Last updated: June 9, 2017
| CMS Measure ID: | CMS108v6 |
|---|---|
| Version: | 6 |
| NQF Number: | 0371 |
| Measure Description: |
This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission |
| Initial Patient Population: |
Patients age 18 and older discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period |
| Denominator Statement: |
All patients in the initial population |
| Denominator Exclusions: |
* Patients who have a length of stay less than 2 days * Patients with comfort measures documented anytime between arrival and the day after hospital admission * Patients with comfort measures documented by the day after surgery end date for surgeries that start the day of or the day after hospital admission * Patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day * Patients with a principal diagnosis of mental disorders or stroke * Patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries |
| Numerator Statement: |
Patients who received VTE prophylaxis: - the day of or the day after hospital admission - the day of or the day after surgery end date for surgeries that end the day of or the day after hospital admission Patients who have documentation of a reason why no VTE prophylaxis was given: - between arrival and hospital admission - the day of or the day after hospital admission - the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission) |
| Numerator Exclusions: |
Not Applicable |
| Denominator Exceptions: |
None |
| Measure Steward: | The Joint Commission |
| Short Name: | VTE1 |
| Previous Version: | Venous Thromboembolism Prophylaxis |
| Improvement Notation: |
Improvement noted as an increase in rate |
| Guidance: |
When low dose unfractionated heparin is not administered due to medical reasons, the intended administration route is subcutaneous |
Specifications
CMS108v6.html
CMS108v6.xml- CMS108v6_SimpleXML.xml
EH_CAH_CMS108v6_NQF0371_VTE1.zip
CMS108v6_TRN_05.05.17.xlsx
Release Notes
Header
Incremented eMeasure Version number.
Section: eMeasure Version number
Source: Measure Lead
Updated Copyright.
Section: Copyright
Source: Annual Update
Added 'Patients age 18 and older discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period' to the Initial Population narrative statement to better align with the logic.
Section: Initial Population
Source: JIRA (CQM-2520)
Logic
Replaced 'Unfractionated Heparin for VTE prophylaxis ingredient specific' value set with 'Low Dose Unfractionated Heparin for VTE Prophylaxis' semantic clinical drug value set to ease implementation burden.
Section: Numerator (QDM Variable)
Source: JIRA (CQM-1835)
Replaced 'Low Molecular Weight Heparin for VTE prophylaxis ingredient specific' value set with 'Low Molecular Weight Heparin for VTE Prophylaxis' semantic clinical drug value set to ease implementation burden.
Section: Numerator (QDM Variable)
Source: JIRA (CQM-1835)
Replaced 'Injectable factor Xa inhibitor for VTE prophylaxis ingredient specific' value set with 'Injectable factor Xa inhibitor for VTE Prophylaxis' semantic clinical drug value set to ease implementation burden.
Section: Numerator (QDM Variable)
Source: JIRA (CQM-1835)
Replaced 'Warfarin-only ingredient specific' value set with 'Warfarin' semantic clinical drug value set to ease implementation burden.
Section: Numerator (QDM Variable)
Source: JIRA (CQM-1835)
Replaced temporal operator 'starts after start of' with 'starts after or concurrent with start of' to allow for concurrent data capture.
Section: Denominator Exclusions
Source: JIRA (CQM-2125)
Replaced temporal operator 'starts after end of' with 'starts after or concurrent with end of' to allow for concurrent data capture.
Section: Denominator Exclusions
Source: JIRA (CQM-2125)
Replaced temporal operator 'ends after start of' with 'ends after or concurrent with start of' to allow for concurrent data capture.
Section: Denominator Exclusions
Source: JIRA (CQM-2125)
Replaced temporal operator 'starts after start of' with 'starts after or concurrent with start of' to allow for concurrent data capture.
Section: Numerator
Source: JIRA (CQM-2125)
Replaced temporal operator 'starts after end of' with 'starts after or concurrent with end of' to allow for concurrent data capture.
Section: Numerator
Source: JIRA (CQM-2125)
Replaced temporal operator 'ends after start of' with 'ends after or concurrent with start of' to allow for concurrent data capture.
Section: Numerator
Source: JIRA (CQM-2125)
Replaced 'Risk Category Assessment' datatype with 'Assessment, Performed' datatype to conform with QDM 4.3 changes.
Section: Numerator
Source: QDM Standards
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Replaced Warfarin-only ingredient specific value set (2.16.840.1.113762.1.4.1021.10) with Warfarin (2.16.840.1.113883.3.117.1.7.1.232) value set.
Section: None
Source: JIRA (CQM-1835)
Replaced Injectable factor Xa inhibitor for VTE prophylaxis ingredient specific value set (2.16.840.1.113762.1.4.1021.11) with Injectable factor Xa inhibitor for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.211) value set.
Section: None
Source: JIRA (CQM-1835)
Replaced Low Molecular Weight Heparin for VTE prophylaxis ingredient specific value set (2.16.840.1.113762.1.4.1021.12) with Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219) value set.
Section: None
Source: JIRA (CQM-1835)
Replaced Unfractionated Heparin for VTE prophylaxis ingredient specific value set (2.16.840.1.113762.1.4.1021.13) with Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39) value set.
Section: None
Source: JIRA (CQM-1835)
Value set Glycoprotein IIb/IIIa Inhibitors (2.16.840.1.113762.1.4.1045.41): Added 5 RXNORM codes (1736470, 1736477, 1737466, 1737471, 1813035) and deleted 3 RXNORM codes (200326, 200348, 205253).
Section: None
Source: None
Value set Direct Thrombin Inhibitor (2.16.840.1.113883.3.117.1.7.1.205): Added 3 RXNORM codes (1804735, 1804737, 1804738) and deleted 1 RXNORM code (1110708).
Section: None
Source: None
Value set Obstetrics VTE (2.16.840.1.113883.3.117.1.7.1.264): Deleted 35 ICD9CM codes.
Section: None
Source: None
Value set Venous Thromboembolism (2.16.840.1.113883.3.117.1.7.1.279): Deleted 14 ICD9CM codes.
Section: None
Source: None
Value set Patient Refusal (2.16.840.1.113883.3.117.1.7.1.93): Added 3 SNOMEDCT codes (183946001, 183956002, 609589008).
Section: None
Source: None
Value set Hemorrhagic Stroke (2.16.840.1.113883.3.117.1.7.1.212): Deleted 2 ICD9CM codes (430, 431).
Section: None
Source: None
Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Deleted 12 ICD9CM codes.
Section: None
Source: None
Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Added 78 ICD10CM codes and deleted 8 ICD10CM codes (O00.0, O00.1, O00.2, O00.8, O00.9, O33.7, O34.21, O70.2). Added 4 SNOMEDCT codes (459166009, 459167000, 713575004, 713576003) and deleted 4 SNOMEDCT codes (200074009, 200080001, 237088009, 237246007).
Section: None
Source: None
Value set Mental Health Diagnoses (2.16.840.1.113883.3.464.1003.105.12.1004): Added 180 SNOMEDCT codes and deleted 22 SNOMEDCT codes. Deleted 365 ICD9CM codes. Deleted 13 ICD10CM codes.
Section: None
Source: None