Download WSHA Labor Management Roadmap Outcome Measures and

WSHA Labor Management Roadmap and Partnership for Patients Measures for WSHA-CMDC and WSHA-QBS
Numerator and Denominator Specifications (ICD-10 version effective starting with discharges 10/1/15)
WSHA Labor Management Roadmap Outcome Measures and Partnership for Patients Measures:
Measure Definitions with Numerator and Denominator Specifications
(ICD-10 version effective with October 1, 2015 discharges)
This document is intended for the following hospital options for source of measurement data:
1WSHA-CMDC system: Hospitals submit administrative Patient Discharge Data (PDD) and Core Clinical Maternal and Newborn Data to WSHA-CMDC
system which then calculates measure rates based on definitions below and provides secure web-interface for focused supplemental chart review where
indicated for selected measures. Core Clinical Maternal and Newborn data files are special names given to supplemental data files with specific data elements
required for submission of data to WSHA-CMDC
2WSHA-QBS system: Hospitals submit to WSHA-QBS System their own numerator and denominator values for each measure based on definitions
below, internal hospital data analyst support and supplemental chart review data where indicated. WSHA will calculate measures 4.a., 5.a, 9.a., and 9.c. using
CHARS. Hospitals will not need to collect/submit data for these measures.
SUMMARY OF CHANGES AND UPDATES SINCE LAST UPDATE (July 7, 2015, v. 19)
ICD-9 codes were changed to ICD-10 codes.
Other changes summarized below reflect WSHA decisions resulting from: 1) gaps in direct mapping of ICD-9 to ICD-10 coding for Induction of Labor, 2) updated national
measure specifications for two maternal blood transfusion-related measures, 3) Pending national finalization of ICD-10 code specifications for Primary TSV C-section (AHRQ),
Unexpected Newborn Complications (CMQCC), Pre-eclampsia with Severe Maternal Morbidity (CMQCC), Severe Maternal Morbidity per All Deliveries >= 20 wks (a New
Roadmap Outcome measure based on CMQCC and CDC measure)
Induction of Labor Measures
New Required Supplemental Data Field “Induced” (Yes / No). The addition of a clinical “Induced” data element will enable continued calculation of the two outcome
measures for CS Rates for Term Inductions of Labor in Multiparous and Nulliparous Women >= 39 Week.
Transfusion Measures
Two of the Optional Safe Deliveries Roadmap Transfusion measures have been aligned with national measures from CMS and Joint Commission. Changes have occurred
nationally to the blood product types captured for these measures. Washington State Safe Deliveries Roadmap is making changes to these two measures to align with the
national measures.
1. CMS OB Adverse Event Measure (original measure defined by CMS in 2014): Total number of blood products transfused per 1,000 delivering mothers >= 20 wks. This
measure has been changed to focus on RBC and FFP units only (platelets and cryoprecipitate packs will no longer counted because of variations in these unit volumes)
2. Joint Commission Maternal Sentinel Event-Massive Blood Transfusion >= 4 units (deliveries >= 20 wks): This measure is now focused on RBCs only (FFP, platelets and
cryoprecipitate packs will Not be included per this Joint Commission Maternal Sentinel Event definition)
Draft measure specifications provided in this document for two measures (finalized versions expected January 2016)
1. Primary TSV Cesarean Delivery (#2) (AHRQ)
2. Unexpected Newborn Complications (#8) (CMQCC)
Measure specifications for two Severe Maternal Morbidity measures pending - ICD-10 codes availability expected January 2016
1. Severe maternal morbidity with pre-eclampsia diagnosis (CMQCC)
2. Severe maternal morbidity for all deliveries >= 20 wks gestation – NEW 2016 Safe Deliveries Roadmap outcome measure addition (CMQCC and CDC)
Outcome
Measure
Numerator
Description
Denominator
Description
Definition
Source
Data Source
Numerator Specifications
Denominator Specifications
1.
Nulliparous
Term
Singleton
Vertex
Cesarean
Section Rate
(NTSV)
All cesarean
deliveries
among the
denominator
Nulliparous
(first birth)
women > 37
weeks.
Joint
Commission
PC-02
current for
the time
period
Patient
Discharge Data
Plus
Gestational
Age at Delivery,
And Parity
From either:
Cases among the denominator
who had cesarean delivery
Nulliparous patients delivering live term singleton
newborn in vertex presentation.
Included populations:
-ICD-10-PCS procedure codes for delivery as defined in
Joint Commission Appendix A, Table 11.01.1:
-Nulliparous patients with ICD-10-CM Principal Diagnosis
Code or ICD-10-CM Other Diagnosis Codes for outcome of
delivery as defined in Appendix A, Table 11.08 and with
delivery of a newborn with 37 weeks or more of gestation
completed
Exclusions:
breech or
transverse
presentation,
preterm
births, fetal
deaths, and
multiple
gestations.
When birth
certificate
data is
available
additional
exclusions
added will
be: planned
home birth or
birthing clinic
or
transferred
to hospital
for higher
level of care
for maternal
or fetal
indications
for delivery
Plus state
additions to
exclusion list:
planned
place of birth
and transfer
to higher
level of care
when birth
certificate
data available
Core Clinical
Maternal data
OR
Birth Certificate
data
December 23, 2015 (V1 effective starting with discharges 10/1/15)
Included Populations: ICD-10PCS Principal Procedure Code or
ICD-10-PCS Other Procedure
Codes for cesarean section as
defined in Appendix A, Table
11.06:
10D00Z0 Classical cesarean
10D00Z1 Low cervical cesarean
10D00Z2 Extraperitoneal
cesarean
Excluded Populations: None
Excluded populations:
-ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other
Diagnosis Codes, for contraindications to vaginal delivery
as defined in Appendix A, Table 11.09
-Less than 8 yrs of age
-Greater than or equal to 65 yrs of age
-Length of stay >120 days
-Enrolled in clinical trials
-Gestational Age < 37 weeks
NOTE: SEE JOINT COMMISSION CODE TABLE APPENDICES
FOR COMPLETE LIST OF CODES
When birth certificate data available add to exclusions
“Planned Birth Place, if different” = Home or
Freestanding Birth Center (item 4b on Birth Certificate)
and “mother was transferred to hospital for higher level
of care for maternal or fetal indications for delivery” (item
45 on Birth Certificate)
p. 2
2.
Primary
Term
Singleton
Vertex (TSV)
Cesarean
Section Rate
All cesarean
deliveries
among the
denominator
Delivering
women > 37
weeks who
have not had
a prior
cesarean
section.
Safe
Deliveries
Roadmap
Measure
Patient
Discharge Data
Plus
Gestational age
at Delivery
From either:
Core Clinical
Maternal data
OR
Birth Certificate
data.
When birth
certificate data
available add to
exclusions:
Previous csection (# 57.7
on Birth
Certificate)
Cesarean delivery among the
denominator defined by either
Cesarean Delivery DRG, MS-DRG
or ICD-10-CM procedure codes
defined by
DRG codes:
370 Cesarean w cc,
371 Cesarean c/o cc
OR
MS-DRG codes:
765 Cesarean w cc/mcc
766 Cesarean w/o cc/mcc
OR
ICD-10 Cesarean Delivery
Procedure Codes:
10D00Z0 Classical cesarean
10D00Z1 Low cervical cesarean
10D00Z2 Extraperitoneal
cesarean
Safe
Deliveries
Roadmap
Patient
Discharge Data
Plus
Gestational
Age at delivery
and
Parity
From either:
Discharges among the
denominator with either:
DRG, MS-DRG, or
ICD-10-CM procedure codes for
Cesarean delivery
Exclude:
breech or
transverse
presentation,
preterm
births, fetal
deaths, and
multiple
gestations
3a.
C-Section
rate for
Term
Inductions
of Labor in
Nulliparous
women >=
All cesarean
deliveries
among the
denominator
Nulliparous
women
whose labor
was induced
with delivery
>= 39 weeks
gestation
December 23, 2015 (V1 effective starting with discharges 10/1/15)
DRG codes:
370 Cesarean w cc
Include: All deliveries, identified by DRG, MS-DRG or ICD10 codes defined by
DRG Codes: 370 Cesarean w cc, 371 Cesarean w/o cc, 372
Vaginal del w cc, 373 Vaginal del w/o cc, 374 Vaginal del
w sterilization &/or D&C, 375 Vaginal del w operating
room proc except steril &/or D&C
OR
MS-DRG codes: 765 Cesarean w cc/mcc, 766 Cesarean
w/o cc/mcc, 767 Vaginal del w sterilization &/or D&C, 768
Vaginal del w OR proc except steril &/or D&C, 774 Vaginal
del w cc, 775 Vaginal del w/o cc
OR
ICD-10 codes from Joint Commission Appendix A: Table
11.01.1
Exclude cases with:
-Gestational Age < 37 weeks at delivery
-Any listed ICD-10-CM diagnosis code for contraindication
to vaginal delivery: abnormal presentation, breech,
preterm, fetal death, or multiple gestation (see Appendix
for detail on ICD-10 codes)
- Any listed ICD-10-CM diagnosis code for Previous
Cesarean delivery (034.21 Maternal care for scar from
previous cesarean delivery)
When WA birth certificate data available add to
exclusions: History of previous cesarean delivery (field
#57.7 on Birth Certificate)
SEE “TWO APPENDIX DOCUMENTS FOR PRIMARY TERM
SINGLETON VERTEX CESAREAN RATE” FOR COMPLETE
LIST OF CODES
FINALIZED APPENDICES PENDING CLARIFICATIONS
FROM AHRQ IN 2016
Include all delivering women identified by DRG, MS-DRG
or ICD-10 codes below with
Parity = 0
Gestational Age >= 39 weeks at delivery
Induction of Labor (based on supplemental Maternal
Data from internal electronic or manual data) until ICD
10 code for Induction of Labor added nationally sometime
later in 2016
p. 3
39 weeks
gestation at
delivery
3b.
C-Section
rate for
Term
Inductions
of Labor in
Multiparous
women >=
39 weeks
gestation at
delivery
All cesarean
deliveries
among the
denominator
Multiparous
women
whose labor
was induced
with delivery
>= 39 weeks
gestation
Safe
Deliveries
Roadmap
Core Clinical
Maternal data:
OR
Birth Certificate
data
And
Induction of
Labor (Y/N)
from either
Supplemental
Maternal Data,
internal data or
chart review
data
371 Cesarean c/o cc
OR
MS-DRG codes:
765 Cesarean w cc/mcc
766 Cesarean w/o cc/mcc
OR
ICD-10 Cesarean Delivery
Procedure Codes:
10D00Z0 Classical cesarean
10D00Z1 Low cervical cesarean
10D00Z2 Extraperitoneal
cesarean
Patient
Discharge Data
Plus
Gestational
Age at delivery
and
Parity
From either:
Core Clinical
Maternal data
OR
Birth Certificate
data
And
Induction of
Labor (Y/N)
from either
Supplemental
Maternal Data,
internal data or
chart review
data
Discharges among the
denominator with either:
DRG or MS-DRG codes for
Cesarean delivery; or
Any listed ICD-10-CM procedure
codes for Cesarean delivery
December 23, 2015 (V1 effective starting with discharges 10/1/15)
Cesarean Delivery DRG codes:
370 Cesarean w cc
371 Cesarean c/o cc
OR
Cesarean Delivery MS-DRG
codes:
765 Cesarean w cc/mcc
766 Cesarean w/o cc/mcc
OR
ICD-10 Cesarean Delivery
Procedure Codes:
10D00Z0 Classical cesarean
10D00Z1 Low cervical cesarean
10D00Z2 Extraperitoneal
cesarean
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc, 372 Vaginal del
w cc, 373 Vaginal del w/o cc, 374 Vaginal del w
sterilization &/or D&C, 375 Vaginal del w OR proc except
steril &/or D&C
OR
Delivery MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc,
767 Vaginal del w sterilization &/or D&C
768 Vaginal del w OR proc except steril &/or D&C
774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
ICD-10-CM Codes: See Joint Commission Appendix A:
Table 11.01.1
Include all delivering women identified by DRG, MS-DRG
or ICD-10 codes below with
Parity >=1
Gestational Age >= 39 weeks at delivery
Induction of Labor (based on supplemental Maternal
Data from internal electronic or manual data) until ICD
10 code for Induction of Labor added nationally sometime
later in 2016
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc, 372 Vaginal del
w cc, 373 Vaginal del w/o cc, 374 Vaginal del w
sterilization &/or D&C, 375 Vaginal del w OR proc except
steril &/or D&C
OR
Delivery MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc,
767 Vaginal del w sterilization &/or D&C
768 Vaginal del w OR proc except steril &/or D&C
774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
ICD-10-CM Codes: See Joint Commission Appendix
A:Table 11.01.1
p. 4
4a.
Number of
Maternal
admissions
to ICU per
all
deliveries
>= 20 weeks
gestation
4b.
Number of
maternal
ICU days per
100
deliveries
>= 20 weeks
gestation
All maternal
admissions to
ICU anytime
during
delivery
hospitalizatio
n among the
denominator
Number of
ICU days
among the
denominator
OPTIONAL
5a.
Percent of
Number of
women
Women with
delivery at
any
gestational
age >= 20
weeks
gestation
Women with
delivery at
any
gestational
age >= 20
weeks
gestation,
calculated
per 100
delivering
women
Women who
delivered at
SD Roadmap
harmonized
with
Partnership
for Patients
ICU-related
measure
Safe
Deliveries
Roadmap
WSHA 2014
Partnership
Patient
Discharge Data
including
Billing Revenue
Code data (for
ICU stay)
Plus
Gestational age
at delivery
From either:
Core Clinical
Maternal Data
OR
Birth certificate
data
Patient
Discharge Data
including
Billing Revenue
Code data (for
ICU stay)
Plus
Gestational age
at delivery
From either:
Core Clinical
Maternal Data
OR
Birth Certificate
Data
Patient
Discharge Data
December 23, 2015 (V1 effective starting with discharges 10/1/15)
Discharges among the
denominator who had an ICU
admission during their stay as
identified by either:
Any Revenue Charge code in
Accommodations 0200 series
(ICU) from PDD
OR IF REVENUE CODES NEED
SUPPORT FROM SUPPLEMENTAL
DATA:
ICU_days > 0
For WSHA-CMDC system: data
in Maternal Supplemental
Clinical Data
OR
For WSHA-QBS system: data
from other internal hospital
data source
Among the denominator
number of maternal ICU days as
identified by either:
Number of unit charge codes
associated with Revenue code in
Accommodations 0200 series
(ICU) from PDD
OR
Number of ICU days from
Maternal Supplemental Clinical
Data
OR
OPTIONAL chart review via:
WSHA-CMDC: secure chart
review web interface
OR
WSHA-QBS: other hospital chart
review source
Calculated per 100 Discharges
among the denominator
Among the denominator,
number of patients with any
Include all delivering women identified by DRG, MS-DRG,
or ICD-10 codes below with
Gestational Age >= 20 weeks at delivery
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc, 372 Vaginal del
w cc, 373 Vaginal del w/o cc, 374 Vaginal del w
sterilization &/or D&C, 375 Vaginal del w OR proc except
steril &/or D&C
OR
MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc,
767 Vaginal del w sterilization &/or D&C,
768 Vaginal del w OR proc except steril &/or D&C,
774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
Delivery ICD-10-CM codes:
Joint Commission Appendix A: Table 11.01.1
Include all delivering women identified by DRG, MS-DRG
or ICD-10 codes below with
Gestational Age >= 20 weeks at delivery
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc,372 Vaginal del
w cc, 373 Vaginal del w/o cc, 374 Vaginal del w
sterilization &/or D&C, 375 Vaginal del w OR proc except
steril &/or D&C
OR
MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc,
767 Vaginal del w sterilization &/or D&C,
768 Vaginal del w OR proc except steril &/or D&C,
774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
Delivery ICD-10 codes: Joint Commission Appendix A:
Table 11.01.1
Include all delivering women identified by ICD-10 codes,
DRG, or MS-DRG codes below with
p. 5
delivering
women who
received a
blood
transfusion
>= 20 weeks
gestation
among the
denominator
who received
any
transfusion of
blood
products
(RBC, FFP,
Platelet
packs,
Cryoprecipita
te) identified
by ICD-10-CM
procedure
codes from
among the
denominator
>= 20 weeks
gestational
age
for Patients
Plus
Gestational age
at delivery
From either:
Core Clinical
Maternal Data
OR
Birth Certificate
Data
ICD-10 Procedure code for
specific transfusions identified
by any of 28 ICD-10 codes:
30233H1
30233N1
30233P1
30243H1
30243N1
30243P1
30253H1
30253N1
30253P1
December 23, 2015 (V1 effective starting with discharges 10/1/15)
Transfusion of
Nonautologous
Whole Blood into
Peripheral Vein,
Percutaneous
Approach
Transfusion of
Nonautologous Red
Blood Cells into
Peripheral Vein,
Percutaneous
Approach
Transfusion of
Nonautologous
Frozen Red Cells into
Peripheral Vein,
Percutaneous
Approach
Transfusion of
Nonautologous
Whole Blood into
Central Vein,
Percutaneous
Approach
Transfusion of
Nonautologous Red
Blood Cells into
Central Vein,
Percutaneous
Approach
Transfusion of
Nonautologous
Frozen Red Cells into
Central Vein,
Percutaneous
Approach
Transfusion of
Nonautologous
Whole Blood into
Peripheral Artery,
Percutaneous
Approach
Transfusion of
Nonautologous Red
Blood Cells into
Peripheral Artery,
Percutaneous
Approach
Transfusion of
Nonautologous
Frozen Red Cells into
Gestational Age >= 20 weeks at delivery
Delivery ICD-10 codes:
Joint Commission Appendix A: Table 11.01.1
OR
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o c,372 Vaginal del w
cc, 373 Vaginal del w/o cc, 374 Vaginal del w sterilization
&/or D&C, 375 Vaginal del w OR proc except steril &/or
D&C
OR
MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc
767 Vaginal del w sterilization &/or D&C,
768 Vaginal del w OR proc except steril &/or D&C,
774 Vaginal del w cc, 775 Vaginal del w/o cc
p. 6
30263H1
30263N1
30263P1
30233K1
30233L1
30243K1
30243L1
30253K1
30253L1
December 23, 2015 (V1 effective starting with discharges 10/1/15)
Peripheral Artery,
Percutaneous
Approach
Transfusion of
Nonautologous
Whole Blood into
Central Artery,
Percutaneous
Approach
Transfusion of
Nonautologous Red
Blood Cells into
Central Artery,
Percutaneous
Approach
Transfusion of
Nonautologous
Frozen Red Cells into
Central Artery,
Percutaneous
Approach
Transfusion of
Nonautologous
Frozen Plasma into
Peripheral Vein,
Percutaneous
Approach
Transfusion of
Nonautologous Fresh
Plasma into
Peripheral Vein,
Percutaneous
Approach
Transfusion of
Nonautologous
Frozen Plasma into
Central Vein,
Percutaneous
Approach
Transfusion of
Nonautologous Fresh
Plasma into Central
Vein, Percutaneous
Approach
Transfusion of
Nonautologous
Frozen Plasma into
Peripheral Artery,
Percutaneous
Approach
Transfusion of
Nonautologous Fresh
Plasma into
Peripheral Artery,
Percutaneous
p. 7
Approach
30263K1
30263L1
30233M1
30233R1
30243M1
30243R1
30253M1
30253R1
30263M1
December 23, 2015 (V1 effective starting with discharges 10/1/15)
Transfusion of
Nonautologous
Frozen Plasma into
Central Artery,
Percutaneous
Approach
Transfusion of
Nonautologous Fresh
Plasma into Central
Artery, Percutaneous
Approach
Transfusion of
Nonautologous
Plasma
Cryoprecipitate into
Peripheral Vein,
Percutaneous
Approach
Transfusion of
Nonautologous
Platelets into
Peripheral Vein,
Percutaneous
Approach
Transfusion of
Nonautologous
Plasma
Cryoprecipitate into
Central Vein,
Percutaneous
Approach
Transfusion of
Nonautologous
Platelets into Central
Vein, Percutaneous
Approach
Transfusion of
Nonautologous
Plasma
Cryoprecipitate into
Peripheral Artery,
Percutaneous
Approach
Transfusion of
Nonautologous
Platelets into
Peripheral Artery,
Percutaneous
Approach
Transfusion of
Nonautologous
Plasma
Cryoprecipitate into
p. 8
30263R1
5b.
Total
number of
blood
products
transfused
per 1,000
delivering
women >=
20 weeks
gestation
Number of
blood
product units
transfused
from among
the
denominator
Women who
delivered at
any
gestational
age >= 20
wks,
calculated
per 1000
delivering
women
Safe
Deliveries
Roadmap
OPTIONAL
5c.
Total
Number of
delivering
Women who
delivered at
Safe
Deliveries
Patient
Discharge
Admin Data
Plus
Gestational age
at delivery
From either:
Core Clinical
Maternal Data
OR
Birth Certificate
Data
Plus
If Revenue
codes in PDD
need
supplemental
backup:
transfusions
with validation
from hospital
lab, blood bank,
transfusion log
book
OR
optional chart
review for
blood
transfusion
data via WSHACMDC System
Interface or
WSHA-QBS:
internal
hospital chart
review
Patient
Discharge Data
December 23, 2015 (V1 effective starting with discharges 10/1/15)
Central Artery,
Percutaneous
Approach
Transfusion of
Nonautologous
Platelets into Central
Artery, Percutaneous
Approach
Among the denominator
number of blood products
transfused by each type and
total: RBCs and FFP
Identified by either:
Revenue code 0380 series for
transfusion blood units/types
and associated Service Unit –
counts
OR
HCPC charge code for type and
associated Service Units counts
OR
From Maternal Supplemental
Clinical File: number of units
transfused for RBCs, FFP,
Platelets and Cryoprecipitate
OR
OPTIONAL chart review via:
WSHA-CMDC: secure chart
review web interface
OR
WSHA-QBS: other hospital chart
review source
Include all delivering women identified by DRG, MS-DRG
codes, or ICD-10-CM codes below with
Gestational Age >= 20 weeks at delivery
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc, 372 Vaginal del
w cc, 373 Vaginal del w/o cc, 374 Vaginal del w
sterilization &/or D&C, 375 Vaginal del w OR proc except
steril &/or D&C
OR
MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc,
767 Vaginal del w sterilization &/or D&C,
768 Vaginal del w OR proc except steril &/or D&C,
774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
Delivery ICD-10 codes:
Joint Commission Appendix A: Table 11.01.1
Calculated per 1000 cases in the
denominator
Calculated per 1000 cases in the
denominator.
Include all delivering women identified by ICD-10-CM
codes, DRG, or MS-DRG codes below with
p. 9
number of
massive
blood
transfusions
(>= 4 units
RBCs) per
1000
delivering
women >=
20 weeks
gestation
women who
received >= 4
units of blood
products
(RBCs) per
1000
delivering
women >= 20
weeks
gestation
>= 20 wks
gestation
calculated
per 1000
delivering
women
OPTIONAL
6a.
Percent of
women
with LOS >=
4 days from
delivery to
discharge
per women
who
delivered
vaginally >=
20 wks
Number of
women with
LOS >= 4 days
from date of
delivery to
discharge
date among
the
denominator
All delivering
women >= 20
wks gestation
who
delivered
vaginally
Roadmap
harmonized
with Joint
Commission
Maternal
Sentinel
EventMassive
Transfusions
and
Partnership
for Patients
Measure
Safe
Deliveries
Roadmap
Plus
Gestational age
at delivery
From either:
Core Clinical
Maternal Data
OR
Birth Certificate
Data
Plus
If Revenue
codes in PDD
need
supplemental
backup:
back-up
validation from
hospital lab,
blood bank,
transfusion log
book
or
optional chart
review for
blood
transfusion
data via WSHACMDC Interface
or WSHA-QBS:
internal
hospital chart
review
Patient
Discharge Data
Plus
Gestational
Age at Delivery
AND
Date of
newborn birth
Identified by
either:
Core Clinical
Newborn and
December 23, 2015 (V1 effective starting with discharges 10/1/15)
Gestational Age >= 20 weeks at delivery
Among the denominator
number of patients with >= 4
units RBCs transfused as
identified by either:
Revenue code 0380 series for
transfusion blood units/types
and associated Service Unit –
counts
OR
HCPC charge code for RBCs, FFP,
Platelets and Cryoprecipitate
and associated Service Units per
type >= 4 units (counts) per
patient
Delivery ICD-10 codes:
Joint Commission Appendix A: Tables 11.01.1
OR
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc,
372 Vaginal del w cc, 373 Vaginal del w/o cc,
374 Vaginal del w sterilization &/or D&C,
375 Vaginal del w OR proc except steril &/or D&C
OR
MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc,
767 Vaginal del w sterilization &/or D&C,
768 Vaginal del w OR proc except steril &/or D&C,
774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
From Maternal Supplemental
Clinical File: >= 4 units
transfused for RBCs, FFP,
Platelets and Cryoprecipitate
per patient
OR
optional hospital chart review
via:
WSHA-CMDC: secure web
interface
Or
WSHA-QBS: other hospital chart
review source
Discharges among the
denominator with maternal
length of stay from delivery day
to discharge date >= 4 days
Include all women delivering vaginally identified by DRG,
MS-DRG or ICD-10-CM codes below with
Gestational Age >= 20 weeks at delivery
Vaginal Delivery DRG Codes:
372 Vaginal del w cc, 373 Vaginal del w/o cc,
374 Vaginal del w sterilization &/or D&C
375 Vaginal del w OR proc except steril &/or D&C
OR
Vaginal Delivery MS-DRG codes:
767 Vaginal del w sterilization &/or D&C,
p. 10
gestation
Maternal data
768 Vaginal del w OR proc except steril &/or D&C,
774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
ICD-10-CM codes
OR
Birth certificate
data
6b.
Percent of
women
with LOS >=
6 days from
delivery to
discharge
per women
who
delivered by
cesarean
section >=
20 wks
gestation
Number of
women with
LOS >= 6 days
from delivery
to discharge
among the
denominator
7.
Percent of
operative
vaginal
deliveries
per all
vaginal
deliveries
Number of
operative
deliveries by
forceps or
vacuum from
among the
denominator
All delivering
women >= 20
wks gestation
who
delivered by
cesarean
section
Number of
vaginal
deliveries
Safe
Deliveries
Roadmap
Safe
Deliveries
Roadmap
Patient
Discharge Data
Plus
Gestational
Age at Delivery
AND
Date of
newborn birth
Identified by
either:
Core Clinical
Newborn and
Maternal data
OR
Birth certificate
data
Discharges among the
denominator with maternal
length of stay from delivery day
to discharge date >= 6 days
Patient
Discharge Data
From among the denominator
Operative Assisted delivery with
Instrument (forceps or vacuum)
10D07Z3 Low forceps
10D07Z4 Mid forceps
10D07Z5 High forceps
10D07Z6 Vacuum
10D07Z8 Other specified or
unspecified instrument
December 23, 2015 (V1 effective starting with discharges 10/1/15)
Method to filter out all but vaginal deliveries by ICD-10
codes:
Step 1) Start with All Delivery ICD-10-CM codes:
Joint Commission Appendix A: Table 11.01.1
Step 2) Exclude cases with Procedure codes for Cesarean
Delivery Table 11.06 codes:
10D00Z0 Classical cesarean
10D00Z1 Low cervical cesarean
10D00Z2 Extraperitoneal cesarean.
Step 3) Cases remaining are with vaginal delivery
Include all women delivering by cesarean identified by
DRG, MS-DRG or ICD-10-CM codes below with
Gestational Age >= 20 weeks at delivery
Cesarean Delivery DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc
OR
Cesarean Delivery MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc
Cesarean Delivery ICD-10-CM Procedure Codes
Identify by Procedure codes for Cesarean Delivery (JC
Appendix Table 11.06 codes):
10D00Z0 Classical cesarean
10D00Z1 Low cervical cesarean
10D00Z2 Extraperitoneal cesarean
Include all women delivering vaginally identified by DRG,
MS-DRG or ICD-10-CM codes
Vaginal Delivery DRG Codes:
372 Vaginal del w cc
373 Vaginal del w/o cc
374 Vaginal del w sterilization &/or D&C
375 Vaginal del w OR proc except steril &/or D&C
p. 11
OR
Vaginal Delivery MS-DRG codes:
767 Vaginal del w sterilization &/or D&C
768 Vaginal del w OR proc except steril &/or D&C
774 Vaginal del w cc
775 Vaginal del w/o cc
8.
Unexpected
Newborn
Complicatio
ns (UNCs)
per 100 live
births
(Inborn)
NQF 716
Total rate
per 100
with two
subgroups:
A.Severe
rate per 100
B.Moderate
rate per 100
Number of
term
neonates
with any
unexpected
newborn
complications
(Total UNCs)
among the
denominator
Subgroup A:
with any
severe UNCs
among the
denominator
Subgroup B:
with any
moderate
UNCs among
the
denominator
Liveborn
Inborn Term
neonates w/o
preexisting
conditions
calculated
per 100
livebirths:
Exclude –
preterm,
<2500gm,
multiple
gestations, all
congenital
anomalies,
other fetal
and placental
conditions,
exposure to
maternal
drug use
(prescribed
or illicit)
NQF 716
Use diagnosis
and
procedure
codes plus
supplemental
data per NQF
716 measure
definition
(see
Appendix)
OR
By ICD-10 codes:
Method to filter out all but vaginal deliveries by ICD-10
codes:
Step 1) Start with All Delivery ICD-10-CM codes:
Joint Commission Appendix A: Table 11.01.1
Step 2) Exclude cases with Procedure codes for Cesarean
Delivery Table 11.06 codes:
10D00Z0 Classical cesarean
10D00Z1 Low cervical cesarean
10D00Z2 Extraperitoneal cesarean.
Step 3) Cases remaining are with vaginal delivery
SEE APPENDICES FOR UNEXPECTED NEWBORN
COMPLICATIONS COMPLETE LIST OF CODES AND
DEFINITIONS
FINALIZED APPENDICES PENDING FROM CMQCC IN
JANUARY 2016
Patient
Discharge Data
Plus
linked motherbaby records,
Plus
5 min Apgar 10
min Apgar (if
available) birth
weight
Gestational age
at delivery
From among the denominator
Total Complications per 100 in
the denominator
And two sub categoriesSevere and Moderate
Severe Complications per 100 in
the denominator identified by:
>= 2500 gr BW (supplemental file)
from either:
Neonatal Death (by discharge
disposition-death)
GA >= 37 weeks
(supplemental linked maternal file)
Neonatal Transfer (by discharge
disposition-transfer)
From the above Appendices exclude – congenital
anomalies, other fetal / placental conditions, and
exposure to maternal drug use- prescribed or illicit
Core Clinical
Maternal and
Newborn data
OR
birth certificate
data
OR
December 23, 2015 (V1 effective starting with discharges 10/1/15)
(complications identified in
hierarchical order
SEE APPENDICES FOR DETAILS)
Include Liveborn Inborn Term neonates w/o preexisting
conditions calculated per 100 livebirths as identified by:
Singleton Liveborn in hospital:
5’ or 10’ Apgar score <= 3 (by
supplemental newborn file)
Severe ICD-10 diagnosis or
procedure code) (see Appendix
Groups 3A-3I)
p. 12
Sepsis and LOS > 4 days (LOS > 4
days with Appendix Group 3J)
Moderate Complications per
100 in the denominator
identified by:
ICD-10 diagnosis and procedure
codes (Appendix Groups 4A-4C)
Long LOS with Moderate
Complications (>4 days Csection Delivery and LOS >2 days
Vaginal Delivery identified by
Newborn LOS linked with
maternal delivery type (see
above for delivery-type I.D.)
AND presence of moderate ICD10-CM Codes (Appendix Groups
4D-4H)
9a. For
women
with a
diagnosis of
Preeclampsia,
Percent of
Maternal
ICU
Admissions
Number of
delivering
patients with
any
admission to
ICU from
among the
denominator
All women
giving birth
>= 20 weeks
with any
diagnosis
code for
Preeclampsia
WSHA
Partnership
for Patients
2014
Patient
Discharge Data
Plus
Billing Revenue
Code data (for
ICU stay)
Plus
Gestational
Age at Delivery
From either:
Core Clinical
Maternal Data
OR
Birth Certificate
Data
December 23, 2015 (V1 effective starting with discharges 10/1/15)
Long LOS > 5 days (Exclude
Jaundice and social issues)
identified by:
Newborn LOS > 5 days excluding
those with neonatal jaundice or
social indications (Appendix1
Groups 5A-5C)
Among those in the
denominator who had an ICU
admission during their stay as
identified by either:
Any Revenue Charge code in
Accommodations 0200 series
(ICU) from PDD (Section B)
OR
ICU_days > 0 from Maternal
Supplemental Clinical Data File
Include all delivering women identified by ICD-10 codes,
DRG, or MS-DRG codes (see below) and Gestational Age
>= 20 weeks at delivery
Delivery ICD-10-CM codes:
Joint Commission Appendix A: Table 11.01.01
OR
Delivery DRG Codes:
370 Cesarean w cc
371 Cesarean w/o cc
372 Vaginal del w cc
373 Vaginal del w/o cc
374 Vaginal del w sterilization &/or D&C
375 Vaginal del w OR proc except steril &/or D&C
OR
p. 13
Delivery MS-DRG codes:
765 Cesarean w cc/mcc
766 Cesarean w/o cc/mcc
767 Vaginal del w sterilization &/or D&C
768 Vaginal del w OR proc except steril &/or D&C
774 Vaginal del w cc
775 Vaginal del w/o cc
9b.
ICU Days
with Preeclampsia
diagnosis
per 100
Total number
of ICU days
from patients
among the
denominator
All women
giving birth
>= 20 weeks
with any
diagnosis
code for
2014
Partnership
for Patients
Measure
Patient
Discharge Data
Including
Billing Revenue
Code data (for
ICU stay)
December 23, 2015 (V1 effective starting with discharges 10/1/15)
Among the denominator
number of maternal ICU days as
identified by either:
Number of charge codes
associated with Revenue Charge
code in Accommodations 0200
AND with any diagnosis code for Preeclampsia, Severe
preeclampsia, Eclampsia, or preeclampsia superimposed
on pre-existing HTN:
014.00 Mild to moderate pre-eclampsia, unspecified
trimester
014.02 Mild to moderate pre-eclampsia, second trimester
014.03 Mild to moderate pre-eclampsia, third trimester
014.90 Unspecified pre-eclampsia, unspecified trimester
014.92 Unspecified pre-eclampsia, second trimester
014.93 Unspecified pre-eclampsia, third trimester
011.1 Pre-existing hypertension with pre-eclampsia, first
trimester
011.2 Pre-existing hypertension with pre-eclampsia,
second trimester
011.3 Pre-existing hypertension with pre-eclampsia, third
trimester
011.9 Pre-existing hypertension with pre-eclampsia,
unspecified trimester
014.10 Severe pre-eclampsia, unspecified trimester
014.12 Severe pre-eclampsia, second trimester
014.13 Severe pre-eclampsia, third trimester
014.20 HELLP syndrome, unspecified trimester
014.22 HELLP syndrome, second trimester
014.23 HELLP syndrome, third trimester
015.00 Eclampsia in pregnancy, unspecified trimester
015.02 Eclampsia in pregnancy, second trimester
015.03 Eclampsia in pregnancy, third trimester
015.1 Eclampsia in labor
015.2 Eclampsia in the puerperium
015.9 Eclampsia, unspecified as to time period
Include all delivering women identified by DRG,MS-DRG
or ICD-10-CM codes below, with
Gestational Age >= 20 weeks at delivery
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc,
p. 14
delivering
women >=
20 weeks
gestation
with preeclampsia
diagnosis
Preeclampsia
Plus
Gestational
Age at Delivery
From either:
Core Clinical
Maternal Data
OR
Birth Certificate
Data
OPTIONAL
series (ICU) from PDD
OR
Number of ICU_days from
Maternal Supplemental Clinical
Data File
OR
OPTIONAL hospital chart review
via:
WSHA-CMDC secure website
OR
WSHA-QBS: hospital internal
chart review or other data
source
Calculated per 100 Discharges
among the denominator
9c.
Total number
All delivering
CMQCC
Hospital
December 23, 2015 (V1 effective starting with discharges 10/1/15)
Among the denominator
372 Vaginal del w cc, 373 Vaginal del w/o cc
374 Vaginal del w sterilization &/or D&C
375 Vaginal del w OR proc except steril &/or D&C
OR
MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc
767 Vaginal del w sterilization &/or D&C
768 Vaginal del w OR proc except steril &/or D&C
774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
Delivery ICD-10-CM codes:
Joint Commission Appendix A: Tables 11.01, 11.02, 11.03,
11.04
AND with any diagnosis code for Preeclampsia, Severe
preeclampsia, Eclampsia, or preeclampsia superimposed
on pre-existing HTN
014.00 Mild to moderate pre-eclampsia, unspecified
trimester
014.02 Mild to moderate pre-eclampsia, second trimester
014.03 Mild to moderate pre-eclampsia, third trimester
014.90 Unspecified pre-eclampsia, unspecified trimester
014.92 Unspecified pre-eclampsia, second trimester
014.93 Unspecified pre-eclampsia, third trimester
011.1 Pre-existing hypertension with pre-eclampsia, first
trimester
011.2 Pre-existing hypertension with pre-eclampsia,
second trimester
011.3 Pre-existing hypertension with pre-eclampsia, third
trimester
011.9 Pre-existing hypertension with pre-eclampsia,
unspecified trimester
014.10 Severe pre-eclampsia, unspecified trimester
014.12 Severe pre-eclampsia, second trimester
014.13 Severe pre-eclampsia, third trimester
014.20 HELLP syndrome, unspecified trimester
014.22 HELLP syndrome, second trimester
014.23 HELLP syndrome, third trimester
015.00 Eclampsia in pregnancy, unspecified trimester
015.02 Eclampsia in pregnancy, second trimester
015.03 Eclampsia in pregnancy, third trimester
015.1 Eclampsia in labor
015.2 Eclampsia in the puerperium
015.9 Eclampsia, unspecified as to time period
Include all delivering women identified by DRG, MS-DRG,
p. 15
Rate of
severe
maternal
morbidity
for
Delivering
women
with a
diagnosis of
Preeclampsia,
Severe
Morbidity
based on
ICD-10
codes
typical of an
ICU
admission
PENDING –
CMQCC /
Expected
January
2016
of women
with Severe
Maternal
Morbidity
from patients
among the
denominator
women with
any diagnosis
code for
Preeclampsia
Preeclampsia
Collaborative
Measure
Patient
Discharge Data
number of women with Severe
Maternal Morbidity (based on
ICD-10 diagnosis-procedure
codes typical of an ICU
admission):
Diagnosis Codes:
SECTION PENDING ICD-10
CODES (CMQCC):
Acute Renal Failure:
Pulmonary Edema:
Adult Respiratory Distress
Syndrome
Puerperal Cerebrovascular
Disorder:
Disseminated Intravascular
Coagulation Syndrome:
Postpartum Hemorrhage:
Abruptio Placentae:
OR
Procedure Codes:
Ventilation:
Transfusion:
ICD-10 UPDATE FOR
NUMERATOR PENDING FROM
CMQCC / THESE ICD-10
DEFINITIONS EXPECTED FROM
CMQCC IN JANUARY 2016
PENDING: PLEASE SEE APPENDIX
FOR DETAILED LIST OF SEVERE
MATERNAL MORBIDITY WITH
PREECLAMPSIA-ECLAMPSIA ICD10-CM CODES
December 23, 2015 (V1 effective starting with discharges 10/1/15)
or ICD-10-CM codes below, with
Gestational Age >= 20 weeks at delivery
Delivery DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc
372 Vaginal del w cc, 373 Vaginal del w/o cc
374 Vaginal del w sterilization &/or D&C
375 Vaginal del w OR proc except steril &/or D&C
OR
MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc
767 Vaginal del w sterilization &/or D&C
768 Vaginal del w OR proc except steril &/or D&C
774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
ICD-10-CM codes:
Joint Commission Appendix A: Table 11.01.1
AND with any diagnosis code for Preeclampsia, Severe
preeclampsia, Eclampsia, or preeclampsia superimposed
on pre-existing HTN
014.00 Mild to moderate pre-eclampsia, unspecified
trimester
014.02 Mild to moderate pre-eclampsia, second trimester
014.03 Mild to moderate pre-eclampsia, third trimester
014.90 Unspecified pre-eclampsia, unspecified trimester
014.92 Unspecified pre-eclampsia, second trimester
014.93 Unspecified pre-eclampsia, third trimester
011.1 Pre-existing hypertension with pre-eclampsia, first
trimester
011.2 Pre-existing hypertension with pre-eclampsia,
second trimester
011.3 Pre-existing hypertension with pre-eclampsia, third
trimester
011.9 Pre-existing hypertension with pre-eclampsia,
unspecified trimester
014.10 Severe pre-eclampsia, unspecified trimester
014.12 Severe pre-eclampsia, second trimester
014.13 Severe pre-eclampsia, third trimester
014.20 HELLP syndrome, unspecified trimester
014.22 HELLP syndrome, second trimester
014.23 HELLP syndrome, third trimester
015.00 Eclampsia in pregnancy, unspecified trimester
015.02 Eclampsia in pregnancy, second trimester
p. 16
015.03 Eclampsia in pregnancy, third trimester
015.1 Eclampsia in labor
015.2 Eclampsia in the puerperium
015.9 Eclampsia, unspecified as to time period
PENDING CMQCC ICD-10 DEFINITIONS
PLEASE SEE APPENDIX WHEN AVAILABLE FOR DETAILED
LIST OF SEVERE MATERNAL MORBIDITY WITH
PREECLAMPSIA-ECLAMPSIA ICD-10-CM CODES
10.
Percent
with Timely
Treatment
for
delivering
women
with Severe
Range BP at
gestational
age >= 20
weeks
OPTIONAL
11.
Severe
Maternal
Morbidity
for all
deliveries
>= 20 weeks
gestation
CMQCC and
CDC –
Those
treated
within 60
minutes with
appropriate
treatment:
first-line
medications
(IV labetalol
or IV
hydralazine
or PO
nifedipine or
labetalol if IV
access has
not been
established.
All women
giving birth
>= 20 weeks
with any
diagnosis
code and
confirmation
by chart
review for
severe range
BP
Roadmap
Measure
based on
California
CMQCC Preeclampsia
Collaborative
Measure
Patient
Discharge Data
Plus
Hospital chart
abstracted data
for focused
cases on Severe
BP confirmation
and
appropriate
medication
administration
<= 60 minutes
Via
WSHA-CMDC
secure web
interface
OR
WSHA-QBS:
Internal
hospital chart
review resource
CDC Measure
(2015)
December 23, 2015 (V1 effective starting with discharges 10/1/15)
Cases with appropriate
medication administered within
<= 60 minutes from
confirmation of Severe BP
measurement
Chart review for
administration of first line
medications <=60 minutes from
confirmation of severe range
BP: (IV labetalol, IV hydralazine
or PO nifedipine or labetalol if IV
access not established)
Chart Review via:
WSHA-CMDC: chart review with
secure web interface
Or
WSHA-QBS: internal hospital
chart review process
PENDING ICD-10 CODES FROM
CMQCC and CDC IN JANUARY
2016
These denominator cases will initially be identified as in
#9a, b, and c above and will then need additional chart
review for confirmation of Severe Range BP measurement
>= 160 systolic or >=100 Diastolic to confirm each
denominator case.
Chart review involves confirmation of severe HTN
measurement x2 at least 15 minutes apart per guideline
systolic >=160
diastolic >= 110
Chart review via:
WSHA-CMDC: chart review with secure web interface
Or
WSHA-QBS: other hospital chart review source
PENDING ICD-10 CODES FROM CMQCC and CDC IN
JANUARY 2016
p. 17
expected
January
2016
Note For Measures 3.a., 3.b., 4.a., 4.b., 5.a., 5.b., 5.c., 8, 9a, 9b, 9c, 11:
These measures are intended for collaborative and similar QI projects that utilize time series designs (same hospital before and after). These are
not designed or validated to be used as inter-hospital quality measures (comparing hospital A to B or to compare practices of individual
clinicians). These are metrics that will need some case mix/risk adjustment with validation work before any comparisons between hospitals can
be done, but they are valuable to hospitals in trending their own data.
December 23, 2015 (V1 effective starting with discharges 10/1/15)
p. 18