004): Added 69 SNOMEDCT codes and deleted 3 SNOMEDCT codes (21061000119107, 231457005, 231535000). Added 1 ICD10CM code (F50.82).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

External Resources