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National Hospital Inpatient Quality Reporting Measures Specifications Manual

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Release Notes Version: 5.0 Release Notes Completed: March 9, 2015

Guidelines for Using Release Notes

The Release Notes Version 5.0 provides modifications to the Specifications Manual for National Hospital Inpatient Quality Measures. The information in this document is to be used as a reference and is not intended to be used to program abstraction tools. Please refer to the Specifications Manual for National Hospital Inpatient Quality Measures for the complete and current technical specifications and abstraction information.

The notes are organized to follow the order of the Table of Contents. The implementation date is 10-01-2015, unless otherwise specified. The headings are described below:

Impacts - used to identify the impacted measures and portion(s) of the Manual Section. (i.e., Alphabetical Data Dictionary, Measure Information Form (MIF) and Flowchart (Algorithm)).

Description of Changes - used to identify the section within the document where the change occurs, e.g., Definition, Data Collection Question, Allowable Values, and Denominator Statement - Data Elements.

Rationale - provided for the change being made.

Data elements that cross multiple measures and contain the same changes will be consolidated.

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Note: click on any section title in the Release Notes to return to Table of Contents page

Table of Contents ... 1

Acknowledgement ... 3

Introduction ... 3

Using the Specifications Manual for National Hospital Inpatient Quality Measures ... 4

SECTION 1 – Data Dictionary ... 5

Introduction to Data Dictionary ... 5

Alphabetical Data Dictionary ... 6

SECTION 2 – Measurement Information ... 36

Subsection 2.1 – Acute Myocardial Infarction (AMI) ... 37

Subsection 2.2 – Severe Sepsis and Septic Shock (SEP) ... 40

Subsection 2.3 – Surgical Care Improvement Project (SCIP) ... 40

Subsection 2.5 – Children’s Asthma Care (CAC) ... 46

Subsection 2.6 – Venous Thromboembolism (VTE) ... 47

Subsection 2.7 – Stroke (STK) ... 55

Subsection 2.8 – Global Initial Patient Population (ED, IMM, TOB, SUB) ... 60

Subsection 2.9 – Emergency Department (ED) ... 60

Subsection 2.10 – Prevention ... 61

2.10.1 – Immunization (IMM) ... 61

2.10.2 – Tobacco Treatment (TOB) ... 63

2.10.3 – Substance Use (SUB) ... 66

SECTION 3 – Missing and Invalid Data ... 70

SECTION 4 – Population and Sampling Specifications ... 71

SECTION 9 – Data Transmission ... 73

Transmission Alphabetical Data Dictionary ... 78

Transmission Data Processing Flow: Clinical ... 79

Transmission Data Processing Flow: Population and Sampling ... 80

Hospital Clinical Data XML File Layout ... 80

Hospital Initial Patient Population Data XML File Layout ... 92

SECTION 10 – CMS Outcome Measures (Claims Based) ... 93

Subsection 10.1 – Introduction Risk Standardized Mortality Measures ... 93

Subsection 10.2 – Introduction Risk Standardized Readmission and Complication Measures 93 Subsection 10.3 – Agency for Healthcare Research and Quality (AHRQ) Measures ... 95

Subsection 10.4 – Healthcare Associated Infections (HAI) Measures ... 95

Subsection 10.5 – CMS Episode-of-Care Payment Measures ... 95

Subsection 10.6 – Structural Measures ... 95

APPENDICES ... 96

Appendix A – ICD-10 Code Tables ... 96

Appendix C – Medication Tables ... 97

Appendix D – Glossary of Terms ... 100

Appendix E – Overview of Measure Information Form and Flowchart Formats ... 103

Appendix F – Measure Name Crosswalk ... 103

Appendix G – Resources ... 105

Appendix H – Miscellaneous Tables ... 106

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The content below is organized to follow the Table of Contents in the specifications manual.

Table of Contents

Impacts:

Section 2 Measure Information

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Section 2 Measure Information

2.1 Acute Myocardial Infarction (AMI)

Measure Information Form (MIF) and Flowchart (algorithm) Remove:

AMI-1, AMI-3, AMI-5, AMI-7, AMI-8, AMI-8a Remove entire section:

2.2 Heart Failure (HF) 2.3 Pneumonia (PN)

Surgical Care Improvement Project (SCIP) Change subsection title from:

2.4 Surgical Care Improvement Project (SCIP) To

2.3 Surgical Care Improvement Project (SCIP)

Measure Information Form (MIF) and Flowchart (Algorithm) SCIP Infection Module

Remove:

SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-6, SCIP-Inf-9 SCIP Cardiac Module

SCIP-Card-2 SCIP VTE Module SCIP-VTE-2

Children’s Asthma Care (CAC) Change subsection title from:

2.6 Children’s Asthma Care (CAC) To

2.5 Children’s Asthma Care (CAC) Venous Thromboembolism (VTE) Change subsection title from:

2.7 Venous Thromboembolism (VTE) To

2.6 Venous Thromboembolism (VTE)

Measure Information Form (MIF) and Flowchart (Algorithm) Remove:

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Stroke (STK)

Change subsection title from: 2.8 Stroke (STK)

To

2.7 Stroke (STK)

Global Initial Patient Population Change subsection title from:

2.9 Global Initial Patient Population (ED, IMM, TOB, SUB) To

2.8 Global Initial Patient Population (ED, IMM, TOB, SUB) Emergency Department (ED)

Change subsection title from: 2.10 Emergency Department (ED) To

2.9 Emergency Department (ED) Prevention

Change subsection title from: Section 2.11 Prevention 2.11.1 Immunization (IMM)

2.11.2 Tobacco Treatment (TOB) 2.11.3 Substance Use (SUB) To

Section 2.10 Prevention 2.10.1 Immunization (IMM)

2.10.2 Tobacco Treatment (TOB) 2.10.3 Substance Use (SUB) Appendices

Remove under “A.1”: HF, PN

Impacts:

Section 2 Measure Information

Rationale: A new measure set is being added to align with CY 2015 IPPS Final Rule. Description of Changes:

Add:

2.2 Severe Sepsis and Septic Shock (SEP)

Sepsis National Hospital Inpatient Quality Measures SEP Data Element List

SEP Initial Patient Population

SEP Initial Patient Population Algorithm SEP Sample Size Requirements

Measure Information Form (MIF) and Flowchart (Algorithm) SEP-1

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Impacts: Appendices

Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation.

Description of Changes: Change:

ICD-9-CM Code Tables To

ICD-10 Code Tables Impacts:

Appendices

Rationale: A new measure set is being added to align with CY 2015 IPPS Final Rule. Description of Changes:

A.1 ICD-10 Code Tables Add:

SEP

Acknowledgement

No updates in the Acknowledgement section.

Introduction

Impacts:

Priority Focus Process

Strategic Surveillance System (S3™)

Rationale: Remove references to processes no longer used. Description of Changes:

Remove following sections: Priority Focus Process

The Priority Focus Process (PFP) is a data-driven tool that helps focus survey activity on issues most relevant to patient safety and quality of care at the specific health care

organization being surveyed. The survey is directed by a PFP that aggregates organization-specific information through an automated, rules-based tool. Input information includes ORYX® measure data, previous recommendations, demographic data related to clinical service groups and diagnostic-related groups, complaints, sentinel event information, and MedPar data. The process identifies systems and processes that are relevant to patient safety and healthcare quality.

Strategic Surveillance System (S3™)

The Strategic Surveillance System is a benefit provided to hospitals accredited by the Joint Commission. S3™ is a tool that provides a series of risk assessment and comparative

performance measure reports to help hospitals improve their care processes. Specifically S3™ uses data the Joint Commission currently has, which includes past survey findings, ORYX® core measure data, data from the Office of Quality Monitoring (complaints and non-self-reported sentinel events), data from an organization’s electronic application and Med PAR data.

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Using the Specifications Manual for National Hospital Inpatient Quality Measures

Impacts: N/A

Rationale: These changes are needed to revise outdated language. Description of Changes:

Change throughout document: QIO Clinical Warehouse

To

CMS Clinical Warehouse Impacts: N/A

Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation.

Description of Changes:

Appendix A –ICD-9-CM Code Tables Change sub-header from:

Appendix A –ICD-9-CM Code Tables To

Appendix A – ICD-10 Code Tables Change in first sentence in paragraph: ICD-9-CMdiagnosis and procedure To

ICD-10-CMdiagnosis and ICD-10-PCS procedure Change in second sentence in paragraph:

ICD-9-CMcode tables To

ICD-10 code tables

Change in fifth sentence in paragraph: ICD-9-CMcodes

To

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SECTION 1 – Data Dictionary

Introduction to Data Dictionary Impacts: N/A

Rationale: Changes related to the conversion of ICD-9 to ICD-10 and removal of measures and/or data elements.

Description of Changes: Introduction

Change:

ICD-9-CM Other Diagnosis Codes ICD-9-CM Other Procedure Codes ICD-9-CM Other Procedure Dates ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code ICD-9-CM Principal Procedure Date To

ICD-10-CM Other Diagnosis Codes ICD-10-PCS Other Procedure Codes ICD-10-PCS Other Procedure Dates ICD-10-CM Principal Diagnosis Code ICD-10-PCS Principal Procedure Code ICD-10-PCS Principal Procedure Date Missing and Invalid Data

Change:

QIO Clinical Warehouse To

CMS Clinical Warehouse

Interpretation of Data Dictionary Terms Change in third bullet:

Infection Prior to Anesthesia To

ED Departure Date SCIP measures To

ED measures

Medical Record Documentation

Change in fifth paragraph, first bullet under ‘Examples’: Antibiotic Administration Time

To

ED Departure Time

Change in fifth paragraph, second bullet under ‘Examples’: Antibiotic Administration Date

To

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Alphabetical Data Dictionary Impacts:

Index

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Remove in their entirety: ACEI Prescribed at Discharge Anesthesia End Date

Anesthesia End Time Anesthesia Start Time Another Source of Infection Antibiotic Administration Date Antibiotic Administration Route Antibiotic Administration Time Antibiotic Allergy

Antibiotic Name Antibiotic Received

ARB Prescribed at Discharge

Aspirin Received Within 24 Hours Before or After Hospital Arrival Beta-Blocker Current Medication

Beta-Blocker During Pregnancy Beta-Blocker Perioperative

Beta-Blocker Prescribed at Discharge Catheter Removed

Chest X-Ray First PCI Date First PCI Time LVF Assessment LVSD Monitoring Documentation Non-Primary PCI Oral Antibiotics Other Surgeries Perioperative Death

Pneumonia Diagnosis: ED/Direct Admit Preadmission Oral Anticoagulation Therapy Preoperative Hair Removal

Pseudomonas Risk

Reason for Alternative Empiric Antibiotic Therapy Reason for Delay in PCI

Reason for No ACEI and No ARB at Discharge Reason for No Aspirin on Arrival

Reason for No Beta-Blocker at Discharge

Reason for Not Administering Beta-Blocker Perioperative Reason for Not Administering VTE Prophylaxis

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Reasons for Continuing Urinary Catheterization Reasons to Extend Antibiotics

Surgical Incision Date Surgical Incision Time

UFH Therapy Administration Urinary Catheter

Vancomycin VTE Timely

Anesthesia Start Date

Remove under ‘Collected For’ column:

SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP- Inf-6, SCIP-Inf-9, SCIP-Card-2, SCIP-VTE-2 Arrival Date

Remove under ‘Collected For’ column: AMI-1, AMI-7, AMI-8, AMI-8a, PN-6 Arrival Time

Remove under ‘Collected For’ column: AMI-7, AMI-8, AMI-8a, PN-6

Clinical Trial

Change ‘Collected For’ column to:

AMI-7a, CAC-3, SCIP-Inf-4, All STK Measures, VTE-1, VTE-2, VTE-3, VTE-5, VTE-6 Comfort Measures Only

Remove under ‘Collected For’ column: AMI-1, AMI-3, AMI-5, HF-2, PN-6, VTE-4 Discharge Disposition

Remove under ‘Collected For’ column: AMI-1, AMI-3, AMI-5, HF-2, VTE-4 Fibrinolytic Administration

Initial ECG Interpretation

Remove under ‘Collected For’ column: AMI-7, AMI-8, AMI-8a

Fibrinolytic Administration Date Fibrinolytic Administration Time

Reason for Delay in Fibrinolytic Therapy Remove under ‘Collected For’ column: AMI-7

ICU Admission or Transfer

Remove under ‘Collected For’ column: PN-6

Infection Prior to Anesthesia

Remove under ‘Collected For’ column: SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3

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VTE Confirmed VTE Diagnostic Test

Remove under ‘Collected For’ column: VTE-4

VTE Prophylaxis

Remove under ‘Collected For’ column: SCIP-VTE-2

Impacts: Index

Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation.

Description of Changes:

Change ICD-9-CM Other Diagnosis Codes to: ICD-10-CM Other Diagnosis Codes

Change ICD-9-CM Other Procedure Codes to: ICD-10-PCS Other Procedure Codes

Change ICD-9-CM Other Procedure Dates to: ICD-10-PCS Other Procedure Dates

Change ICD-9-CM Principal Diagnosis Code to: ICD-10-CM Principal Diagnosis Code

Change ICD-9-CM Principal Procedure Code to: ICD-10-PCS Principal Procedure Code

Change ICD-9-CM Principal Procedure Date to: ICD-10-PCS Principal Procedure Date

Impacts: Index

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Measurement Value

Remove under ‘Collected For’ column: AMI-7, AMI-8

Impacts:

New Data Elements

Rationale: A new measure set is being added to align with CY 2015 IPPS Final Rule. Description of Changes:

Add new data element names to ‘Index’ and data element pages: Administrative Contraindication to Care

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Bedside Cardiovascular Ultrasound Time Blood Culture Collection

Blood Culture Collection Date Blood Culture Collection Time

Broad Spectrum or Other Antibiotic Administration Broad Spectrum or Other Antibiotic Administration Date Broad Spectrum or Other Antibiotic Administration Selection Broad Spectrum or Other Antibiotic Administration Time Capillary Refill Examination Date

Capillary Refill Examination Performed Capillary Refill Examination Time Cardiopulmonary Evaluation Date Cardiopulmonary Evaluation Performed Cardiopulmonary Evaluation Time Central Venous Oxygen Measurement Central Venous Oxygen Measurement Date Central Venous Oxygen Measurement Time Central Venous Pressure Measurement Central Venous Pressure Measurement Date Central Venous Pressure Measurement Time Crystalloid Fluid Administration

Crystalloid Fluid Administration Date Crystalloid Fluid Administration Time Directive for Comfort Care, Septic Shock Directive for Comfort Care, Severe Sepsis Discharge Time

Fluid Challenge Date Fluid Challenge Performed Fluid Challenge Time Hypotension

Initial Lactate Level Collection Initial Lactate Level Date Initial Lactate Level Result Initial Lactate Level Time Passive Leg Raise Exam Date Passive Leg Raise Exam Performed Passive Leg Raise Exam Time Peripheral Pulse Evaluation Date Peripheral Pulse Evaluation Performed Peripheral Pulse Evaluation Time Repeat Lactate Level Collection Repeat Lactate Level Date Repeat Lactate Level Time Septic Shock Present

Septic Shock Presentation Date Septic Shock Presentation Time Severe Sepsis Present

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Severe Sepsis Presentation Time Skin Examination Date

Skin Examination Performed Skin Examination Time Vasopressor Administration Vasopressor Administration Date Vasopressor Administration Time Vital Signs Review Date

Vital Signs Review Performed Vital Signs Review Time Impacts:

Alcohol or Drug Disorder

Rationale: The data element is duplicative of Tables 13.2 and 13.3 which are already used to identify patients with alcohol or drug disorders via ICD-9-CM diagnosis codes. Removal of this data element will greatly reduce the burden of data abstraction.

Description of Changes: Index

Remove row:

Alcohol or Drug Disorder Data Elements

Remove in its entirety: Alcohol or Drug Disorder Impacts:

Alcohol or Drug Use Status Post Discharge - Counseling Alcohol or Drug Use Status Post Discharge - Medication Alcohol Use Status Post Discharge - Quit Status

Drug Use Status Post Discharge - Quit Status

Rationale: The Joint Commission SUB and TOB Technical Advisory Panels have

recommended that SUB-4 and TOB-4 be inactivated due to burden of data abstraction. In addition, there are no future plans to adopt these measures by CMS for the IQR program. Description of Changes:

Collected For Change to:

The Joint Commission: SUB-4 data collection suspended Impacts:

Alcohol Use Status

Rationale: Allowable values have been updated to include high risk patients. The list of single item screeners was updated based on current evidence and clarifications have been added throughout the notes for abstraction to better reflect the intent of the data element.

Description of Changes: Definition

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Allowable Values Change “2” from:

2 The patient was screened with a validated tool within the first three days of admission and the score on the alcohol screen indicates unhealthy alcohol use (moderate risk) benefiting from brief intervention.

To

2 The patient was screened with a validated tool within the first three days of admission and the score on the alcohol screen indicates unhealthy alcohol use (moderate or high risk) benefiting from brief intervention.

Change “4” from:

4 The patient was screened with a non-validated tool within the first three days of admission and the score on the alcohol screen indicates unhealthy alcohol use (moderate risk) benefiting from brief intervention.

To

4 The patient was screened with a non-validated tool within the first three days of admission and the score on the alcohol screen indicates unhealthy alcohol use (moderate or high risk) benefiting from brief intervention.

Notes for Abstraction Change first bullet to:

• If patient has a blood alcohol test with a result of .08 or greater or the clinician documents the patient was acutely intoxicated per blood alcohol test results select Value “2.”

Change second bullet to:

• Screening may be done with a Single-item Validated Questionnaire (SASQ) in order to identify those patients with no risk or low risk or who do not drink. Further screening should be done with a validated tool for those patients with a positive result to determine if there is need for a brief intervention.

Examples of SASQs include:

o “On any single occasion during the past 3 months, have you had more than 5 drinks containing alcohol?” (Yes response is considered positive.)

o "When was the last time you had more than X drinks in 1 day?" (X = 4 for women and 5 for men) (Within the last 3 months is considered positive.)

o “How many times in the past year have you had X or more drinks in a day?" (X = 5 men and 4 women) (Response of >1 is considered positive.)

o How often have you had 6 or more drinks on one occasion in the past year? (Ever in the past year considered positive.)

o How often do you have X or more drinks on one occasion? (X = 4 for women and 5 for men) (Ever in the past year considered positive.)

Remove under seventh bullet:

Examples of cognitive impairment include: o Altered Level of Consciousness (LOC) o Altered Mental Status

o Cognitive impairment o Cognitively impaired o Confused

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o Memory loss o Mentally retarded

o Obtunded

Add new eighth and ninth bullet:

• If there is documentation that the patient was psychotic with documented symptoms e.g., hallucinating, non-communicative, catatonic, etc. which prevented them from answering questions reliably, they would be considered cognitively impaired.

• If there is documentation that the patient is not a reliable historian, a relative or guardian if available, may answer the screening questions on behalf of the patient.

Examples of cognitive impairment include: o Altered Level of Consciousness (LOC) o Altered Mental Status

o Cognitive impairment o Cognitively impaired o Confused o Memory loss o Mentally retarded o Obtunded

Inclusion Guidelines for Abstraction Change sentence to:

Validated Screening Tools for Unhealthy Alcohol Use: This list is not ALL Inclusive. Exclusion Guidelines for Abstraction

Change to:

Any tool which specifically screens for alcohol use disorder, alcohol dependency or alcohol abuse. Examples include, but are not limited to:

• CAGE • SASSI • S2BI Impacts:

Alcohol Use Status

Rationale: There are no future plans to adopt these measures by CMS for the IQR program. Description of Changes:

Collected For Remove:

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Impacts:

Anesthesia Start Date

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Remove under ‘Collected For’:

CMS Voluntary Only: SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-6, SCIP-Inf-9, SCIP-Card-2, SCIP-VTE-2

Impacts:

Anesthesia Start Date Clinical Trial

Glucose

Infection Prior to Anesthesia

Rationale: The Centers for Medicare & Medicaid Services (CMS) and The Joint Commission made the decision to suspend SCIP-Inf-4 beginning with discharges effective July 1, 2014. Description of Changes:

Change under ‘Collected For’: SCIP-Inf-4

To

SCIP-Inf-4 suspended Impacts:

Antithrombotic Therapy Administered by End of Hospital Day 2

IV OR IA Thrombolytic (t-PA) Therapy Administered at This Hospital or Within 24 Hours Prior to Arrival

Reason for Not Administering Antithrombotic Therapy by End of Hospital Day 2

Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-5 as an electronic clinical quality measure, as stated in the CY 2015 IPPS Final Rule.

Description of Changes: Collected For

Remove:

CMS Voluntary Only: STK-5 Impacts:

Anticoagulation Therapy Prescribed at Discharge Atrial Fibrillation/Flutter

Reason for Not Prescribing Anticoagulation Therapy at Discharge

Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-3 as an electronic clinical quality measure, as stated in the CY 2015 IPPS Final Rule.

Description of Changes: Collected For

Remove:

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Impacts:

Antithrombotic Therapy Prescribed at Discharge

Reason for Not Prescribing Antithrombotic Therapy at Discharge

Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-2, as electronic clinical quality measures, as stated in the CY 2015 IPPS Final Rule.

Description of Changes: Collected For Remove: CMS Voluntary Only: STK-2 Impacts: Arrival Date

Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-5 measure as an electronic clinical quality measure, as stated in the CY 2015 IPPS Final Rule. The STK-5 measure will now be collected for The Joint Commission Only.

Description of Changes: Collected For

Remove under ‘CMS Voluntary Only’: STK-5

Impacts: Arrival Date Arrival Time

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Collected For

Remove:

CMS Voluntary Only: AMI-1, AMI-7, AMI-8, AMI-8a, PN-6 Impacts:

Assessed for Rehabilitation Services

Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-10 as an electronic clinical quality measure, as stated in the CY 2015 IPPS Final Rule.

Description of Changes: Collected For Remove: CMS Voluntary Only: STK-10 Impacts: Atrial Fibrillation/Flutter

Rationale: The change provides clarification for cases discharged from the hospital with telemetry monitoring.

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Description of Changes: Notes for Abstraction Add new fifth bullet:

• If there is documentation to monitor the patient for atrial fibrillation/flutter after discharge and no other documentation of a confirmed diagnosis or history of atrial fibrillation/flutter in the medical record, select “No.”

Example:

Possible cardioembolic origin. Telemetry monitoring for 30 days to exclude PAF. Impacts:

Brief Intervention

Rationale: Additional notes for abstraction were added to clarify the use of a trained peer support person to perform the intervention.

Description of Changes: Definition

Change first sentence to:

A single interaction conducted by a qualified healthcare professional or trained peer support person with the patient, following a positive screening result for unhealthy alcohol use or alcohol use disorder (abuse or dependence).

Notes for Abstraction Add new second bullet:

A peer support person who has received specialized training in brief intervention may perform the brief intervention in lieu of a qualified healthcare professional.

Impacts:

Brief Intervention

Rationale: There are no future plans to adopt these measures by CMS for the IQR program. Description of Changes:

Collected For Remove:

CMS Informational Only: SUB-2 Impacts:

Clinical Trial

Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-2, STK-3, STK-5, and STK-10 as electronic clinical quality measures, as stated in the CY 2015 IPPS Final Rule.

Description of Changes: Collected For

Remove under ‘CMS Voluntary Only’: STK-2, STK-3, STK-5, STK-10

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Impacts: Clinical Trial

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Collected For

Remove:

CMS Voluntary Only: AMI-1, AMI-3, AMI-5, AMI-7, AMI-8, AMI-8a, HF-2, PN-6, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-6, SCIP-Inf-9, SCIP-Card-2, SCIP-VTE-2,VTE-4

Definition Remove: HF, PN

Allowable Values

Remove in ‘Yes’ and in ‘No’: HF, PN

Notes for Abstraction

Remove under first bullet in ‘2’: HF, PN

Remove: HF:

Only capture patients enrolled in clinical trials studying patients with heart failure (HF). PN:

Only capture patients enrolled in clinical trials studying patients with pneumonia.

Impacts:

Comfort Measures Only

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes:

Remove under ‘CMS Voluntary Only’: AMI-1, AMI-3, AMI-5, HF-2, PN-6, VTE-4

Impacts:

Comfort Measures Only

Rationale: There are no future plans to adopt these measures by CMS for the IQR program. Description of Changes:

CMS Informational Only: All SUB Measures, All TOB Measures Collected For

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Impacts:

Comfort Measures Only

Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-2, STK-3, STK-5, and STK-10 as electronic clinical quality measures, as stated in the CY 2015 IPPS Final Rule. Description of Changes: Collected For Remove: CMS Voluntary Only: STK-2, STK-3, STK-5, STK-10 Impacts: Discharge Disposition

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes:

Remove under ‘CMS Voluntary Only’: AMI-1, AMI-3, AMI-5, HF-2, VTE-4 Impacts:

Discharge Disposition

Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-2, STK-3, and STK-10 as electronic clinical quality measures, as stated in the CY 2015 IPPS Final Rule. Description of Changes:

Remove under ‘CMS Voluntary Only’: STK-2, STK-3, STK-10

Impacts:

Discharge Disposition

Rationale: The Joint Commission SUB and TOB Technical Advisory Panels have

recommended that SUB-4 and TOB-4 be inactivated due to burden of data abstraction. In addition, there are no future plans to adopt these measures by CMS for the IQR program. Description of Changes:

Collected For

Change ‘SUB-4’ under “The Joint Commission Only” to: SUB-4 data collection suspended

Change ‘TOB-4’ under “The Joint Commission Only” to: TOB-4 data collection suspended

Remove:

CMS Informational Only: SUB-3, SUB-4, TOB-3, TOB-4 Impacts:

Discharge Disposition

Transfer From Another Hospital or ASC

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Description of Changes: Index and Data Elements Add under “Collected For”: CMS Only: SEP-1

Impacts:

Elective Carotid Intervention

Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-2, STK-3, STK-5, and STK-10 as electronic clinical quality measures, as stated in the CY 2015 IPPS Final Rule.

Description of Changes: Remove under ‘Collected For’:

CMS Voluntary Only: STK-2, STK-3, STK-5, STK-10 Impacts:

Elective Carotid Intervention

Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation.

Description of Changes:

Inclusion Guidelines for Abstraction Change in paragraph:

ICD-9-CM To

ICD-10-PCS

Exclusion Guidelines for Abstraction Change in paragraph: ICD-9-CM To ICD-10-PCS Impacts: Fibrinolytic Administration

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Collected For

Remove:

CMS Voluntary Only: AMI-7, AMI-8, AMI-8a Impacts:

Fibrinolytic Administration Date

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

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Description of Changes: Collected For

Remove:

CMS Voluntary Only: AMI-7

Impacts:

Fibrinolytic Administration Time

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Collected For

Remove:

CMS Voluntary Only: AMI-7

Impacts:

Follow-Up Contact Follow-Up Contact Date

Rationale: The Joint Commission SUB and TOB Technical Advisory Panels have

recommended that SUB-4 and TOB-4 be inactivated due to burden of data abstraction. In addition, there are no future plans to adopt these measures by CMS for the IQR program. Description of Changes:

Collected For

Change under “The Joint Commission Only” to:

SUB-4 data collection suspended, TOB-4 data collection suspended Remove:

CMS Informational Only: SUB-4, TOB-4

Impacts: Glucose

Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation.

Description of Changes: Allowable Values

Change in fifth bullet in ‘5’: ICD-9-CM

To

ICD-10-PCS

Impacts:

ICD-9-CM Other Diagnosis Codes

Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation.

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Description of Changes:

Change data element name from: ICD-9-CM Other Diagnosis Codes To

ICD-10-CM Other Diagnosis Codes Definition

Change: ICD-9-CM To

ICD-10-CM

Suggested Data Collection Question Change: ICD-9-CM To ICD-10-CM Format: Change to:

Length: 3 - 7 (without decimal point or dot) Type: Character (upper or lower case) Occurs: 24

Allowable Values: Change to:

Any valid diagnosis code as per the CMS ICD-10-CM master code table (2015 Code Descriptions in Tabular Order):

http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-and-GEMs.html

Impacts:

ICD-9-CM Other Procedure Codes

Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation.

Description of Changes:

Change data element name from: ICD-9-CM Other Procedure Codes To

ICD-10-PCS Other Procedure Codes Definition

Change: ICD-9-CM To

ICD-10-PCS

Suggested Data Collection Question Change:

ICD-9-CM To

(23)

Format: Change to:

Length: 3 - 7 (without decimal point or dot) Type: Character (upper or lower case) Occurs: 24

Allowable Values: Change to:

Any valid procedure code as per the CMS ICD-10-PCS master code table (2015 PCS Long and Abbreviated Titles):

http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-PCS-and-GEMs.html

Impacts:

ICD-9-CM Other Procedure Dates

Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation.

Description of Changes:

Change data element name from: ICD-9-CM Other Procedure Dates To

ICD-10-PCS Other Procedure Dates Notes for Abstraction

Change under second bullet: ICD-9-CM

To

ICD-10-PCS

Change in ‘Note’, first sentence: QIO Clinical Warehouse

To

CMS Clinical Warehouse

Change in ‘Note’, second sentence: ICD-9-CM

To

ICD-10-PCS Impacts:

ICD-9-CM Principal Diagnosis Code

Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation.

Description of Changes:

Change data element name from: ICD-9-CM Principal Diagnosis Code To

(24)

Definition Change: ICD-9-CM To

ICD-10-CM

Suggested Data Collection Question Change: ICD-9-CM To ICD-10-CM Format Change to:

Length: 3 - 7 (without decimal point or dot) Type: Character (upper or lower case) Occurs: 1

Allowable Values Change to:

Any valid diagnosis code as per the CMS ICD-10-CM master code table (2015 Code Descriptions in Tabular Order):

http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-and-GEMs.html Impacts:

ICD-9-CM Principal Procedure Code

Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation.

Description of Changes:

Change data element name from: ICD-9-CM Principal Procedure Code To

ICD-10-PCS Principal Procedure Code Suggested Data Collection Question Change: ICD-9-CM To ICD-10-PCS Format Change to:

Length: 3 - 7 (without decimal point or dot) Type: Character (upper or lower case) Occurs: 1

Allowable Values Change to:

Any valid procedure code as per the CMS ICD-10-PCS master code table (2015 PCS Long and Abbreviated Titles):

(25)

Impacts:

ICD-9-CM Principal Procedure Date

Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation.

Description of Changes:

Change throughout, data element name from: ICD-9-CM Principal Procedure Date

To

ICD-10-PCS Principal Procedure Date Notes for Abstraction

Change in ‘Note’, first sentence: QIO Clinical Warehouse

To

CMS Clinical Warehouse

Change in ‘Note’, second sentence: ICD-9-CM

To

ICD-10-PCS Impacts:

ICU Admission or Transfer

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Allowable Values

Remove in ‘1 (Yes)’, ‘2 (No)’, and ‘3 (UTD)’:

(at this hospital within the first 24 hours following arrival at this hospital for PN). Impacts:

ICU Admission or Transfer

Rationale: Additional acceptable data sources were added to assist the field in abstraction. Description of Changes:

Collected For Remove:

CMS Voluntary Only: PN-6 Notes for Abstraction

Add new first and second bullets:

• In order to select Value “1” for this data element there must be a Physician/APN/PA order for admission or transfer to an ICU. Documentation of ICU admit or transfer can be found in the physician orders or in the secondary data sources.

• When the physician orders do not have a clear admission or transfer to the ICU,

additional information listed in the secondary data sources, such as protocol to transfer to ICU, can be used to support the order to admit or transfer to the ICU.

(26)

Example:

Patient has a code blue on medical floor. The code blue sheet notes transfer from medical bed to ICU bed when stabilized. The code blue sheet is signed and dated. Hospital protocol indicates that all code blue patients are transferred to ICU.

Select “Yes.”

Add new seventh and eighth bullets:

• For patients who are admitted to Observation status and then transferred to full admission to ICU, a physician order must be present to select “Yes.”

Example:

Medical record documentation reflects that the patient was admitted to

observation on 04-05-20xx. On 04-06-20xx the physician writes an order to admit to ICU. Select “Yes.”

• The patient was admitted or transferred with a physician/APN/PA order to the ICU anytime during this hospitalization regardless of the patient location select Value “1”. Remove PN and VTE sections:

PN:

The patient was admitted or transferred to the intensive care unit (ICU) at this hospital within the first 24 hours following arrival at this hospital.

• In order to select value “1” (yes) for this data element there must be a physician order for admission or transfer to an ICU AND documentation that the patient was transferred or admitted to the ICU within 24 hours following hospital arrival.

• The 24-hour timeframe relates to the time from hospital arrival to arrival in the ICU unit, not the time of the physician order to admit or transfer to the ICU.

• If documentation reflects ICU graphic sheets or ICU nursing notes and there is no physician order for ICU, select value “2” (No).

• If other pneumonia related reasons for transfer or admission, such as septic shock, respiratory distress or failure, hypotension, tachypnea, hypoxemia or the need for a ventilator are documented, select value “1.”

• If the patient was transferred or admitted to the ICU at this hospital within the first 24 hours after arrival to the hospital for reasons other than complications due to

pneumonia, select value “2” to this question (i.e., a patient presents to the ED with pneumonia and shortly after arrival has a GI bleed or cardiac arrhythmia or the ICU may be the only place with monitored beds).

• If there is no other documented reason why the patient was transferred/admitted to the ICU at this hospital, assume it was for complications due to pneumonia.

VTE:

The patient was admitted or transferred to the ICU anytime during this hospitalization regardless of the patient location select value “1” (yes). Suggested Data Sources

Change to:

Priority Data Source (required) Physician/APN/PA orders

(27)

Add:

Secondary Data Souces for the Physician/APN/PA order: • Ambulance record

• Code Blue/RRT Sheet

• Emergency Department record • Helicopter record

• Order to transfer

• Protocol to transfer to ICU Remove:

PN ONLY

Suggested data sources to support admission or transfer to ICU • Emergency Department record

• ICU Nursing admission assessment • ICU Nursing notes

Impacts:

ICU Admission or Transfer Date

Rationale: Additional acceptable data sources were added to assist the field in abstraction. Description of Changes:

Notes for Abstraction Change to:

• The intent of this data element is to determine the date that the patient was actually admitted to ICU. In order to find the ICU admission date for this data element, there must be a Physician/APN/PA order for ICU admission or transfer to an ICU.

• Documentation of the date a patient was admitted or transferred to the ICU can be found in the physician orders in the secondary data sources.

• When the physician orders for ICU admission or transfer date are not clear,

documentation in the secondary data sources, such as the date of a protocol to transfer to ICU, can be used.

Example:

Patient has a code blue on the medical floor. The code blue sheet is signed and dated 1/1/XX, and notes the patient is transfer from medical bed to ICU bed. Hospital protocol indicates that all code blue patients are transferred to ICU, use the date noted on the code blue sheet.

• For patients who are admitted to Observation status and subsequently admitted to ICU, abstract the date the order was written to admit to ICU. Do not abstract the date that the patient was admitted to Observation.

Example:

Medical record documentation reflects that the patient was admitted to

observation on 04-05-20xx. On 04-06-20xx the physician writes an order to admit to ICU. The ICU Admission or Transfer Date would be abstracted as 04-06-20xx; the date the determination was made to admit to acute inpatient care and the order was written.

• If a patient has more than one admission to the ICU for more than one day, subsequent transfers back to an ICU during the same hospitalization will NOT be abstracted.

(28)

• If a patient is admitted to ICU on 10/19/xx and discharged to a medical floor on

10/20/xx, that is equal to one day, regardless of the number of hours. More than a day in ICU is when a patient is admitted to ICU on 10/19/xx and discharged on 10/21/xx, regardless of the number of hours.

• Abstract the date that the admission/transfer was ordered regardless of whether the patient is physically placed into the ICU on the same date.

• The medical record must be abstracted as documented (taken at “face value”). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select “UTD.”

Example:

Documentation indicates the ICU Admission or Transfer Date was 03-42-20xx. No other physician order in the medical record provides a valid date. Since the ICU Admission or Transfer Date is outside of the range listed in the Allowable Values for “Day,” it is not a valid date and the abstractor should select “UTD.” Note: Transmission of a case with an invalid date as described above will be rejected from the CMS Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” allows the case to be accepted into the warehouses.

Suggested Data Sources Change to:

Primary Data Source: Physician/APN/PA orders

Secondary Data Source to support Admission or Transfer Date • Admit Discharge Transfer (ADT) record

• Ambulance record • Code Blue/ RRT Sheet

• Emergency Department record • Helicopter record

• Medication Reconciliation

• Nursing admission assessment/admitting note • Observation record

• Order to transfer • Physician H& P

• Physician Progress Notes • Protocol to transfer to ICU Impacts:

Infection Prior to Anesthesia

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Remove under ‘Collected For’:

(29)

Impacts:

Initial ECG Interpretation

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Collected For

Remove:

CMS Voluntary Only: AMI-7, AMI-8, AMI-8a Impacts:

LDL-c Greater Than or Equal to 100 mg/dL

LDL-c Measured Within the First 48 Hours or 30 Days Prior to Hospital Arrival Pre-Arrival Lipid-Lowering Agent

Rationale: This change is to update measure information to align with 2013 guideline recommendations on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease in adults.

Description of Changes:

Remove in Index and Data Dictionary in their entirety: LDL-c Greater Than or Equal to 100 mg/dL

LDL-c Measured Within the First 48 Hours or 30 Days Prior to Hospital Arrival Pre-Arrival Lipid-Lowering Agent

Impacts:

Measurement Value

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Remove under ‘Collected For’: AMI-7, AMI-8

Impacts:

Prescription for Alcohol or Drug Disorder Medication Referral for Addictions Treatment

Rationale: There are no future plans to adopt these measures by CMS for the IQR program. Description of Changes:

CMS Informational Only: SUB-3 Impacts:

Prescription for Tobacco Cessation Medication

Referral for Outpatient Tobacco Cessation Counseling

Rationale: The Joint Commission SUB and TOB Technical Advisory Panels have

recommended that SUB-4 and TOB-4 be inactivated due to burden of data abstraction. In addition, there are no future plans to adopt these measures by CMS for the IQR program. Collected For

(30)

Description of Changes: Collected For

Change ‘TOB-4’ under “The Joint Commission Only” to: TOB-4 data collection suspended

Remove:

CMS Informational Only: TOB-3, TOB-4 Impacts:

Reason for Delay in Fibrinolytic Therapy

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Remove under ‘Collected For’: CMS Voluntary Only: AMI-7 Impacts:

Reason for Discontinuation of Parenteral Anticoagulation Therapy

Rationale: This change is to correct the measure so that the FDA approval of Pradaxa for VTE treatment can pass the measure. IVC Filter is not an acceptable reason for the discontinuation of the parenteral therapy.

Description of Changes:

Inclusion Guidelines for Abstraction Change bullets to:

• Administration of Oral Factor Xa Inhibitors o Xarelto or rivaroxaban

o Eliquis or apixaban

• Administration of Direct Thrombin Inhibitor o Pradaxa or dabigatran

• Documentation of active bleeding • Documentation of a plan for surgery

• Documentation of a plan for blood transfusion

• Documentation that patient is not a candidate for anticoagulation therapy • Documentation of thrombocytopenia

Refer to Appendix H, Table 2.3 VTE Parenteral Therapy Table and Appendix C, Table 1.4 Warfarin Therapy.

Exclusion Guidelines for Abstraction Add new bullet:

• IVC filter is not an acceptable reason for discontinuing parenteral therapy prior to five days of treatment unless physician/APN/PA indicates a reason.

Impacts:

Reason for No Administration of VTE Prophylaxis

Rationale: This change is to correct the measure so that the FDA approval of Pradaxa for VTE treatment can pass the measure.

(31)

Description of Changes: Notes for Abstraction EXCEPTIONS

Add new bullet:

• For patients receiving anticoagulant therapy other than warfarin for atrial fibrillation or other conditions the day of or the day after hospital admission, select “Yes.”

Inclusion Guidelines for Abstraction Add:

Refer to Appendix H, Table 2.7 Anticoagulation Therapy for Atrial Fibrillation and Other Conditions.

Impacts:

Reason for No Overlap Therapy

Rationale: This change is to correct the measure so that the FDA approval of Pradaxa for VTE treatment can pass the measure.

Description of Changes:

Inclusion Guidelines for Abstraction Change bullets to:

• Administration of Oral Factor Xa Inhibitors o Xarelto or rivaroxaban

o Eliquis or apixaban

• Administration of Direct Thrombin Inhibitor o Pradaxa or dabigatran

• Documentation of active bleeding • Documentation of a plan for surgery

• Documentation of a plan for blood transfusion

• Documentation that patient is not a candidate for anticoagulation therapy Impacts:

Reason for No Tobacco Cessation Medication at Discharge

Rationale: There are no future plans to adopt these measures by CMS for the IQR program. Description of Changes:

Collected For Remove:

CMS Informational Only: TOB-3 Impacts:

Reason for No Tobacco Cessation Medication During the Hospital Stay Tobacco Use Treatment FDA - Approved Cessation Medication

Tobacco Use Treatment Practical Counseling

Rationale: There are no future plans to adopt these measures by CMS for the IQR program. Description of Changes:

CMS Informational Only: TOB-2 Collected For

(32)

Impacts:

Reason for No Tobacco Cessation Medication During the Hospital Stay

Rationale: This change corrects a typo in the data element Reason for No Tobacco Cessation Medication During the Hospital Stay.

Description of Changes: Notes for Abstraction Change first bullet to:

• Reasons for not administering FDA-approved tobacco cessation medications must be documented by a physician/APN/PA or pharmacist.

Impacts:

Reason for No Tobacco Cessation Medication During the Hospital Stay

Rationale: Due to confusion related to data abstraction, change in terminology to reflect that tobacco treatment should be provided during the hospital stay within the 3rd day of admission. Description of Changes:

Definition

Change sentence to:

Reasons for not administering an FDA-approved tobacco cessation medication documented during the hospital stay within the first three days of admission include:

Suggested Data Collection Question Change to:

Is there documentation of a reason for not administering one of the FDA-approved tobacco cessation medications during the hospital stay within the first three days of admission? Allowable Values

Change from:

Y (Yes) There is documentation of a reason for not administering an FDA-approved cessation medication during the first three days of admission.

N (No) There is no documentation of a reason for not administering an FDA-approved cessation medication during the first three days of admission or unable to determine from medical record documentation.

To

Y (Yes) There is documentation of a reason for not administering an FDA-approved cessation medication during the hospital stay within the first three days of admission.

N (No) There is no documentation of a reason for not administering an FDA-approved cessation medication during the hospital stay within the first three days of admission or unable to determine from medical record documentation.

Impacts:

Reason for Not Administering Antithrombotic Therapy by End of Hospital Day 2

Rationale: This change is needed to reinforce that reason documentation must be within the timeframe of arrival to end of hospital day 2.

(33)

Description of Changes:

Exclusion Guidelines for Abstraction Change to:

• Delay in stroke diagnosis Impacts:

Reason for Not Prescribing Statin Medication at Discharge

Rationale: This change is to update measure information to align with 2013 guideline recommendations on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease in adults.

Description of Changes: Definition

Add new bullet:

• LDL-c less than 70 mg/dL Notes for Abstraction

Add new third bullet:

• Documentation of a LDL-c less than 70 mg/dL anytime during the hospital stay is an

acceptable stand-alone reason for not prescribing statin medication at discharge – Linkage with statin is not needed. Direct or calculated, fasting or non-fasting values are both

acceptable. LDL values obtained within 30 days prior to hospital arrival are acceptable to select “Yes.”

Impacts:

Reason for Oral Factor Xa Inhibitor

Rationale: This change is being made to remove ICD-9 codes that were used to determine if a record has evidence of atrial fibrillation/flutter or history of total hip or total knee surgery. Description of Changes:

Inclusion Guidelines for Abstraction

Remove:

ICD-9-CM Principal/Other Diagnosis Code of 427.31 or 427.32

ICD-9-CM Other Procedure Codes of 81.51, 81.52, 81.53, 81.54, 81.55. Impacts:

Reason for Oral Factor Xa Inhibitor - ICU Admission

Rationale: This change is being made to remove ICD-9 codes that were used to determine if a record has evidence of atrial fibrillation/flutter or history of total hip or total knee surgery. Description of Changes:

Inclusion Guidelines for Abstraction

Remove:

• ICD-9-CM Other Procedure Code of 81.51, 81.52, 81.53, 81.54 or 81.55 • ICD-9-CM Principal/Other Diagnosis Code of 427.31 or 427.32

(34)

Impacts:

Tobacco Use Status

Rationale: There are no future plans to adopt these measures by CMS for the IQR program. Description of Changes:

CMS Informational Only: All TOB Measures Impacts:

Tobacco Use Status

Rationale: This change clarifies a non-tobacco substance in the data element Tobacco Use Status.

Description of Changes:

Exclusion Guidelines for Abstraction Change third bullet to:

• Marijuana use only Impacts:

Tobacco Use Status Post Discharge - Counseling Tobacco Use Status Post Discharge – Medication Tobacco Use Status Post Discharge – Quit Status

Rationale: The Joint Commission SUB and TOB Technical Advisory Panels have

recommended that SUB-4 and TOB-4 be inactivated due to burden of data abstraction. In addition, there are no future plans to adopt these measures by CMS for the IQR program. Description of Changes:

Collected For

Change ‘TOB-4’ under “The Joint Commission Only” to: TOB-4 data collection suspended

Remove:

CMS Informational Only: TOB-4 Impacts:

Tobacco Use Treatment FDA - Approved Cessation Medication

Rationale: Due to confusion related to data abstraction, change in terminology to reflect that tobacco treatment should be provided during the hospital stay within the 3rd day of admission. Description of Changes:

Suggested Data Collection Question Change to:

Did the patient receive one of the FDA-approved tobacco cessation medications during the hospital stay within the first three days after admission?

Allowable Values Change from:

1 The patient received one of the FDA-approved tobacco cessation medications during the first three days after admission.

Collected For Remove:

(35)

2 The patient refused the FDA-approved tobacco cessation medications during the first three days after admission.

3 FDA-approved tobacco cessation medications were not offered to the patient during the first three days after admission or unable to determine from medical record

documentation. To

1 The patient received one of the FDA-approved tobacco cessation medications during the hospital stay within the first three days after admission.

2 The patient refused the FDA-approved tobacco cessation medications during the hospital stay within the first three days after admission.

3 FDA-approved tobacco cessation medications were not offered to the patient during the hospital stay within the first three days after admission or unable to determine from medical record documentation.

Impacts:

Tobacco Use Treatment Practical Counseling

Rationale: Due to confusion related to data abstraction, change in terminology to reflect that tobacco treatment should be provided during the hospital stay within the 3rd day of admission. Description of Changes:

Suggested Data Collection Question Change to:

Did the patient receive all of the components of practical counseling during the hospital stay within the first three days after admission?

Allowable Values Change from:

1 The patient received all components of practical counseling during the first three days after admission.

2 The patient refused/declined practical counseling during the first three days after admission.

3 Practical counseling was not offered to the patient during the first three days after admission or unable to determine if tobacco use treatment was provided from medical record documentation.

To

1 The patient received all components of practical counseling during the hospital stay within the first three days after admission.

2 The patient refused/declined practical counseling during the hospital stay within the first three days after admission.

3 Practical counseling was not offered to the patient during the hospital stay within the first three days after admission or unable to determine if tobacco use treatment was provided from medical record documentation.

Impacts:

Transfer From Another Hospital or ASC

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

(36)

Description of Changes: Collected For

Remove:

CMS Voluntary Only: AMI-7, AMI-8, AMI-8a, PN-6 Impacts:

VTE Confirmed

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Remove under ‘Collected For’: CMS Voluntary Only: VTE-4 Impacts:

VTE Confirmed

Rationale: This change improves listed identification of all acceptable locations of veins for emboli.

Description of Changes: VTE Location

Remove:

• DVT located in the proximal leg veins, including superficial femoral vein • DVT located in the inferior vena cava (IVC)

• DVT located in the iliac, femoral or popliteal veins Add:

DVT Located in:

• Common femoral vein • Common Iliac

• External Iliac vein

• Femoral/superficial femoral vein • Inferior vena cava (IVC)

• Internal iliac • Popliteal vein

• Profunda/deep femoral vein

Impacts:

VTE Diagnostic Test

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Remove under ‘Collected For’: CMS Voluntary Only: VTE-4

(37)

Impacts:

VTE Prophylaxis

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Collected For

Remove:

CMS Voluntary Only: SCIP-VTE-2 Notes for Abstraction

Remove: SCIP

• For the purposes of abstraction, mechanical VTE prophylaxis does not require a

physician order to be abstracted; there is no order or copy of hospital protocol required. Abstract any form of mechanical VTE prophylaxis that is documented as ordered or as placed on the patient at any time from hospital arrival to 24 hours after Anesthesia End Time.

Abstract any pharmacological VTE prophylaxis that was ordered/substituted at any time

from hospital arrival to 24 hours after Anesthesia End Time. If one pharmacological medication is ordered and another medication is substituted (such as per pharmacy formulary substitution or protocol), abstract both medications for VTE Prophylaxis and for VTE Timely.

Note: No copy of the formulary or protocol is required in the medical record. Examples:

o Lovenox is ordered and not received and is substituted with Arixtra, which is

received by the patient. Abstract Lovenox as value "2" for VTE Prophylaxis and "No" for VTE Timely. Abstract Arixtra as value "5" for VTE Prophylaxis and abstract VTE Timely accordingly.

o Lovenox is ordered and not received; heparin is ordered and is received. SCDs

are placed. Abstract Lovenox as value "2" for VTE Prophylaxis and "No" for VTE Timely. Abstract heparin as value "1" and SCDs as value "3" for VTE Prophylaxis and abstract VTE Timely accordingly.

• To select value “9,” there must be an order for aspirin for VTE prophylaxis. For hip and knee arthroplasties, aspirin must be received in the timeframe specified for VTE Timely. Suggested Data Sources

Remove: SCIP

ONLY ACCEPTABLE SOURCE FOR PHARMACOLOGIC PROPHYLAXIS: Physician orders

MECHANICAL PROPHYLAXIS: • Circulator notes

• Graphic/flow sheets

• Medication administration record • Nursing notes

(38)

• Physician notes

• Preoperative nursing notes • Progress notes

SECTION 2 – Measurement Information

Impacts: Measure(s) HF-2

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes:

Remove Measure Set in its entirety:

HEART FAILURE NATIONAL HOSPITAL INPATIENT QUALITY MEASURES Impacts:

Measure(s) PN-6

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes:

Remove Measure Set in its entirety:

PNEUMONIA NATIONAL HOSPITAL INPATIENT QUALITY MEASURES Impacts:

Algorithm(s)

Initial Patient Population of AMI, SCIP, CAC, VTE, STK ED-1, ED-2

IMM-1, IMM-2 SCIP-Inf-4

STK-2, STK-3, STK-4, STK-5, STK-6 SUB-3, SUB-4

TOB-2, TOB-3, TOB-4

VTE-1, VTE-2, VTE-3, VTE-5, VTE-6

Rationale: The ICD-9 codes used to report medical diagnosis and inpatient procedures are being replaced by ICD-10 codes per legislation.

Description of Changes:

Change:

ICD-9-CM Principal Diagnosis Code To: ICD-10-CM Principal Diagnosis Code ICD-9-CM Other Diagnosis Codes

To: ICD-10-CM Other Diagnosis Codes ICD-9-CM Principal Procedure Code To: ICD-10-PCS Principal Procedure Code

(39)

ICD-9-CM Principal Procedure Date To: ICD-10-PCS Principal Procedure Date ICD-9-CM Other Procedure Codes

To: ICD-10-PCS Other Procedure Codes ICD-9-CM Other Procedure Dates

To: ICD-10-PCS Other Procedure Dates

Subsection 2.1 – Acute Myocardial Infarction (AMI) Impacts:

AMI Measure Set List

Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation.

Description of Changes: AMI DATA ELEMENT LIST Change:

ICD-9-CM Other Diagnosis Codes ICD-9-CM Other Procedure Codes ICD-9-CM Other Procedure Dates ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code ICD-9-CM Principal Procedure Date To:

ICD-10-CM Other Diagnosis Codes ICD-10-PCS Other Procedure Codes ICD-10-PCS Other Procedure Dates ICD-10-CM Principal Diagnosis Code ICD-10-PCS Principal Procedure Code ICD-10-PCS Principal Procedure Date

Acute Myocardial Infarction (AMI) Initial Patient Population Change throughout:

ICD-9-CM Principal Diagnosis Code To

ICD-10-CM Principal Diagnosis Code Impacts:

AMI Measure Set List

Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule.

Description of Changes: Set Measure ID #

Remove rows: AMI-1

References

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