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CMS Measure ID: CMS1028v2    Performance/Reporting Period: 2024    NQF Number: Not Applicable
Description:

Patients with severe obstetric complications which occur during the inpatient delivery hospitalization

Data Elements and coded QDM Attributes contained within the eCQM

+ Expand all

Direct Reference Code

Constrained to 'Date and time of obstetric delivery' LOINC code

QDM Datatype and Definition

"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 'Delivery date Estimated' LOINC code

QDM Datatype and Definition

"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 describe concepts of assessment for estimated gestational age at delivery.
Data Element Scope: This value set may use a model element related to assessment.
Inclusion Criteria: Includes concepts that define an assessment of the estimated gestational age at delivery.
Exclusion Criteria: No exclusions.

Constrained to codes in the Estimated Gestational Age at Delivery value set (2.16.840.1.113762.1.4.1045.26)

QDM Datatype and Definition

"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 group diagnoses of 20-42 weeks gestation.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of weeks gestation equal to 20-42 weeks.
Exclusion Criteria: Excludes concepts that identify a diagnosis of weeks gestation less than 20 weeks.

Constrained to codes in the 20 to 42 Plus Weeks Gestation value set (2.16.840.1.113762.1.4.1110.67)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 identify diagnoses of asthma with an indication of acute, persistent, and/or asthmaticus status.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of asthma.
Exclusion Criteria: Excludes concepts of uncomplicated mild intermittent asthma.

Constrained to codes in the Acute or Persistent Asthma value set (2.16.840.1.113883.3.117.1.7.1.271)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of anemia.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of an anemia.
Exclusion Criteria: No exclusions.

Constrained to codes in the Anemia value set (2.16.840.1.113762.1.4.1029.323)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of autoimmune disease.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of an autoimmune disease.
Exclusion Criteria: No exclusions.

Constrained to codes in the Autoimmune Disease value set (2.16.840.1.113762.1.4.1029.311)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of bariatric surgery.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a bariatric surgery.
Exclusion Criteria: No exclusions.

Constrained to codes in the Bariatric Surgery value set (2.16.840.1.113762.1.4.1029.317)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of a bleeding disorders.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a bleeding disorder.
Exclusion Criteria: No exclusions.

Constrained to codes in the Bleeding Disorder value set (2.16.840.1.113762.1.4.1029.287)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of cardiac disease.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of cardiac disease.
Exclusion Criteria: No exclusions.

Constrained to codes in the Cardiac Disease value set (2.16.840.1.113762.1.4.1029.341)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of COVID-19.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of COVID-19.
Exclusion Criteria: Excludes concepts that identify a suspected, probable COVID-19, or possible exposure to COVID-19.

Constrained to codes in the COVID 19 Confirmed value set (2.16.840.1.113762.1.4.1029.373)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of economic housing instability.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of an economic housing instability.
Exclusion Criteria: No exclusions.

Constrained to codes in the Economic Housing Instability value set (2.16.840.1.113762.1.4.1029.292)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of gastrointestinal diseases.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a gastrointestinal disease.
Exclusion Criteria: No exclusions.

Constrained to codes in the Gastrointestinal Disease value set (2.16.840.1.113762.1.4.1029.338)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of gestational diabetes.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of gestational diabetes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Gestational Diabetes value set (2.16.840.1.113762.1.4.1029.269)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of human immunodeficiency virus (HIV) during pregnancy, childbirth, and puerperium.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of human immunodeficiency virus (HIV).
Exclusion Criteria: No exclusions.

Constrained to codes in the HIV in Pregnancy Childbirth and Puerperium value set (2.16.840.1.113762.1.4.1029.272)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of pre-existing hypertension.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of pre-existing hypertension.
Exclusion Criteria: Excludes concepts of a diagnosis of acute hypertension.

Constrained to codes in the Hypertension value set (2.16.840.1.113762.1.4.1029.332)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses for long term use of anticoagulants.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis for current long term use of anticoagulants.
Exclusion Criteria: Excludes concepts of a diagnosis of short term use or history of anticoagulants.

Constrained to codes in the Long Term Anticoagulant Use value set (2.16.840.1.113762.1.4.1029.366)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of mental health disorders.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a mental health disorder related to psychotic, nonpsychotic, and mood disorders.
Exclusion Criteria: Excludes concepts of a diagnosis of mental disorders due to substance abuse, developmental disorders, and intellectual disabilities.

Constrained to codes in the Mental Health Disorder value set (2.16.840.1.113762.1.4.1029.314)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of mild or moderate pre-eclampsia.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of mild or moderate pre-eclampsia.
Exclusion Criteria: Excludes concepts that identify a diagnosis of severe pre-eclampsia.

Constrained to codes in the Mild or Moderate Preeclampsia value set (2.16.840.1.113762.1.4.1029.329)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of morbid obesity.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of morbid obesity.
Exclusion Criteria: Excludes concepts that identify a diagnosis of a body mass index less than 40.

Constrained to codes in the Morbid or Severe Obesity value set (2.16.840.1.113762.1.4.1029.290)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of a multiple pregnancy.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a multiple pregnancy.
Exclusion Criteria: No exclusions.

Constrained to codes in the Multiple Pregnancy value set (2.16.840.1.113762.1.4.1029.284)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of neuromuscular disease.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a neuromuscular disease.
Exclusion Criteria: No exclusions.

Constrained to codes in the Neuromuscular Disease value set (2.16.840.1.113762.1.4.1029.308)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 identify diagnoses of a placenta previa.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a complete or partial placenta previa during the 3rd trimester or when trimester is unspecified.
Exclusion Criteria: Excludes concepts that represent placenta previa in 1st or 2nd trimester.

Constrained to codes in the Placenta Previa value set (2.16.840.1.113762.1.4.1110.35)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of placental abruption.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a placental abruption.
Exclusion Criteria: No exclusions.

Constrained to codes in the Placental Abruption value set (2.16.840.1.113762.1.4.1029.305)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of a placental accreta spectrum.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a placental accreta, percreta, or increta during the 3rd trimester.
Exclusion Criteria: Excludes concepts that represent a diagnosis of a placental accreta, percreta, or increta during the 1st or 2nd trimester.

Constrained to codes in the Placental Accreta Spectrum value set (2.16.840.1.113762.1.4.1029.302)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of pre-existing diabetes.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of pre-existing diabetes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Preexisting Diabetes value set (2.16.840.1.113762.1.4.1029.275)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 identify that diagnosis is not present on admission or unable to determine.
Data Element Scope: This value set may use a model element related to encounter diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis indicator of not being present on admission.
Exclusion Criteria: Excludes concepts that represent a diagnosis indicator being present on admission.

Constrained to codes in the Present on Admission is No or Unable To Determine value set (2.16.840.1.113762.1.4.1029.370)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 identify that diagnosis is present on admission or exempt from POA status.
Data Element Scope: This value set may use a model element related to encounter diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis indicator of being present on admission or exempt from POA status.
Exclusion Criteria: Excludes concepts that represent a diagnosis indicator of not being present on admission or unable to determine.

Constrained to codes in the Present On Admission is Yes or Exempt value set (2.16.840.1.113762.1.4.1110.63)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of a preterm birth.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a gestation <=36 weeks.
Exclusion Criteria: Excludes concepts that represent a diagnosis of a gestation >=37 weeks.

Constrained to codes in the Preterm Birth value set (2.16.840.1.113762.1.4.1029.299)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of a previous cesarean section.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a previous cesarean section.
Exclusion Criteria: No exclusions.

Constrained to codes in the Previous Cesarean value set (2.16.840.1.113762.1.4.1029.278)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of pulmonary hypertension.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a pulmonary hypertension.
Exclusion Criteria: No exclusions.

Constrained to codes in the Pulmonary Hypertension value set (2.16.840.1.113762.1.4.1029.281)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of renal disease.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of renal disease.
Exclusion Criteria: No exclusions.

Constrained to codes in the Renal Disease value set (2.16.840.1.113762.1.4.1029.335)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of respiratory conditions that when present with a confirmed COVID-19 diagnoses are indicative of a COVID-19 complication.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify diagnoses of respiratory conditions that are possibly present with COVID-19 or caused by COVID-19.
Exclusion Criteria: No exclusions.

Constrained to codes in the Respiratory Conditions Related to COVID 19 value set (2.16.840.1.113762.1.4.1029.376)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of severe maternal morbidities.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a severe maternal morbidity.
Exclusion Criteria: No exclusions.

Constrained to codes in the Severe Maternal Morbidity Diagnoses value set (2.16.840.1.113762.1.4.1029.255)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of severe pre-eclampsia.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a severe pre-eclampsia.
Exclusion Criteria: No exclusions.

Constrained to codes in the Severe Preeclampsia value set (2.16.840.1.113762.1.4.1029.327)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of substance abuse.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of substance abuse.
Exclusion Criteria: No exclusions.

Constrained to codes in the Substance Abuse value set (2.16.840.1.113762.1.4.1029.320)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of thyrotoxicosis.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of thyrotoxicosis.
Exclusion Criteria: No exclusions.

Constrained to codes in the Thyrotoxicosis value set (2.16.840.1.113762.1.4.1029.296)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 group diagnoses of an obstetrical venous thromboembolism (VTE) in pregnancy.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of an obstetrical venous thromboembolism (VTE) in pregnancy.
Exclusion Criteria: No exclusions.

Constrained to codes in the Venous Thromboembolism in Pregnancy value set (2.16.840.1.113762.1.4.1029.363)

QDM Attribute and Definition

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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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 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 Patient Expired value set (2.16.840.1.113883.3.117.1.7.1.309)

QDM Attribute and Definition

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 group concepts for encounters in the emergency department (ED) or OB triage represented as observation status.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter occurring in the emergency department (ED) or OB triage represented as observation status.
Exclusion Criteria: Excludes concepts that represent services not performed in the emergency department or OB triage represented as observation status.

Constrained to codes in the ED Visit and OB Triage value set (2.16.840.1.113762.1.4.1029.369)

QDM Datatype and Definition

"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 5.6 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 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 Inpatient value set (2.16.840.1.113883.3.666.5.307)

QDM Datatype and Definition

"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 5.6 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 for encounters for observation.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for observation in the inpatient or outpatient setting.
Exclusion Criteria: No exclusions.

Constrained to codes in the Observation Services value set (2.16.840.1.113762.1.4.1111.143)

QDM Datatype and Definition

"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 5.6 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 for laboratory tests measuring hematocrit.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent a laboratory test measuring hematocrit in the specimen source of blood.
Exclusion Criteria: Excludes concepts that represent laboratory tests for hematocrit using the specimen source of capillary blood.

Constrained to codes in the Hematocrit lab test value set (2.16.840.1.113762.1.4.1045.114)

QDM Datatype and Definition

"Laboratory Test, Performed"

Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.

Timing:

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

Examples:

  • Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – use relevant dateTime to reference this single point in time for many specimen collections
  • Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection – use relevantPeriod to reference the start to stop time for this event.

Notes:

  • The time that the result report is available is a separate attribute than the time of the study (specimen collection).
  • 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 laboratory tests measuring white blood cells.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent a laboratory test measuring white blood cell count in the specimen source of blood.
Exclusion Criteria: No exclusions.

Constrained to codes in the White blood cells count lab test value set (2.16.840.1.113762.1.4.1045.129)

QDM Datatype and Definition

"Laboratory Test, Performed"

Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.

Timing:

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

Examples:

  • Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – use relevant dateTime to reference this single point in time for many specimen collections
  • Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection – use relevantPeriod to reference the start to stop time for this event.

Notes:

  • The time that the result report is available is a separate attribute than the time of the study (specimen collection).
  • 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: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Ethnicity value set (2.16.840.1.114222.4.11.837)

QDM Datatype and Definition

"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 payer 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 Payer value set (2.16.840.1.114222.4.11.3591)

QDM Datatype and Definition

"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 Race value set (2.16.840.1.114222.4.11.836)

QDM Datatype and Definition

"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 ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

QDM Datatype and Definition

"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.

Direct Reference Code

Constrained to 'Heart rate' LOINC code

QDM Datatype and Definition

"Physical Exam, Performed"

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

Timing:

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

Notes:

  • Timing refers to a single instance of a physical examination activity. If a measure seeks to evaluate multiple physical examination activities over a period of time, the measure developer should use CQL logic to represent the query request.
  • 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 'Systolic blood pressure' LOINC code

QDM Datatype and Definition

"Physical Exam, Performed"

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

Timing:

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

Notes:

  • Timing refers to a single instance of a physical examination activity. If a measure seeks to evaluate multiple physical examination activities over a period of time, the measure developer should use CQL logic to represent the query request.
  • 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 group procedures of blood transfusions.
Data Element Scope: This value set may use a model element related to procedure.
Inclusion Criteria: Includes concepts that represent procedures of a blood transfusion.
Exclusion Criteria: No exclusions.

Constrained to codes in the Blood Transfusion value set (2.16.840.1.113762.1.4.1029.213)

QDM Datatype and Definition

"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.
  • See section 6.4 for guidance about differentiating between successful and unsuccessful procedures.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to group concepts of procedures for delivery.
Data Element Scope: This value set may use a model element related to procedure.
Inclusion Criteria: Includes concepts that represent a procedure of delivery.
Exclusion Criteria: No exclusions.

Constrained to codes in the Delivery Procedures value set (2.16.840.1.113762.1.4.1045.59)

QDM Datatype and Definition

"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.
  • See section 6.4 for guidance about differentiating between successful and unsuccessful procedures.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to group concepts of respiratory support procedures that when present with a confirmed COVID-19 diagnoses are indicative of a COVID-19 complication.
Data Element Scope: This value set may use a model element related to procedure.
Inclusion Criteria: Includes concepts that identify respiratory support procedures that are possibly performed with confirmed COVID-19 cases.
Exclusion Criteria: No exclusions.

Constrained to codes in the Respiratory Support Procedures Related to COVID 19 value set (2.16.840.1.113762.1.4.1029.379)

QDM Datatype and Definition

"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.
  • See section 6.4 for guidance about differentiating between successful and unsuccessful procedures.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to group concepts of procedures for severe maternal morbidities.
Data Element Scope: This value set may use a model element related to procedure.
Inclusion Criteria: Includes concepts that represent procedures of a severe maternal morbidity.
Exclusion Criteria: No exclusions.

Constrained to codes in the Severe Maternal Morbidity Procedures value set (2.16.840.1.113762.1.4.1029.256)

QDM Datatype and Definition

"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.
  • See section 6.4 for guidance about differentiating between successful and unsuccessful procedures.