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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:WSHA-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 WSHA-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 MeasuresNew 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 MeasuresTwo 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.??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)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) Primary TSV Cesarean Delivery (#2) (AHRQ) Unexpected Newborn Complications (#8) (CMQCC)Measure specifications for two Severe Maternal Morbidity measures pending - ICD-10 codes availability expected January 2016 Severe maternal morbidity with pre-eclampsia diagnosis (CMQCC)Severe maternal morbidity for all deliveries >= 20 wks gestation – NEW 2016 Safe Deliveries Roadmap outcome measure addition (CMQCC and CDC)Outcome Measure Numerator DescriptionDenominator DescriptionDefinition SourceData SourceNumerator SpecificationsDenominator Specifications1.Nulliparous Term Singleton Vertex Cesarean Section Rate (NTSV) All cesarean deliveries among the denominatorNulliparous (first birth) women > 37 weeks. 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 Joint Commission PC-02 current for the time period Plus state additions to exclusion list: planned place of birth and transfer to higher level of care when birth certificate data availablePatient Discharge Data PlusGestational Age at Delivery,And ParityFrom either: Core Clinical Maternal dataORBirth Certificate dataCases among the denominator who had cesarean deliveryIncluded Populations: ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for cesarean section as defined in Appendix A, Table 11.06:10D00Z0 Classical cesarean10D00Z1 Low cervical cesarean10D00Z2 Extraperitoneal cesareanExcluded Populations: NoneNulliparous 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 completedExcluded 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 weeksNOTE: SEE JOINT COMMISSION CODE TABLE APPENDICES FOR COMPLETE LIST OF CODESWhen 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) 2.Primary Term Singleton Vertex (TSV) Cesarean Section RateAll cesarean deliveries among the denominator Delivering women > 37 weeks who have not had a prior cesarean section. Exclude: breech or transverse presentation, preterm births, fetal deaths, and multiple gestationsSafe Deliveries Roadmap Measure Patient Discharge DataPlus Gestational age at Delivery From either: Core Clinical Maternal data ORBirth Certificate data.When birth certificate data available add to exclusions: Previous c-section (# 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 byDRG codes:370 Cesarean w cc, 371 Cesarean c/o ccORMS-DRG codes:765 Cesarean w cc/mcc766 Cesarean w/o cc/mccORICD-10 Cesarean Delivery Procedure Codes:10D00Z0 Classical cesarean10D00Z1 Low cervical cesarean10D00Z2 Extraperitoneal cesareanInclude: All deliveries, identified by DRG, MS-DRG or ICD-10 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&COR 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 ccOR ICD-10 codes from Joint Commission Appendix A: Table 11.01.1Exclude 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 CODESFINALIZED APPENDICES PENDING CLARIFICATIONS FROM AHRQ IN 20163a.C-Section rate for Term Inductions of Labor in Nulliparous women >= 39 weeks gestation at delivery All cesarean deliveries among the denominator Nulliparous women whose labor was induced with delivery >= 39 weeks gestationSafe Deliveries Roadmap Patient Discharge Data PlusGestational Age at deliveryandParity From either: Core Clinical Maternal data: ORBirth Certificate dataAndInduction of Labor (Y/N) from either Supplemental Maternal Data, internal data or chart review data Discharges among the denominator with either:DRG, MS-DRG, orICD-10-CM procedure codes for Cesarean delivery DRG codes: 370 Cesarean w cc371 Cesarean c/o ccORMS-DRG codes:765 Cesarean w cc/mcc766 Cesarean w/o cc/mccORICD-10 Cesarean Delivery Procedure Codes:10D00Z0 Classical cesarean10D00Z1 Low cervical cesarean10D00Z2 Extraperitoneal cesareanInclude all delivering women identified by DRG, MS-DRG or ICD-10 codes below with Parity = 0Gestational 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&CORDelivery MS-DRG codes:765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc,767 Vaginal del w sterilization &/or D&C768 Vaginal del w OR proc except steril &/or D&C774 Vaginal del w cc, 775 Vaginal del w/o ccOR ICD-10-CM Codes: See Joint Commission Appendix A: Table 11.01.13b.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 Patient Discharge Data PlusGestational Age at deliveryandParity From either: Core Clinical Maternal data ORBirth Certificate dataAndInduction of Labor (Y/N) from either Supplemental Maternal Data, internal data or chart review dataDischarges among the denominator with either:DRG or MS-DRG codes for Cesarean delivery; orAny listed ICD-10-CM procedure codes for Cesarean delivery Cesarean Delivery DRG codes:370 Cesarean w cc371 Cesarean c/o ccORCesarean Delivery MS-DRG codes:765 Cesarean w cc/mcc766 Cesarean w/o cc/mccORICD-10 Cesarean Delivery Procedure Codes:10D00Z0 Classical cesarean10D00Z1 Low cervical cesarean10D00Z2 Extraperitoneal cesarean Include all delivering women identified by DRG, MS-DRG or ICD-10 codes below with Parity >=1 Gestational Age >= 39 weeks at deliveryInduction 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&CORDelivery MS-DRG codes:765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc,767 Vaginal del w sterilization &/or D&C768 Vaginal del w OR proc except steril &/or D&C774 Vaginal del w cc, 775 Vaginal del w/o ccOR ICD-10-CM Codes: See Joint Commission Appendix A:Table 11.01.14a.Number of Maternal admissions to ICU per all deliveries >= 20 weeks gestationAll maternal admissions to ICU anytime during delivery hospitalization among the denominatorWomen with delivery at any gestational age >= 20 weeks gestation SD Roadmap harmonized with Partnership for Patients ICU-related measurePatient Discharge Data includingBilling Revenue Code data (for ICU stay)PlusGestational age at delivery From either:Core Clinical Maternal Data ORBirth certificate dataDischarges 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 Include all delivering women identified by DRG, MS-DRG, or ICD-10 codes below with Gestational Age >= 20 weeks at deliveryDRG 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&CORMS-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 ccORDelivery ICD-10-CM codes:Joint Commission Appendix A: Table 11.01.14b.Number of maternal ICU days per 100 deliveries >= 20 weeks gestation OPTIONALNumber of ICU days among the denominator Women with delivery at any gestational age >= 20 weeks gestation, calculated per 100 delivering women Safe Deliveries Roadmap Patient Discharge Data including Billing Revenue Code data (for ICU stay)Plus Gestational age at delivery From either:Core Clinical Maternal Data ORBirth Certificate DataAmong the denominatornumber 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 DataOROPTIONAL chart review via:WSHA-CMDC: secure chart review web interfaceORWSHA-QBS: other hospital chart review sourceCalculated per 100 Discharges among the denominatorInclude 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&CORMS-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 ccORDelivery ICD-10 codes: Joint Commission Appendix A: Table 11.01.15a.Percent of delivering women who received a blood transfusion>= 20 weeks gestation Number of women among the denominator who received any transfusion of blood products (RBC, FFP, Platelet packs, Cryoprecipitate) identified by ICD-10-CM procedure codes from among the denominatorWomen who delivered at >= 20 weeks gestational ageWSHA 2014 Partnership for Patients Patient Discharge Data Plus Gestational age at delivery From either:Core Clinical Maternal Data ORBirth Certificate DataAmong the denominator, number of patients with any ICD-10 Procedure code for specific transfusions identified by any of 28 ICD-10 codes:30233H1Transfusion of Nonautologous Whole Blood into Peripheral Vein, Percutaneous Approach30233N1Transfusion of Nonautologous Red Blood Cells into Peripheral Vein, Percutaneous Approach30233P1Transfusion of Nonautologous Frozen Red Cells into Peripheral Vein, Percutaneous Approach30243H1Transfusion of Nonautologous Whole Blood into Central Vein, Percutaneous Approach30243N1Transfusion of Nonautologous Red Blood Cells into Central Vein, Percutaneous Approach30243P1Transfusion of Nonautologous Frozen Red Cells into Central Vein, Percutaneous Approach30253H1Transfusion of Nonautologous Whole Blood into Peripheral Artery, Percutaneous Approach30253N1Transfusion of Nonautologous Red Blood Cells into Peripheral Artery, Percutaneous Approach30253P1Transfusion of Nonautologous Frozen Red Cells into Peripheral Artery, Percutaneous Approach30263H1Transfusion of Nonautologous Whole Blood into Central Artery, Percutaneous Approach30263N1Transfusion of Nonautologous Red Blood Cells into Central Artery, Percutaneous Approach30263P1Transfusion of Nonautologous Frozen Red Cells into Central Artery, Percutaneous Approach30233K1Transfusion of Nonautologous Frozen Plasma into Peripheral Vein, Percutaneous Approach30233L1Transfusion of Nonautologous Fresh Plasma into Peripheral Vein, Percutaneous Approach30243K1Transfusion of Nonautologous Frozen Plasma into Central Vein, Percutaneous Approach30243L1Transfusion of Nonautologous Fresh Plasma into Central Vein, Percutaneous Approach30253K1Transfusion of Nonautologous Frozen Plasma into Peripheral Artery, Percutaneous Approach30253L1Transfusion of Nonautologous Fresh Plasma into Peripheral Artery, Percutaneous Approach30263K1Transfusion of Nonautologous Frozen Plasma into Central Artery, Percutaneous Approach30263L1Transfusion of Nonautologous Fresh Plasma into Central Artery, Percutaneous Approach30233M1Transfusion of Nonautologous Plasma Cryoprecipitate into Peripheral Vein, Percutaneous Approach30233R1Transfusion of Nonautologous Platelets into Peripheral Vein, Percutaneous Approach30243M1Transfusion of Nonautologous Plasma Cryoprecipitate into Central Vein, Percutaneous Approach30243R1Transfusion of Nonautologous Platelets into Central Vein, Percutaneous Approach30253M1Transfusion of Nonautologous Plasma Cryoprecipitate into Peripheral Artery, Percutaneous Approach30253R1Transfusion of Nonautologous Platelets into Peripheral Artery, Percutaneous Approach30263M1Transfusion of Nonautologous Plasma Cryoprecipitate into Central Artery, Percutaneous Approach30263R1Transfusion of Nonautologous Platelets into Central Artery, Percutaneous ApproachInclude all delivering women identified by ICD-10 codes, DRG, or MS-DRG codes below withGestational Age >= 20 weeks at deliveryDelivery ICD-10 codes:Joint Commission Appendix A: Table 11.01.1OR 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&CORMS-DRG codes:765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc767 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 cc5b.Total number of blood products transfused per 1,000 delivering women >= 20 weeks gestationOPTIONAL Number of blood product units transfused from among the denominatorWomen who delivered at any gestational age >= 20 wks, calculated per 1000 delivering women Safe Deliveries Roadmap Patient Discharge Admin Data Plus Gestational age at delivery From either:Core Clinical Maternal Data ORBirth Certificate DataPlusIf Revenue codes in PDD need supplemental backup: transfusions with validation from hospital lab, blood bank, transfusion log book ORoptional chart review for blood transfusion data via WSHA-CMDC System Interface or WSHA-QBS: internal hospital chart review Among the denominatornumber of blood products transfused by each type and total: RBCs and FFPIdentified by either:Revenue code 0380 series for transfusion blood units/types and associated Service Unit –counts ORHCPC charge code for type and associated Service Units countsORFrom Maternal Supplemental Clinical File: number of units transfused for RBCs, FFP, Platelets and CryoprecipitateOROPTIONAL chart review via:WSHA-CMDC: secure chart review web interfaceORWSHA-QBS: other hospital chart review sourceCalculated per 1000 cases in the denominatorInclude 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&CORMS-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 ccORDelivery ICD-10 codes:Joint Commission Appendix A: Table 11.01.15c.Total number of massive blood transfusions (>= 4 units RBCs) per 1000 delivering women >= 20 weeks gestationOPTIONAL Number of delivering women who received >= 4 units of blood products (RBCs) per 1000 delivering women >= 20 weeks gestationWomen who delivered at >= 20 wks gestation calculated per 1000 delivering women Safe Deliveries Roadmap harmonized with Joint Commission Maternal Sentinel Event-Massive Transfusions and Partnership for Patients MeasurePatient Discharge Data Plus Gestational age at delivery From either:Core Clinical Maternal Data ORBirth Certificate DataPlusIf 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 WSHA-CMDC Interface or WSHA-QBS: internal hospital chart reviewCalculated per 1000 cases in the denominator.Among the denominatornumber 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 ORHCPC charge code for RBCs, FFP, Platelets and Cryoprecipitate and associated Service Units per type >= 4 units (counts) per patientORFrom Maternal Supplemental Clinical File: >= 4 units transfused for RBCs, FFP, Platelets and Cryoprecipitate per patientOR optional hospital chart review via: WSHA-CMDC: secure web interface Or WSHA-QBS: other hospital chart review sourceInclude all delivering women identified by ICD-10-CM codes, DRG, or MS-DRG codes below with Gestational Age >= 20 weeks at deliveryDelivery ICD-10 codes:Joint Commission Appendix A: Tables 11.01.1OR 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&CORMS-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 cc6a.Percent of women with LOS >= 4 days from delivery to discharge per women who delivered vaginally >= 20 wks gestation 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 Safe Deliveries RoadmapPatient Discharge Data Plus Gestational Age at DeliveryANDDate of newborn birthIdentified by either: Core Clinical Newborn and Maternal dataORBirth certificate data Discharges among the denominator with maternal length of stay from delivery day to discharge date >= 4 daysInclude all women delivering vaginally identified by DRG, MS-DRG or ICD-10-CM codes below with Gestational Age >= 20 weeks at deliveryVaginal Delivery DRG Codes: 372 Vaginal del w cc, 373 Vaginal del w/o cc,374 Vaginal del w sterilization &/or D&C375 Vaginal del w OR proc except steril &/or D&CORVaginal 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 ccOR ICD-10-CM codesMethod 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 11.01.1Step 2) Exclude cases with Procedure codes for Cesarean Delivery Table 11.06 codes: 10D00Z0 Classical cesarean10D00Z1 Low cervical cesarean10D00Z2 Extraperitoneal cesarean.Step 3) Cases remaining are with vaginal delivery 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 All delivering women >= 20 wks gestation who delivered by cesarean section Safe Deliveries RoadmapPatient Discharge Data Plus Gestational Age at DeliveryANDDate of newborn birthIdentified by either:Core Clinical Newborn and Maternal dataORBirth certificate dataDischarges among the denominator with maternal length of stay from delivery day to discharge date >= 6 days Include all women delivering by cesarean identified by DRG, MS-DRG or ICD-10-CM codes below with Gestational Age >= 20 weeks at deliveryCesarean Delivery DRG Codes:370 Cesarean w cc, 371 Cesarean w/o ccORCesarean Delivery MS-DRG codes:765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mccCesarean Delivery ICD-10-CM Procedure CodesIdentify by Procedure codes for Cesarean Delivery (JC Appendix Table 11.06 codes):10D00Z0 Classical cesarean10D00Z1 Low cervical cesarean10D00Z2 Extraperitoneal cesarean 7.Percent of operative vaginal deliveries per all vaginal deliveriesNumber of operative deliveries by forceps or vacuum from among the denominator Number of vaginal deliveries Safe Deliveries Roadmap Patient Discharge DataFrom among the denominatorOperative Assisted delivery with Instrument (forceps or vacuum) 10D07Z3 Low forceps10D07Z4 Mid forceps10D07Z5 High forceps10D07Z6 Vacuum10D07Z8 Other specified or unspecified instrumentInclude all women delivering vaginally identified by DRG, MS-DRG or ICD-10-CM codesVaginal Delivery DRG Codes:372 Vaginal del w cc373 Vaginal del w/o cc374 Vaginal del w sterilization &/or D&C375 Vaginal del w OR proc except steril &/or D&CORVaginal Delivery MS-DRG codes:767 Vaginal del w sterilization &/or D&C768 Vaginal del w OR proc except steril &/or D&C774 Vaginal del w cc775 Vaginal del w/o ccOR 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 11.01.1Step 2) Exclude cases with Procedure codes for Cesarean Delivery Table 11.06 codes: 10D00Z0 Classical cesarean10D00Z1 Low cervical cesarean10D00Z2 Extraperitoneal cesarean.Step 3) Cases remaining are with vaginal delivery 8.Unexpected Newborn Complications (UNCs) per 100 live births (Inborn) NQF 716Total rate per 100 with two subgroups:A.Severe rate per 100B.Moderate rate per 100Number of term neonates with any unexpected newborn complications (Total UNCs) among the denominatorSubgroup A: with any severe UNCs among the denominatorSubgroup 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)Patient Discharge DataPluslinked mother-baby records, Plus5 min Apgar 10 min Apgar (if available) birth weight Gestational age at deliveryfrom either:Core Clinical Maternal and Newborn dataOR birth certificate data ORFrom among the denominator Total Complications per 100 in the denominator And two sub categories-Severe and Moderate(complications identified in hierarchical order SEE APPENDICES FOR DETAILS)Severe Complications per 100 in the denominator identified by:Neonatal Death (by discharge disposition-death)Neonatal Transfer (by discharge disposition-transfer)5’ or 10’ Apgar score <= 3 (by supplemental newborn file)Severe ICD-10 diagnosis or procedure code) (see Appendix Groups 3A-3I)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 C-section 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 ICD-10-CM Codes (Appendix Groups 4D-4H)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)SEE APPENDICES FOR UNEXPECTED NEWBORN COMPLICATIONS COMPLETE LIST OF CODES AND DEFINITIONSFINALIZED APPENDICES PENDING FROM CMQCC IN JANUARY 2016Include Liveborn Inborn Term neonates w/o preexisting conditions calculated per 100 livebirths as identified by: Singleton Liveborn in hospital:>= 2500 gr BW (supplemental file)GA >= 37 weeks(supplemental linked maternal file)From the above Appendices exclude – congenital anomalies, other fetal / placental conditions, and exposure to maternal drug use- prescribed or illicit9a. For women with a diagnosis of Pre-eclampsia,Percent of Maternal ICU AdmissionsNumber of delivering patients with any admission to ICU from among the denominatorAll women giving birth >= 20 weeks with any diagnosis code for Preeclampsia WSHA Partnership for Patients2014 Patient Discharge Data Plus Billing Revenue Code data (for ICU stay)PlusGestational Age at DeliveryFrom either:Core Clinical Maternal Data ORBirth Certificate DataAmong 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) ORICU_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 11.01.01OR Delivery DRG Codes:370 Cesarean w cc371 Cesarean w/o cc372 Vaginal del w cc373 Vaginal del w/o cc374 Vaginal del w sterilization &/or D&C375 Vaginal del w OR proc except steril &/or D&CORDelivery MS-DRG codes:765 Cesarean w cc/mcc766 Cesarean w/o cc/mcc767 Vaginal del w sterilization &/or D&C768 Vaginal del w OR proc except steril &/or D&C774 Vaginal del w cc775 Vaginal del w/o cc 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 trimester014.02 Mild to moderate pre-eclampsia, second trimester014.03 Mild to moderate pre-eclampsia, third trimester014.90 Unspecified pre-eclampsia, unspecified trimester014.92 Unspecified pre-eclampsia, second trimester014.93 Unspecified pre-eclampsia, third trimester011.1 Pre-existing hypertension with pre-eclampsia, first trimester011.2 Pre-existing hypertension with pre-eclampsia, second trimester011.3 Pre-existing hypertension with pre-eclampsia, third trimester011.9 Pre-existing hypertension with pre-eclampsia, unspecified trimester014.10 Severe pre-eclampsia, unspecified trimester014.12 Severe pre-eclampsia, second trimester014.13 Severe pre-eclampsia, third trimester014.20 HELLP syndrome, unspecified trimester014.22 HELLP syndrome, second trimester014.23 HELLP syndrome, third trimester015.00 Eclampsia in pregnancy, unspecified trimester015.02 Eclampsia in pregnancy, second trimester015.03 Eclampsia in pregnancy, third trimester015.1 Eclampsia in labor015.2 Eclampsia in the puerperium015.9 Eclampsia, unspecified as to time period9b.ICU Days with Pre-eclampsia diagnosis per 100 delivering women >= 20 weeks gestation with pre-eclampsia diagnosis OPTIONAL Total number of ICU days from patients among the denominator All women giving birth >= 20 weeks with any diagnosis code for Preeclampsia 2014 Partnership for Patients MeasurePatient Discharge Data Including Billing Revenue Code data (for ICU stay)PlusGestational Age at DeliveryFrom either:Core Clinical Maternal Data ORBirth Certificate DataAmong the denominatornumber of maternal ICU days as identified by either:Number of charge codes associated with Revenue Charge code in Accommodations 0200 series (ICU) from PDD OR Number of ICU_days from Maternal Supplemental Clinical Data FileOR OPTIONAL hospital chart review via:WSHA-CMDC secure websiteORWSHA-QBS: hospital internal chart review or other data sourceCalculated per 100 Discharges among the denominatorInclude all delivering women identified by DRG,MS-DRG or ICD-10-CM codes below, with Gestational Age >= 20 weeks at deliveryDRG Codes:370 Cesarean w cc, 371 Cesarean w/o cc,372 Vaginal del w cc, 373 Vaginal del w/o cc374 Vaginal del w sterilization &/or D&C375 Vaginal del w OR proc except steril &/or D&CORMS-DRG codes:765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc767 Vaginal del w sterilization &/or D&C768 Vaginal del w OR proc except steril &/or D&C774 Vaginal del w cc, 775 Vaginal del w/o cc ORDelivery ICD-10-CM codes:Joint Commission Appendix A: Tables 11.01, 11.02, 11.03, 11.04AND with any diagnosis code for Preeclampsia, Severe preeclampsia, Eclampsia, or preeclampsia superimposed on pre-existing HTN 014.00 Mild to moderate pre-eclampsia, unspecified trimester014.02 Mild to moderate pre-eclampsia, second trimester014.03 Mild to moderate pre-eclampsia, third trimester014.90 Unspecified pre-eclampsia, unspecified trimester014.92 Unspecified pre-eclampsia, second trimester014.93 Unspecified pre-eclampsia, third trimester011.1 Pre-existing hypertension with pre-eclampsia, first trimester011.2 Pre-existing hypertension with pre-eclampsia, second trimester011.3 Pre-existing hypertension with pre-eclampsia, third trimester011.9 Pre-existing hypertension with pre-eclampsia, unspecified trimester014.10 Severe pre-eclampsia, unspecified trimester014.12 Severe pre-eclampsia, second trimester014.13 Severe pre-eclampsia, third trimester014.20 HELLP syndrome, unspecified trimester014.22 HELLP syndrome, second trimester014.23 HELLP syndrome, third trimester015.00 Eclampsia in pregnancy, unspecified trimester015.02 Eclampsia in pregnancy, second trimester015.03 Eclampsia in pregnancy, third trimester015.1 Eclampsia in labor015.2 Eclampsia in the puerperium015.9 Eclampsia, unspecified as to time period9c.Rate of severe maternal morbidity for Delivering women with a diagnosis of Pre-eclampsia, Severe Morbidity based on ICD-10 codes typical of an ICU admissionPENDING – CMQCC / Expected January 2016 Total number of women with Severe Maternal Morbidity from patients among the denominator All delivering women with any diagnosis code for Preeclampsia CMQCCPreeclampsiaCollaborative MeasureHospital Patient Discharge Data Among the denominatornumber 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 SyndromePuerperal 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 ICD-10-CM CODESInclude all delivering women identified by DRG, MS-DRG, or ICD-10-CM codes below, with Gestational Age >= 20 weeks at deliveryDelivery DRG Codes:370 Cesarean w cc, 371 Cesarean w/o cc372 Vaginal del w cc, 373 Vaginal del w/o cc374 Vaginal del w sterilization &/or D&C375 Vaginal del w OR proc except steril &/or D&CORMS-DRG codes:765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc767 Vaginal del w sterilization &/or D&C768 Vaginal del w OR proc except steril &/or D&C774 Vaginal del w cc, 775 Vaginal del w/o cc OR ICD-10-CM codes:Joint Commission Appendix A: Table 11.01.1AND with any diagnosis code for Preeclampsia, Severe preeclampsia, Eclampsia, or preeclampsia superimposed on pre-existing HTN 014.00 Mild to moderate pre-eclampsia, unspecified trimester014.02 Mild to moderate pre-eclampsia, second trimester014.03 Mild to moderate pre-eclampsia, third trimester014.90 Unspecified pre-eclampsia, unspecified trimester014.92 Unspecified pre-eclampsia, second trimester014.93 Unspecified pre-eclampsia, third trimester011.1 Pre-existing hypertension with pre-eclampsia, first trimester011.2 Pre-existing hypertension with pre-eclampsia, second trimester011.3 Pre-existing hypertension with pre-eclampsia, third trimester011.9 Pre-existing hypertension with pre-eclampsia, unspecified trimester014.10 Severe pre-eclampsia, unspecified trimester014.12 Severe pre-eclampsia, second trimester014.13 Severe pre-eclampsia, third trimester014.20 HELLP syndrome, unspecified trimester014.22 HELLP syndrome, second trimester014.23 HELLP syndrome, third trimester015.00 Eclampsia in pregnancy, unspecified trimester015.02 Eclampsia in pregnancy, second trimester015.03 Eclampsia in pregnancy, third trimester015.1 Eclampsia in labor015.2 Eclampsia in the puerperium015.9 Eclampsia, unspecified as to time periodPENDING CMQCC ICD-10 DEFINITIONSPLEASE SEE APPENDIX WHEN AVAILABLE FOR DETAILED LIST OF SEVERE MATERNAL MORBIDITY WITH PREECLAMPSIA-ECLAMPSIA ICD-10-CM CODES10.Percent with Timely Treatment for delivering women with Severe Range BP at gestational age >= 20 weeks OPTIONALThose 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 BPRoadmap Measure based on California CMQCC Pre-eclampsia Collaborative MeasurePatient Discharge DataPlus Hospital chart abstracted data for focused cases on Severe BP confirmation and appropriate medication administration <= 60 minutesViaWSHA-CMDC secure web interfaceORWSHA-QBS: Internal hospital chart review resourceCases with appropriate medication administered within <= 60 minutes from confirmation of Severe BP measurement Chart review foradministration 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 processThese 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 guidelinesystolic >=160diastolic >= 110Chart review via:WSHA-CMDC: chart review with secure web interface Or WSHA-QBS: other hospital chart review source11.Severe Maternal Morbidity for all deliveries >= 20 weeks gestation CMQCC and CDC – expected January 2016 CDC Measure (2015)PENDING ICD-10 CODES FROM CMQCC and CDC IN JANUARY 2016PENDING ICD-10 CODES FROM CMQCC and CDC IN JANUARY 2016Note 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. ................
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