Healthy Term Newborn

Last updated: July 12, 2017

CMS Measure ID: CMS185v5
Version: 5
NQF Number: 0716
Measure Description:

Percent of term singleton live births (excluding those with diagnoses originating in the fetal period) who DO NOT have significant complications during birth or the nursery care

Initial Patient Population:

All patients who are single liveborn term newborns born in a hospital

Denominator Statement:

The denominator is composed of singleton, term (>=37 weeks), inborn, livebirths in their birth admission. The denominator further has eliminated fetal conditions likely to be present before labor. Maternal and obstetrical conditions (eg hypertension, prior cesarean, malpresentation) are not excluded unless evidence of fetal effect prior to labor (eg IUGR/SGA).

Denominator Exclusions:

Denominator exclusions: multiple gestations, preterm, congenital anomalies or fetuses affected by selected maternal conditions

Numerator Statement:

The absence of conditions or procedures reflecting morbidity that happened during birth and nursery care to an otherwise normal infant

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: Centers for Medicare & Medicaid Services (CMS)
Domain: Patient Safety
Previous Version: Healthy Term Newborn
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

CMS suggests eligible hospitals participating in the Medicare & Medicaid EHR Incentive Programs not select CMS185/NQF0716: Healthy Term Newborn as one of their additional electronic clinical quality measures (eCQMs) for meaningful use. The measure steward is making substantial changes to this measure and is working with NQF on endorsement of the revised measure. CMS will review the changes to this measure and assess its feasibility for future implementation.

The very first step for this measure, identifying all term singleton infants can be surprisingly challenging. Some hospitals do not do a good job of using the proper v-codes or DRGs so that clinical information such as birthweight and gestational age need to be used in the first step.

The logic phrase AND: Occurrence A of Encounter, Performed: Inpatient Encounter (reason: 'Birth') intends to capture admission type of newborn for the encounter. Where this information is available in existing EHR structured fields (eg data that is fed to UB-04, field location 14), it can be used to map the criterion specified in the logic.

The logic phrase AND: Diagnosis, Active: Liveborn Born In Hospital starts during Occurrence A of Encounter, Performed: Inpatient Encounter intends to capture the point of origin for the inpatient admission. Where this information is available in existing EHR structured fields (eg data that is fed to UB-04, field location 15), it can be used to map the criterion specified in 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

Logic

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

    Section: Data Criteria

    Source: QDM Standards

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

    Section: Denominator Exclusions

    Source: QDM Standards

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

    Section: Initial Population

    Source: QDM Standards

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

    Section: Numerator

    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

Value Set

  • Value set Congenital Anomalies Group (2.16.840.1.113883.3.666.5.1570): Deleted 16 SNOMEDCT codes.

    Section: None

    Source: None

  • Value set Gestational age >= 37 weeks (2.16.840.1.113883.3.666.5.1596): Added 7 ICD10CM codes (Z3A.37, Z3A.38, Z3A.39, Z3A.40, Z3A.41, Z3A.42, Z3A.49).

    Section: None

    Source: None

  • Value set Social Reasons Group (2.16.840.1.113883.3.666.5.1595): Deleted 1 SNOMEDCT code (5015009).

    Section: None

    Source: None

External Resources