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Elective Delivery

Last updated: September 14, 2018

CMS Measure ID: CMS113v7
Version: 7
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: PC-01
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 exclusioninfo-icon data element for Stillbirth. The value setinfo-icon for eCQMinfo-icon 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.

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

Logic

  • Added two value setsinfo-icon for procedures, performed to the history of prior uterine surgery procedure to better align with the clinical intent and the chart-abstracted version of the measure.

    Measure Section: Numeratorinfo-icon

    Source of Change: Measure Lead

  • Added supplemental timing attributes to most datatypes in QDMinfo-icon 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 sets.

  • Value set Dinoprostone (2.16.840.1.113762.1.4.1045.56): Added 1 RXNORM code (197619).

    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 Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation (2.16.840.1.113883.3.117.1.7.1.286): Added 3 ICD10CM codes (O26.611, O26.612, O26.613) and deleted 1 ICD10CM code (O90.3).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Uterine Horn (2.16.840.1.113762.1.4.1110.24): Added Uterine Horn.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Metroplasty (2.16.840.1.113762.1.4.1110.25): Added Metroplasty.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Artificial Rupture of Membranes (2.16.840.1.113762.1.4.1045.57): Added 1 SNOMEDCT code (408817009).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Delivery Procedures (2.16.840.1.113762.1.4.1045.59): Added 27 SNOMEDCT codes.

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Cesarean Birth (2.16.840.1.113883.3.117.1.7.1.282): Added 1 SNOMEDCT code (709004006).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Medical Induction of Labor (2.16.840.1.113883.3.117.1.7.1.288): Added 3 ICD10PCS codes (3E0DXGC, 3E0P3VZ, 3E0P7VZ). Added 4 SNOMEDCT codes (225245001, 236971007, 237001001, 288191008).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Perforation of Uterus (2.16.840.1.113762.1.4.1110.14): Added 1 SNOMEDCT code (236738001).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Uterine Rupture (2.16.840.1.113762.1.4.1110.16): Added 2 SNOMEDCT codes (199958008, 23431000119106).

    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 Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation (2.16.840.1.113883.3.117.1.7.1.286): Added 9 ICD10CM codes (O30.131, O30.132, O30.133, O30.231, O30.232, O30.233, O30.831, O30.832, O30.833) and deleted 6 ICD10CM codes (O16.9, O43.219, O44.20, O44.30, O44.40, O44.50). Deleted 5 SNOMEDCT codes (200473005, 200474004, 37382001, 57480000, 80190007).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

External Resources