Incidence of Potentially-Preventable Venous Thromboembolism

Last updated: May 3, 2018

CMS Measure ID: CMS114v3
Version: 3
NQF Number: None
Measure Description:

This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.

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 who developed VTE confirmed by a diagnostic test during hospitalization.

Denominator Exclusions:
  • Patients with comfort measures documented
  • Patients with a principal diagnosis of VTE
  • Patients with VTE present at admission
  • Patients with reasons for not administering mechanical and pharmacologic prophylaxis
Numerator Statement:

Patients who received no VTE prophylaxis prior to the VTE diagnostic test order date.

Numerator Exclusions:

Not Applicable

Denominator Exceptions:


Measure Steward: The Joint Commission
Domain: Patient Safety
Short Name: VTE6
Next Version:
Measure Score: Proportion
Score Type: Outcome
Improvement Notation:

A decrease in the 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.

When low dose unfractionated heparin is not administered due to medical reasons, the intended administration route is subcutaneous.

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


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