Incidence of Potentially-Preventable Venous Thromboembolism

Last updated: July 12, 2017

CMS Measure ID: CMS114v5
Version: 5
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 during the measurement period with a length of stay less than or equal to 120 days with a non-principal diagnosis of venous thromboembolism (VTE)

Denominator Statement:

Patients who developed VTE confirmed by a diagnostic test during hospitalization

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

Patients who did not receive VTE prophylaxis prior to the VTE diagnostic test order date

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Domain: Patient Safety
Short Name: VTE6
Previous Version: Incidence of Potentially-Preventable Venous Thromboembolism
Improvement Notation:

Improvement noted as a decrease in the rate

Guidance:

CMS recognizes the difficulty in capturing the VTE confirmed concept required in this measure and suggests eligible hospitals participating in the Medicare & Medicaid EHR Incentive Programs consider selecting alternative electronic clinical quality measures (eCQMs) to meet program requirements for meaningful use. If suitable alternatives are unavailable, CMS will accept a 0 denominator submission for the eCQM version only for this measure.

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

The denominator logic identifies the first confirmatory VTE diagnostic test because there are logic criteria dependent on the timing of the initial confirmation of the VTE diagnosis. Subsequent references to the VTE diagnostic test use occurrencing to ensure that the first confirmatory VTE diagnostic test is consistently used throughout the logic.

Addendum Notes: Removed from Hospital Quality Reporting

Specifications

Release Notes

Header

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Measure Lead

  • Added guidance statement to clarify use of 'First' operator for VTE diagnostic test.

    Section: Guidance

    Source: Measure Lead

  • 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.

    Section: Guidance

    Source: Measure Lead

Logic

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

    Section: Denominator Exclusions

    Source: QDM Standards

  • Added new attribute 'diagnosis' to 'Encounter, performed' datatype to conform to QDM 4.2 changes and provide more accurate logic.

    Section: Initial Population

    Source: QDM Standards

  • Introduced the operator 'Intersection of' to condense logic and reduce complexity.

    Section: Initial Population

    Source: Measure Lead

  • Introduced the operator 'Union of' to condense logic and reduce complexity.

    Section: Initial Population

    Source: Measure Lead

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

    Section: Initial Population

    Source: QDM Standards

  • Replaced 'Diagnosis, Active: XXX (ordinality: Principal)' datatype with 'Encounter, Performed: XXX (principal diagnosis: XXX)' datatype to conform with QDM 4.2 changes and provide more accurate logic.

    Section: Initial Population

    Source: QDM Standards

  • Added new attribute 'diagnosis' to 'Encounter, performed' datatype to conform to QDM 4.2 changes and provide more accurate logic.

    Section: QDM Data Elements

    Source: QDM Standards

  • Added new attribute 'principal diagnosis' to 'Encounter, performed' datatype to conform to QDM 4.2 changes and provide more accurate logic. Removed QDM data element Attribute: 'Ordinality: Principal' using 'Principal SNOMEDCT Value Set (2.16.840.1.113883.3.1.7.1.14.)’ to conform to QDM 4.2. changes and provide more accurate logic.

    Section: QDM Data Elements

    Source: QDM Standards

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

    Section: QDM Data Elements

    Source: QDM Standards

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

    Section: QDM Variables

    Source: QDM Standards

Value Set

  • Value set Injectable Factor Xa Inhibitor for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.211): Deleted 2 RXNORM codes (349308, 545076).

    Section: None

    Source: None

  • Value set Intermittent pneumatic compression devices (IPC) (2.16.840.1.113883.3.117.1.7.1.214): Added 2 SNOMEDCT codes (469317002, 469365001).

    Section: None

    Source: None

  • Value set Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39): Added 4 RXNORM codes (1658634, 1658637, 1659260, 1659263) and deleted 2 RXNORM codes (1361568, 1362837).

    Section: None

    Source: None

  • Value set Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219): Deleted 3 RXNORM codes (854258, 978717, 978761).

    Section: None

    Source: None

  • Value set Medical Contraindication (2.16.840.1.113883.3.117.1.7.1.412): Deleted 1 SNOMEDCT code (161590003).

    Section: None

    Source: None

  • Value set Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment (2.16.840.1.113883.3.117.1.7.1.134): Added 3 RXNORM codes (1599543, 1599551, 1599555).

    Section: None

    Source: None

  • Value set VTE Diagnostic Test (2.16.840.1.113883.3.117.1.7.1.276): Deleted 12 LOINC codes.

    Section: None

    Source: None

External Resources