Elective Delivery

Last updated: May 3, 2018

CMS Measure ID: CMS113v6
Version: 6
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 to undergo a delivery procedure and had a length of stay less than or equal to 120 days that ends during the measurement period

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
Short Name: PC01
Next Version:
Previous Version:
Improvement Notation:

Improvement noted as a decrease in the rate

Guidance:

Stillbirth: v2017A of chart-abstracted measure PC-01: Elective Delivery contains a denominator exclusion data element for Stillbirth. The value set for eCQM Denominator Exclusion data element Assessment, Performed: Conditions Possibly Justifying Elective Delivery includes SNOMED CT and ICD-10-CM concepts representing Stillbirth and History of Stillbirth.

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.

Notes: Value Set content updated Sept 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 the following statement: 'Stillbirth: v2017A of chart-abstracted measure PC-01: Elective Delivery contains a denominator exclusion data element for Stillbirth. The value set for eCQM Denominator Exclusion data element 'Assessment, Performed: Conditions Possibly Justifying Elective Delivery' includes SNOMEDCT and ICD10CM concepts representing Stillbirth and History of Stillbirth' to align with the new chart-abstracted narrative data element and to help hospitals attempting to map to stillbirth documentation in their record.

    Measure Section: Guidance

    Source of Change: Chart Abstracted Measures

  • Added '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

  • Changed logic from: < 1 day(s) starts before start of ('Physical Exam, Performed: Time of Delivery' starts during Occurrence A of $EncounterInpatient) to < 1 day(s) starts before or concurrent with start of ('Occurrence A of Assessment, Performed: Time of Delivery' starts during Occurrence A of $EncounterInpatient).

    Measure Section: Denominator

    Source of Change: Measure Lead

  • Changed the datatype 'Physical Exam, Performed' to 'Assessment, Performed' for the data elements of Gestational Age, Time of Delivery, and Labor due to the QDM 4.3 changes.

    Measure Section: Denominator

    Source of Change: QDM Standards

  • Changed the datatype 'Physical Exam, Performed' to 'Assessment, Performed' for the data elements of Gestational Age, Time of Delivery, and Labor due to the 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.

  • 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: Measure Lead

  • Value set Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation (2.16.840.1.113883.3.117.1.7.1.286): 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: Measure Lead

  • 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: 2018 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).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

External Resources