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Exclusive Breast Milk Feeding

Last updated: May 16, 2019

CMS Measure ID: CMS9v6
Version: 6
NQF Number: 0480
Measure Description:

PC-05 Exclusive breast milk feeding during the newborn's entire hospitalization

Initial Patient Population:

Single newborns with an estimated gestational age at birth of >=37 weeks who are born in the hospital and who did not have a diagnosis of galactosemia, were not subject to parenteral nutrition, and had a length of stay less than or equal to 120 days that ends during the measurement period

Denominator Statement:

Initial Populationinfo-icon

Denominator Exclusions:

Newborns who were admitted to the Neonatal Intensive Care Unit (NICU), who were transferred to an acute care facility, or who expired during the hospitalization

Numerator Statement:

Newborns who were fed breast milk only since birth

Numerator Exclusions:

Not applicable

Denominator Exceptions:


Measure Steward: The Joint Commission
Short Name: BF
Next Version:
Previous Version:
Measure Scoring: Proportion
Measure Type: Process
Improvement Notation:

Improvement noted as an increase in the rate


A discharge to a designated cancer center or children's hospital should be captured as a discharge to an acute care facility.

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-05, Reference Date is the Birth Date.

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.


Release Notes



  • 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: Initial Population

    Source of Change: QDM Standards

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 setsinfo-icon.

  • Value set Single Live Born Newborn Born in Hospital (2.16.840.1.113883. Deleted 2 ICD9CM codes (V30.00, V30.01).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Galactosemia (2.16.840.1.113883. Deleted 1 ICD9CM code (271.1).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Parenteral Nutrition (2.16.840.1.113883. Deleted 1 ICD9CM code (99.15).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

External Resources