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CMS Measure ID: CMS334v5    Performance/Reporting Period: 2024    NQF Number: 0471e
Description:

Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth

Data Elements and coded QDM Attributes contained within the eCQM

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Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to group diagnoses of a fetus in an abnormal position in the uterus at the time of delivery.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a fetus in an abnormal position.
Exclusion Criteria: Excludes concepts that represent a fetus in a vertex presentation.

Constrained to codes in the Abnormal Presentation value set (2.16.840.1.113762.1.4.1045.105)

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 '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.

Direct Reference Code

Constrained to '[#] Births.preterm' 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 '[#] Births.term' 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 '[#] Parity' 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 '[#] Pregnancies' 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 group diagnoses of 37-42 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 37-42 weeks.
Exclusion Criteria: Excludes concepts that identify a diagnosis of weeks gestation less than 37 weeks.

Constrained to codes in the 37 to 42 Plus Weeks Gestation value set (2.16.840.1.113762.1.4.1110.68)

QDM Datatype 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 fetus in an abnormal position in the uterus at the time of delivery.
Data Element Scope: This value set may use a model element related to diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of a delivery of a single live born newborn.
Exclusion Criteria: No exclusions.

Constrained to codes in the Delivery of Singleton value set (2.16.840.1.113762.1.4.1045.99)

QDM Datatype 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 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: 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.

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

Constrained to codes in the Cesarean Birth value set (2.16.840.1.113883.3.117.1.7.1.282)

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.