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Venous Thromboembolism Prophylaxis

Last updated: September 14, 2018

CMS Measure ID: CMS108v7
Version: 7
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 populationinfo-icon

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: VTE-1
Previous Version:
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

When low dose unfractionated heparin is administered for VTE Prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous.

Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., patient out of bed and ambulating in halls - no VTE prophylaxis needed.

Meaningful Measure: Preventive Care

Specifications

Release Notes

Header

  • Updated Version Number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Added statement to header guidance regarding documentation requirements of reasons for no pharmacologic and no mechanical VTE prophylaxis. Statement clarifies guidance to better meet measure intent.

    Measure Section: Guidance

    Source of Change: JIRAinfo-icon (CQMinfo-icon-2870)

  • Reworded the statement regarding administration of low dose unfractionated heparin to make it more clear.

    Measure Section: Guidance

    Source of Change: Measure Lead

Logic

  • Added 'code' attribute to all datatypes to conform with QDMinfo-icon 5.3 changes.

    Measure Section: Denominator Exclusionsinfo-icon

    Source of Change: Standards Update

  • Modeled the Location attribute for Encounter, Performed to allow for describing the patient’s presence in more than one location during an individual Encounter to conform with QDM 5.3 changes.

    Measure Section: Denominator Exclusions

    Source of Change: Standards Update

  • Replaced 'Encounter, Performed: ICU Admission or Transfer' with an attribute of facility location in 'Intensive Care Unit' to better align with the intent of the measure.

    Measure Section: Denominator Exclusions

    Source of Change: JIRA (CQM-2172)

  • Added 'AuthorDateTime' attribute to QDM datatypes that include negation rationale: 'Medication, Not Administered', 'Medication, Not Ordered', 'Device, Not Applied', and 'Device, Not Ordered' to conform with QDM 5.3 changes.

    Measure Section: Numeratorinfo-icon

    Source of Change: Standards Update

  • Added supplemental timing attributes to most datatypes in QDM 5.3 to facilitate accurate retrieval of time related information within CQLinfo-icon logic. Timing attributes now include a time interval, such as prevalence period or relevant period, and/or actual time of documentation with Author Datetime. Relevant period is the general method to describe start and stop times for datatypes. Prevalence period is used for some datatypes to more accurately define onset and abatement times.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Assigned cardinality to each attribute to be more explicit in guiding specificationinfo-icon and implementation of QDM data elements. Cardinality refers to the number of instances of the attribute that can be included in the measure description. Cardinality for most attributes is 0.. 1 (i.e., can occur up to 1 time), but some attributes have a cardinality of 0.. * (i.e., can occur multiple times).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • CQL libraries contain sets of CQL definitions, or CQL expression statements. A context statement, patient or population, can now be used in a CQL library to clearly establish how the subsequent list of CQL expressions will be interpreted. A 'Population' context will interpret the CQL expression with reference to the entire population of the item being counted, patients or encounters. A 'Patient' context will interpret the CQL expression with reference to a single patient. Context statements are not required, but one or more context statements may be used within a library to help clarify how the CQL expressions will be interpreted. Patient context is the default if none is specified.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Replaced measure-defined definitions with similar definitions and functions from CQL shared libraries for consistency across measures.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated measure logic from Quality Data Model (QDM)-based logic to Clinical Quality Language (CQL)-based logic. Information on CQL can be found at the eCQI Resource centerinfo-icon (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Setinfo-icon

The VSACinfo-icon is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39): Added 4 RXNORM codes (1361226, 1361568, 1658647, 1658659).

    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 1 RXNORM code (1723476).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set ICU Admission or Transfer (2.16.840.1.113883.3.117.1.7.1.305): Removed ICU Admission or Transfer.

    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 6 SNOMEDCT codes (18319008, 235326000, 235331003, 275015005, 37572001, 83462004).

    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): Added 4 ICD10CM codes (O03.85, O04.85, O08.7, O87.8) and deleted 1 ICD10CM code (O87.0). Deleted 2 SNOMEDCT codes (72044001, 88980002).

    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): Deleted 2 SNOMEDCT codes (183956002, 385648002).

    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 1 SNOMEDCT code (28837001).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 11 SOP codes (299, 32127, 32128, 391, 517, 524, 614, 621, 622, 623, 629) and deleted 3 SOP codes (63, 64, 69).

    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 4 SNOMEDCT codes (13010001, 1938002, 200117009, 88980002). Added 185 ICD10CM codes.

    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): Deleted 59 SNOMEDCT codes. Added 12 ICD10CM codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Intensive Care Unit (2.16.840.1.113762.1.4.1110.23): Added Intensive Care Unit.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Replaced LOINC single code value sets with direct referenced codes. A direct referenced code is a single concept code that is used to describe a clinical element directly within the logic. The use of direct referenced codes replaces the need for single code value sets. Measures using other code systems in single value sets may optionally transition to direct referenced codes.

    Measure Section: QDM Data Elements

    Source of Change: Standards Update

  • Value set Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39): Added 1 RXNORM code (1798389).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment (2.16.840.1.113883.3.117.1.7.1.134): Added 2 RXNORM codes (1927856, 1927864).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Direct Thrombin Inhibitor (2.16.840.1.113883.3.117.1.7.1.205): Added 3 RXNORM codes (1798389, 1997015, 1997017).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set General Surgery (2.16.840.1.113883.3.117.1.7.1.255): Deleted 3 SNOMEDCT codes (287330000, 359604006, 359606008).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Gynecological Surgery (2.16.840.1.113883.3.117.1.7.1.257): Deleted 10 SNOMEDCT codes (112917009, 14353000, 176909001, 27950001, 307263006, 307264000, 31545000, 4010009, 53139002, 59750000).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Hip Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.259): Deleted 1 SNOMEDCT code (339905004).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Payer (2.16.840.1.114222.4.11.3591): Deleted 1 SOP code (24).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Added 18 ICD10CM codes and deleted 1 ICD10CM code (O86.0). Deleted 21 SNOMEDCT codes.

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Added 2 ICD10CM codes (I63.81, I63.89) and deleted 1 ICD10CM code (I63.8).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Mental Health Diagnoses (2.16.840.1.113883.3.464.1003.105.12.1004): Added 353 SNOMEDCT codes and deleted 222 SNOMEDCT codes. Added 1 ICD10CM code (F32.8).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

External Resources