Elective Delivery

Last updated: September 15, 2017

CMS Measure ID: CMS113v5
Version: 5
NQF Number: 0469
Measure Description:

Patients with elective vaginal deliveries or elective cesarean births at >= 37 and < 39 weeks of gestation completed

Initial Patient Population:

Patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care and had a length of stay < 120 days who undergo a delivery procedure

Denominator Statement:

Patients delivering newborns with >= 37 and < 39 weeks of gestation completed

Denominator Exclusions:

Patients with conditions possibly justifying elective delivery prior to 39 weeks gestation

Numerator Statement:

Patients with elective deliveries by either:

  • Medical induction of labor while not in labor prior to the procedure
  • Cesarean birth while not in labor and with no history of a prior uterine surgery
Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Domain: Effective Clinical Care
Short Name: PC01
Next Version: Elective Delivery
Previous Version: Elective Delivery
Improvement Notation:

Improvement noted as a decrease in the rate

Guidance:

Wherever the gestational age is mentioned with relative timing to delivery, the intent is to capture the estimated gestational age on the day of delivery.

It is acceptable to calculate Gestational Age using the American College of Obstetricians and Gynecologists ReVITALize guidelines, which define Gestational Age as calculated using the best obstetrical Estimated Due Date (EDD) based on the formula:

Gestational Age= (280-(EDD-Reference Date))/7

where Reference Date is the date on which you are trying to determine gestational age. For PC-01, Reference Date is the Date of Delivery.

Note however that the calculation may yield a non-whole number and gestational age should be rounded off to the nearest completed week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.

Addendum Notes: Value Set content updated, Jan 2017 and Sept 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

  • Added guidance to support calculation of gestational age based on best obstetrical estimated due date (EDD).

    Measure Section: Guidance

    Source of Change: JIRA (CQM-1897)

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

    Measure Section: Data Criteria

    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: Denominator Exclusions

    Source of Change: QDM Standards

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

    Measure Section: Denominator Exclusions

    Source of Change: QDM Standards

  • Removed ICD-9-CM stand-alone value sets for which the existing ICD-10-PCS value set addresses the same concept.

    Measure Section: Initial Population

    Source of Change: JIRA (CQM-1639)

  • Added 2 in-line comments to identify logic representing:- Cesarean birth while not in labor and no history of prior uterine surgery- medical induction of labor while not in labor.

    Measure Section: Numerator

    Source of Change: Measure Lead

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

    Measure Section: Numerator

    Source of Change: QDM Standards

  • Where appropriate, added ICD10 codes and created grouping value sets including both SNOMEDCT and ICD10CM or ICD10PCS representations of numerator conditions, including Perforation of Uterus, Uterine Rupture, Cornual Ectopic Pregnancy, and Transabdominal Cerclage.

    Measure Section: Numerator

    Source of Change: Annual Update

  • ​Removed the ICD-9 Value Set from the 'Cesarean Birth Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.282)'​.

    Measure Section: QDM Data Elements

    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: QDM Data Elements

    Source of Change: QDM Standards

  • Removed ICD-9-CM stand-alone value sets for which the existing ICD-10-PCS value set addresses the same concept.

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1639)

  • 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

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • ​Removed the ICD-9-CM Value Set from the 'Cesarean Birth Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.282)'​.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Cesarean Birth (2.16.840.1.113883.3.117.1.7.1.282): Removed ICD9CM extensional value set (2.16.840.1.113883.3.117.1.7.1.368) including 5 codes and added 2 SNOMEDCT codes (450483001, 450484007).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Classical Cesarean Birth (2.16.840.1.113883.3.117.1.7.1.421): Removed ICD9CM extensional value set (2.16.840.1.113883.3.117.1.7.1.420) including 1 code.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation (2.16.840.1.113883.3.117.1.7.1.286): Deleted 1 SNOMEDCT code (308551004).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value Set Cornual Ectopic Pregnancy: created grouping value set (2.16.840.1.113762.1.4.1110.12) and added 1 ICD-10-CM code (O00.8).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Dinoprostone (2.16.840.1.113762.1.4.1045.56): Added 2 RXNORM codes (309922, 597957) and deleted 1 RXNORM code (197619).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Oxytocin (2.16.840.1.113762.1.4.1045.55): Deleted 1 RXNORM code (1249598).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value Set Perforation of Uterus: Created grouping value set (2.16.840.1.113762.1.4.1110.14) and added 1 ICD-10-CM code (O71.81).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value Set Transabdominal Cerclage: Created grouping value set (2.16.840.1.113762.1.4.1110.18) and added 13 ICD-10-PCS codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value Set Uterine Rupture: Created grouping value set (2.16.840.1.113762.1.4.1110.16) and added 4 ICD-10-CM codes (O71.00, O71.02, O71.03, O71.1).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation (2.16.840.1.113883.3.117.1.7.1.286): Added 18 ICD10CM codes and deleted 18 ICD10CM codes.

    Measure Section: QDM Data Elements

    Source of Change: ICD-10 Addendum

  • Value set Cornual Ectopic Pregnancy (2.16.840.1.113762.1.4.1110.12): Added 2 ICD10CM codes (O00.80, O00.81).

    Measure Section: QDM Data Elements

    Source of Change: ICD-10 Addendum

  • Value set Oxytocin (2.16.840.1.113762.1.4.1045.55): Added 1 RXNORM code (1791721) and deleted 6 RXNORM codes (312191, 317139, 486591, 486593, 486596, 486598).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Medical Induction of Labor (2.16.840.1.113883.3.117.1.7.1.288): Added 1 ICD10PCS code (3E0P7GC) and deleted 4 ICD10PCS codes (10900ZC, 10903ZC, 10904ZC, 10908ZC). Deleted 3 ICD9CM codes (73.01, 73.1, 73.4).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Cornual Ectopic Pregnancy (2.16.840.1.113762.1.4.1110.12): Deleted 1 ICD10CM code (O00.8).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation (2.16.840.1.113883.3.117.1.7.1.286): Added 30 ICD10CM codes and deleted 9 ICD10CM codes (O12.11, O12.12, O12.13, O12.21, O12.22, O12.23, O26.611, O26.612, O26.613). Deleted 73 ICD9CM codes. Added 4 SNOMEDCT codes (459166009, 459167000, 713575004, 713576003) and deleted 3 SNOMEDCT codes (237246007, 240611008, 62246005).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

External Resources