Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram

Last updated: May 15, 2017

CMS Measure ID: CMS109v5
Version: 5
NQF Number: None
Measure Description:

This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol.

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 and a diagnosis of venous thromboembolism (VTE)

Denominator Statement:

Patients with VTE confirmed through a diagnostic test and receiving IV UFH therapy

Denominator Exclusions:
  • Patients with comfort measures documented
  • Patients discharged to an acute care facility
  • Patients who left against medical advice
  • Patients who expired
  • Patients discharged to home for hospice care
  • Patients discharged to a health care facility for hospice care
Numerator Statement:

Patients who have their IV UFH therapy dosages and platelet counts monitored according to defined parameters such as a nomogram or protocol

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Domain: Effective Clinical Care
Short Name: VTE4
Previous Version: Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram
Improvement Notation:

Improvement noted as an increase in 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.

Treatment adjustment by protocol and/or use of a clinical pathway must be specific to unfractionated heparin therapy. Heparin protocols and clinical pathways may include use of a nomogram.

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

  • Removed guidance related to the intent of the logic related to IV heparin. This guidance is no longer needed due to updates to the content of the unfractionated heparin value set.

    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

  • 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

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

    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

  • 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 Unfractionated Heparin (2.16.840.1.113883.3.117.1.7.1.218): Added 4 RXNORM codes (1658717, 1658720, 1659195, 1659197) and deleted 9 RXNORM codes (1361048, 1361226, 1361568, 1361574, 1361577, 1361613, 1361615, 1362831, 1362837).

    Section: None

    Source: JIRA (QDM-1582)

  • Value set Unfractionated Heparin (2.16.840.1.113883.3.117.1.7.1.218): Added 4 RXNORM codes (1658717, 1658720, 1659195, 1659197) and deleted 9 RXNORM codes (1361048, 1361226, 1361568, 1361574, 1361577, 1361613, 1361615, 1362831, 1362837).

    Section: None

    Source: JIRA (QDM-1697)

  • Value set Unfractionated Heparin (2.16.840.1.113883.3.117.1.7.1.218): Added 4 RXNORM codes (1658717, 1658720, 1659195, 1659197) and deleted 9 RXNORM codes (1361048, 1361226, 1361568, 1361574, 1361577, 1361613, 1361615, 1362831, 1362837).

    Section: None

    Source: JIRA (QDM-1771)

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

    Section: None

    Source: Measure Lead

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