Back to top
Top
CMS Measure ID: CMS9v10    Performance/Reporting Period: 2022    Version: 10    NQF Number: 0480e
Description:

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

The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization.

Data Elements and coded QDM Attributes contained within the eCQM

+ Expand all

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for assessments measuring birth weights of newborn.
Data Element Scope: This value set may use a model element related to Assessment.
Inclusion Criteria: Includes concepts that identify an assessment of the birth weight of a newborn.
Exclusion Criteria: No exclusions.

Constrained to codes in the Assessment, Performed: Birth Weight value set (2.16.840.1.113762.1.4.1029.194)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Assessment, Performed"

Data elements that meet criteria using this datatype should document completion of the assessment indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references timing for an assessment that occurs at a single point in time.
  • relevant Period references a start and stop time for an assessment that occurs over a time interval
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.

Direct Reference Code

Constrained to 'Gestational age--at birth' LOINC code

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Assessment, Performed"

Data elements that meet criteria using this datatype should document completion of the assessment indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references timing for an assessment that occurs at a single point in time.
  • relevant Period references a start and stop time for an assessment that occurs over a time interval
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for diagnoses of galactosemia.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of galactosemia.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnoses: Galactosemia value set (2.16.840.1.113883.3.117.1.7.1.35)

QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

diagnoses

Coded diagnoses/problems addressed during the encounter. The diagnoses attribute has three components:

  • diagnosis (code)
  • presentOnAdmissionIndicator (code)
  • rank (positive integer)

To reference an encounter diagnosis, the expression must include the diagnosis code component. The other components are optional. The expression should only include the presentOnAdmissionIndicator if it is necessary to reference present on admission and should only include the rank if it is necessary to reference principal diagnosis.

The "Encounter, Performed" diagnosis attribute is intended to capture ALL diagnoses, including the principal diagnosis, i.e., all diagnoses addressed during the encounter represented by the diagnosis (code) used in the expression.The presentOnAdmissionIndicator (code) allows the eCQM developer to include criteria about whether each specific "Encounter, Performed" diagnosis was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition for information about using the "Encounter, Performed" diagnosis attribute.

The "Encounter, Performed" diagnosis (rank) replaces the principal diagnosis attribute. To reference a principal diagnosis, eCQM developers should express the "Encounter, Performed" diagnosis with a diagnosis (code) and a rank of 1. See definition of rank attribute.

With an "Encounter, Performed" diagnosis, there is no dependency on the timing of the diagnosis in relation to the encounter.

  • Use of the "Encounter, Performed": diagnoses attribute component and the "Diagnosis" datatype is redundant for relating the diagnosis to the "Encounter, Performed". The "Encounter, Performed": diagnoses component syntax is preferred.
  • Referencing the same diagnosis using "Encounter, Performed" (diagnoses attribute) and "Diagnosis" (datatype) should only occur if the measure must define a specified length of a prevalencePeriod, e.g.,
    • The measure must assure that the diagnoses
      • have been present for at least some defined time period before the encounter, and
      • were addressed during the "Encounter, Performed"
    Value Set Description from VSAC
    Clinical Focus: The purpose of this value set is to represent concepts of diagnoses to indicate types of single live newborn deliveries.
    Data Element Scope: This value set may use a model element related to Diagnosis.
    Inclusion Criteria: Includes concepts that represent diagnoses of types of single live newborn deliveries.
    Exclusion Criteria: Excludes concepts that describe deliveries outside of the hospital.

    Constrained to codes in the Diagnoses: Single Live Born Newborn Born In Hospital value set (2.16.840.1.113883.3.117.1.7.1.26)

    QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

    diagnoses

    Coded diagnoses/problems addressed during the encounter. The diagnoses attribute has three components:

    • diagnosis (code)
    • presentOnAdmissionIndicator (code)
    • rank (positive integer)

    To reference an encounter diagnosis, the expression must include the diagnosis code component. The other components are optional. The expression should only include the presentOnAdmissionIndicator if it is necessary to reference present on admission and should only include the rank if it is necessary to reference principal diagnosis.

    The "Encounter, Performed" diagnosis attribute is intended to capture ALL diagnoses, including the principal diagnosis, i.e., all diagnoses addressed during the encounter represented by the diagnosis (code) used in the expression.The presentOnAdmissionIndicator (code) allows the eCQM developer to include criteria about whether each specific "Encounter, Performed" diagnosis was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition for information about using the "Encounter, Performed" diagnosis attribute.

    The "Encounter, Performed" diagnosis (rank) replaces the principal diagnosis attribute. To reference a principal diagnosis, eCQM developers should express the "Encounter, Performed" diagnosis with a diagnosis (code) and a rank of 1. See definition of rank attribute.

    With an "Encounter, Performed" diagnosis, there is no dependency on the timing of the diagnosis in relation to the encounter.

    • Use of the "Encounter, Performed": diagnoses attribute component and the "Diagnosis" datatype is redundant for relating the diagnosis to the "Encounter, Performed". The "Encounter, Performed": diagnoses component syntax is preferred.
    • Referencing the same diagnosis using "Encounter, Performed" (diagnoses attribute) and "Diagnosis" (datatype) should only occur if the measure must define a specified length of a prevalencePeriod, e.g.,
      • The measure must assure that the diagnoses
        • have been present for at least some defined time period before the encounter, and
        • were addressed during the "Encounter, Performed"
      Value Set Description from VSAC
      Clinical Focus: The purpose of this value set is to represent concepts for an encounter with the discharge of a patient to an acute care facility.
      Data Element Scope: This value set may use a model element related to Encounter.
      Inclusion Criteria: Includes concepts that represent an encounter with a discharge to a short-term acute care hospital, including a specialty hospital.
      Exclusion Criteria: No exclusions.

      Constrained to codes in the Discharge Disposition: Discharge To Acute Care Facility value set (2.16.840.1.113883.3.117.1.7.1.87)

      QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

      dischargeDisposition

      The disposition, or location to which the patient is transferred at the time of hospital discharge.
      Value Set Description from VSAC
      Clinical Focus: The purpose of this value set is to represent concepts for encounters in post-acute and psychiatric settings.
      Data Element Scope: This value set may use a model element related to Encounter.
      Inclusion Criteria: Includes concepts that represent an encounter specific to extended care facilities, intermediate care facilities, LTACHs, nursing homes, skilled nursing facilities, veterans homes, and psychiatric hospitals.
      Exclusion Criteria: Excludes concepts that represent acute inpatient and outpatient environments of care.

      Constrained to codes in the Discharge Disposition: Other Health Care Facility value set (2.16.840.1.113762.1.4.1029.67)

      QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

      dischargeDisposition

      The disposition, or location to which the patient is transferred at the time of hospital discharge.
      Value Set Description from VSAC
      Clinical Focus: The purpose of this value set is to represent concepts for an encounter with a discharge disposition of patient who has died in the hospital.
      Data Element Scope: This value set may use a model element related to Encounter.
      Inclusion Criteria: Includes concepts that identify an encounter with a discharge disposition of a patient who has died in the hospital.
      Exclusion Criteria: No exclusions.

      Constrained to codes in the Discharge Disposition: Patient Expired value set (2.16.840.1.113883.3.117.1.7.1.309)

      QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

      dischargeDisposition

      The disposition, or location to which the patient is transferred at the time of hospital discharge.
      Value Set Description from VSAC
      Clinical Focus: The purpose of this value set is to represent concepts of inpatient hospitalization encounters.
      Data Element Scope: This value set may use a model element related to Encounter.
      Inclusion Criteria: Includes concepts that represent an encounter for inpatient hospitalizations.
      Exclusion Criteria: No exclusions.

      Constrained to codes in the Encounter, Performed: Encounter Inpatient value set (2.16.840.1.113883.3.666.5.307)

      QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

      "Encounter, Performed"

      Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

      The "Encounter, Performed" participant references the primary participant.

      Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

      Timing:

      • The relevantPeriod addresses:
        • startTime - The time the encounter began (admission time).
        • stopTime - The time the encounter ended (discharge time).
      • author dateTime references the time the action was recorded.
      • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

      Notes:

      • negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
      • The locationPeriod is an attribute of the attribute facility location that addresses:
        • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
        • stopTime - the time the patient departed from the location.
      Value Set Description from VSAC
      Clinical Focus: The purpose of this value set is to represent concepts of locations of adult or pediatric intensive care units (ICUs).
      Data Element Scope: This value set may use a model element related to Encounter.
      Inclusion Criteria: Includes concepts that represent a location for an adult or pediatric intensive care unit (ICU).
      Exclusion Criteria: Excludes concepts that represent neonatal intensive care units (NICU).

      Constrained to codes in the Facility Locations: Intensive Care Unit value set (2.16.840.1.113762.1.4.1029.206)

      QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

      facilityLocations

      The particular locations in a facility in which the diagnostic study or encounter occurs or occurred. Examples include intensive care units (ICUs), nonICUs, burn critical care unit, neonatal ICU, and respiratory care unit. Each "Encounter, Performed" may have one or more locations. For example, a patient treated in multiple locations during an individual encounter might be expressed as:
      • "Encounter, Performed": Inpatient Admission, facility locations
        • ICU (locationPeriod)
        • Non-ICU Admission (locationPeriod)
        • Rehab (locationPeriod)
      Value Set Description from VSAC
      Clinical Focus: The purpose of this value set is to represent concepts for locations to identify neonatal intensive care units (NICUs).
      Data Element Scope: This value set may use a model element related to Encounter.
      Inclusion Criteria: Includes concepts that represent a location to identify neonatal intensive care units (NICU).
      Exclusion Criteria: No exclusions.

      Constrained to codes in the Facility Locations: Neonatal Intensive Care Unit (NICU) value set (2.16.840.1.113762.1.4.1029.205)

      QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

      facilityLocations

      The particular locations in a facility in which the diagnostic study or encounter occurs or occurred. Examples include intensive care units (ICUs), nonICUs, burn critical care unit, neonatal ICU, and respiratory care unit. Each "Encounter, Performed" may have one or more locations. For example, a patient treated in multiple locations during an individual encounter might be expressed as:
      • "Encounter, Performed": Inpatient Admission, facility locations
        • ICU (locationPeriod)
        • Non-ICU Admission (locationPeriod)
        • Rehab (locationPeriod)
      Value Set Description from VSAC
      Clinical Focus: The purpose of this value set is to represent concepts for administration of total parenteral infusion.
      Data Element Scope: This value set may use a model element related to medication.
      Inclusion Criteria: Includes concepts that represent concepts administration of total parenteral infusion.
      Exclusion Criteria: No exclusions.

      Constrained to codes in the Medication, Administered: Total Parenteral Nutrition value set (2.16.840.1.113762.1.4.1110.54)

      QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

      "Medication, Administered"

      Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set was actually administered to the patient.

      Timing:

      • relevant dateTime references the time the medication is administered if it was given or taken at a single point in time.
      • relevantPeriod references a start and stop time for medication administration if the administration event occurred over a time interval (e.g., an intravenous infusion). The relevantPeriod addresses:
        • startTime - when a single medication administration event starts (e.g., the initiation of an intravenous infusion).
        • stopTime - when a single medication administration event ends (e.g., the end time of the intravenous infusion).
      • author dateTime references the time the action was recorded.
      • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

      Notes:

      • Measure developers should address multiple administrations over a period of time using CQL logic.
      • negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.

      Refer to Special Cases in Appendix A (Section 5.7) for scenarios to consider in calculating cumulative medication duration.
       

      Value Set Description from VSAC
      Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

      Constrained to codes in the Patient Characteristic, Ethnicity: Ethnicity value set (2.16.840.1.114222.4.11.837)

      QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

      "Patient Characteristic, Ethnicity"

      Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set.

      Timing: Ethnicity does not have a specific timing. Measures using "Patient Characteristic, Ethnicity" should address the most recent entry in the clinical record.

      Value Set Description from VSAC
      Clinical Focus: Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
      Data Element Scope: @code in CCDA r2.1 template Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] DYNAMIC
      Inclusion Criteria: All codes in the code system
      Exclusion Criteria: none

      Constrained to codes in the Patient Characteristic, Payer: Payer value set (2.16.840.1.114222.4.11.3591)

      QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

      "Patient Characteristic, Payer"

      Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set.

      Timing:

      The relevantPeriod addresses:

      • startTime – the first day of insurance coverage with the referenced payer.
      • stopTime – the last day of insurance coverage with the referenced payer.
      Value Set Description from VSAC
      Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

      Constrained to codes in the Patient Characteristic, Race: Race value set (2.16.840.1.114222.4.11.836)

      QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

      "Patient Characteristic, Race"

      Data elements that meet criteria using this datatype should document the patient’s race.

      Timing: Race does not have a specific timing. Measures using "Patient Characteristic, Race" should address the most recent entry in the clinical record.

      Value Set Description from VSAC
      Clinical Focus: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.
      Data Element Scope: Gender
      Inclusion Criteria: Male and Female only.
      Exclusion Criteria: Any gender identity that is not male or female.

      Constrained to codes in the Patient Characteristic, Sex: ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

      QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

      "Patient Characteristic, Sex"

      Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

      Timing: Birth (administrative) sex does not have a specific timing.

      Value Set Description from VSAC
      Clinical Focus: The purpose of this value set is to represent concepts for procedures of parenteral infusion.
      Data Element Scope: This value set may use a model element related to Procedure.
      Inclusion Criteria: Includes concepts that represent concepts for procedures of parenteral infusion.
      Exclusion Criteria: No exclusions.

      Constrained to codes in the Procedure, Performed: Parenteral Nutrition value set (2.16.840.1.113883.3.117.1.7.1.38)

      QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

      "Procedure, Performed"

      Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.

      Timing:

      • relevant dateTime references the time the procedure is performed when the procedure occurs at a single point in time.
      • relevantPeriod references a start and stop time for a procedure that occurs over a time interval. relevantPeriod addresses:
        • startTime - The time the procedure begins.
        • stopTime - The time the procedure ends.
      • author dateTime references the time the action was recorded.
      • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

      Notes: 

      • Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
      • The incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
      • negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
      • For clarification, see Appendix 6.6 with 2020 guidance about differentiating between successful and unsuccessful procedures.
      Value Set Description from VSAC
      Clinical Focus: The purpose of this value set is to represent concepts for the substance of breast milk.
      Data Element Scope: This value set may use a model element related to Substance.
      Inclusion Criteria: Includes concepts that identify a substance of breast milk.
      Exclusion Criteria: No exclusions.

      Constrained to codes in the Substance, Administered: Breast Milk value set (2.16.840.1.113883.3.117.1.7.1.30)

      QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

      "Substance, Administered"

      Data elements that meet criteria using this datatype should document that the substance indicated by the QDM category and its corresponding value set was actually given to the patient.

      Timing:

      • relevant dateTime references the time the substance is administered if it was given or taken at a single point in time.
      • relevantPeriod references a start and stop time for substance administration if the administration event occurred over a time interval.
      • The relevantPeriod addresses:
        • startTime - when a single substance administration event starts (e.g., the initiation of an intravenous infusion).
        • stopTime - when a single substance administration event ends (e.g., the end time of the intravenous infusion).
      • author dateTime references the time the substance administration was recorded and applies only when the record has no reference to the time the substance administration occurred and only the recorded time is available.

       

      Value Set Description from VSAC
      Clinical Focus: The purpose of this value set is to represent concepts for a substance of dietary intake other than breast milk.
      Data Element Scope: This value set may use a model element related to Substance.
      Inclusion Criteria: Includes concepts that identify a substance of dietary intake other than breast milk.
      Exclusion Criteria: Excludes concepts that represent breast milk or Sweet-ease and Glucose 40% gel.

      Constrained to codes in the Substance, Administered: Dietary Intake Other than Breast Milk value set (2.16.840.1.113883.3.117.1.7.1.27)

      QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

      "Substance, Administered"

      Data elements that meet criteria using this datatype should document that the substance indicated by the QDM category and its corresponding value set was actually given to the patient.

      Timing:

      • relevant dateTime references the time the substance is administered if it was given or taken at a single point in time.
      • relevantPeriod references a start and stop time for substance administration if the administration event occurred over a time interval.
      • The relevantPeriod addresses:
        • startTime - when a single substance administration event starts (e.g., the initiation of an intravenous infusion).
        • stopTime - when a single substance administration event ends (e.g., the end time of the intravenous infusion).
      • author dateTime references the time the substance administration was recorded and applies only when the record has no reference to the time the substance administration occurred and only the recorded time is available.