Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram

Last updated: May 3, 2018

CMS Measure ID: CMS109v3
Version: 3
NQF Number: None
Measure Description:

This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol.

Initial Patient Population:

Patients age 18 and older discharged from hospital inpatient acute care with a diagnosis of venous thromboembolism (VTE)and a length of stay less than or equal to 120 days.

Denominator Statement:

Patients with VTE confirmed through a diagnostic test and receiving IV UFH therapy

Denominator Exclusions:
  • Patients with comfort measures documented
  • Patients discharged to another hospital
  • Patients who left against medical advice
  • Patients who expired
  • Patients discharged to home for hospice care
  • Patients discharged to a health care facility for hospice care
Numerator Statement:
  • Patients who have their IV UFH therapy dosages and platelet counts monitored according to defined parameters such as a nomogram or protocol.
  • Patients who are on UFH therapy for less than 24 hours and have their UFH therapy dosages monitored according to defined parameters such as a nomogram or protocol.
Numerator Exclusions:

Not Applicable

Denominator Exceptions:


Measure Steward: The Joint Commission
Domain: Effective Clinical Care
Short Name: VTE4
Next Version:
Measure Score: Proportion
Score Type: Process
Improvement Notation:

An increase in rate


The unit of measurement for this measure is an inpatient episode of care. Each distinct hospitalization should be reported, regardless of whether the same patient is admitted for inpatient care more than once during the measurement period. In addition, the eMeasure logic intends to represent events within or surrounding a single occurrence of an inpatient hospitalization.

Treatment adjustment by protocol and/or use of a clinical pathway must be specific to unfractionated heparin therapy. Heparin protocols and clinical pathways may include use of a nomogram.

The construct of Unfractionated Heparin (route: 'Intravenous route') intends to capture continually infused heparin rather than heparin flushes or pushes.


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