National Hospital Inpatient Quality Reporting Measures Specifications Manual Release Notes

Transcription

1 Natinal Hspital Inpatient Quality Reprting Measures Specificatins Manual Release Ntes Fr Manual Versin: 5.6 Cmpleted: Nvember 28, 2018 Guidelines fr Using Release Ntes The Release Ntes prvides mdificatins t the Specificatins Manual fr Natinal Hspital Inpatient Quality Measures, Versin 5.6. The infrmatin in this dcument is t be used as a reference and is nt intended t be used t prgram abstractin tls. Please refer t the Specificatins Manual fr Natinal Hspital Inpatient Quality Measures fr the cmplete and current technical specificatins and abstractin infrmatin. The ntes are rganized t fllw the rder f the Table f Cntents. The implementatin date is 07/01/2019, unless therwise specified. The headings are described belw: Impacts - used t identify the impacted measures and prtin(s) f the Manual Sectin, e.g., Alphabetical Data Dictinary, Measure Infrmatin Frm (MIF) and Flwchart (Algrithm). Descriptin f Changes - used t identify the sectin within the dcument where the change ccurs, e.g., Definitin, Data Cllectin Questin, Allwable Values, and Denminatr Statement - Data Elements. Ratinale - prvided fr the change being made. Data elements that crss multiple measures and cntain the same changes will be cnslidated. NOTE: In additin t being called ut specifically in the Release Ntes dcument, additins are yellw highlighted in the crrespnding dcuments. The changes in the Hspital Initial Patient Ppulatin and Clinical Data XML File Layuts have yellw highlighted cells with actual changes nted in bld fnt.

2 Table f Cntents Nte: click n any sectin title in the Release Ntes t return t Table f Cntents page. Table f Cntents (n updates)... 2 Acknwledgement (n updates)... 2 Intrductin (n updates)... 2 Using the Specificatins Manual fr Natinal Hspital Inpatient Quality Measures (n updates)... 2 SECTION 1 Data Dictinary... 2 Intrductin t Data Dictinary (n updates)... 2 Alphabetical Data Dictinary... 2 SECTION 2 Measurement Infrmatin Subsectin 2.1 Severe Sepsis and Septic Shck (SEP) (n updates) Subsectin 2.2 Venus Thrmbemblism (VTE) Subsectin 2.4 Glbal Initial Patient Ppulatin (ED, IMM, TOB, SUB) (n updates) Subsectin 2.5 Emergency Department (ED) Subsectin Preventin Immunizatin (IMM) Substance Use (SUB) (n updates) Tbacc Treatment (TOB) (n updates) SECTION 3 Missing and Invalid Data (n updates) SECTION 4 Ppulatin and Sampling Specificatins (n updates) SECTION 9 Data Transmissin Transmissin Overview (n updates) Transmissin Alphabetical Data Dictinary (n updates) Hspital Clinical Data XML File Layut Hspital Initial Patient Ppulatin Data XML File Layut (n updates) SECTION 10 CMS Outcme/Inpatient Web-Based Measures Subsectin 10.1 CMS Outcme Measures (n updates) Subsectin 10.2 Inpatient Web-Based Measures (n updates) APPENDICES Appendix A ICD-10 Cde Tables (Wrd and Excel) (n updates) Appendix C Medicatin Tables (Wrd and Excel) Appendix D Glssary f Terms (n updates) Appendix E Overview f Measure Infrmatin Frm and Flwchart Frmats (n updates) Appendix F Measure Name Crsswalk (n updates) Appendix G Resurces (n updates) Appendix H Miscellaneus Tables Appendix P Preview Sectin (n updates) Specificatins Manual fr Hspital Inpatient Quality Measures Page 1

3 The cntent belw is rganized t fllw the Table f Cntents in the specificatins manual. Table f Cntents (n updates) Acknwledgement (n updates) Intrductin (n updates) Using the Specificatins Manual fr Natinal Hspital Inpatient Quality Measures (n updates) SECTION 1 Data Dictinary Intrductin t Data Dictinary (n updates) Alphabetical Data Dictinary Administrative Cntraindicatin t Care, Septic Shck Ratinale: The Administrative Cntraindicatin t Care, Septic Shck data element is being updated with new guidance. Change third bullet pint t: A mre general dcumentatin f refusal f care (e.g. central line, PICC, IO access) r dcumentatin f patient nn-cmpliance with care (e.g., pulling ut IV) that wuld result in the fllwing nt being administered within the specified time frame is acceptable. Bld Draws IV r IO fluid administratin Vaspressrs Administrative Cntraindicatin t Care, Severe Sepsis Ratinale: The Administrative Cntraindicatin t Care, Severe Sepsis data element is being updated with new guidance. Change third bullet pint t: A mre general dcumentatin f refusal f care (e.g. central line, PICC, IO access) r dcumentatin f patient nn-cmpliance with care (e.g., pulling ut IV) that wuld result in the fllwing nt being administered within the specified time frame is acceptable. Bld Draws IV r IO fluid administratin Vaspressrs Specificatins Manual fr Hspital Inpatient Quality Measures Page 2

4 Brad Spectrum r Other Antibitic Administratin Selectin Ratinale: The Brad Spectrum r Other Antibitic Administratin Selectin data element is being updated with new guidance. Change under fifth bullet pint, Examples t: Example: Change first sub-bullet pint under sixth bullet pint t: There is physician/apn/pa dcumentatin within 24 hurs prir t the antibitic start time identifying the presence f C. difficile. Dcumentatin that C. difficile is suspected r likely is acceptable. Directive fr Cmfrt Care r Palliative Care, Septic Shck Ratinale: The Directive fr Cmfrt Care, Septic Shck data element is being updated with new guidance t further specify that nly inclusin terms dcumented in specific cntext are acceptable. Change secnd bullet pint t: Only the earliest physician/apn/pa dcumentatin f an inclusin term dcumented in the fllwing cntexts suffices: Cmfrt measures nly recmmendatin Order fr cnsultatin r evaluatin by a hspice care service Patient r patient representative request fr cmfrt measures nly Plan fr cmfrt measures nly Referral t hspice care service Directive fr Cmfrt Care r Palliative Care, Severe Sepsis Ratinale: The Directive fr Cmfrt Care, Septic Shck data element is being updated with new guidance t further specify that nly inclusin terms dcumented in specific cntext are acceptable. Change secnd bullet pint t: Only the earliest physician/apn/pa dcumentatin f an inclusin term dcumented in the fllwing cntexts suffices: Cmfrt measures nly recmmendatin Order fr cnsultatin r evaluatin by a hspice care service Patient r patient representative request fr cmfrt measures nly Plan fr cmfrt measures nly Referral t hspice care service Specificatins Manual fr Hspital Inpatient Quality Measures Page 3

5 Discharge Dispsitin Ratinale: The data element is being updated t prvide abstractin guidance regarding dcumentatin related t patient discharge t rehabilitatin facilities fr chemical and alchl dependency. Inclusin Guidelines fr Abstractin Under Other Health Care Facility (Value 5): Change fifth bullet pint t: Rehabilitatin Facility including, but nt limited t: Inpatient Rehabilitatin Facility/Hspital, Rehabilitatin Unit f a Hspital, Chemical Dependency/Alchl Rehabilitatin Facility Initial Hyptensin Ratinale: The Initial Hyptensin data element is being updated with clarifying guidance. Change furth bullet pint t: Hyptensive BPs btained within the perating rm (OR), interventinal radilgy, during active delivery, r prcedural/cnscius sedatin shuld nt be used. Change seventh bullet pint t: Dcumentatin f a term that represents r is defined by an SBP <90 mmhg r MAP <65 mmhg is acceptable in place f an abnrmal value when dcumented as nrmal fr the patient, due t a chrnic cnditin, due t a medicatin, r due t an acute cnditin that has a nn-infectius surce/prcess. Example: Hyptensin (Systlic bld pressure <90 mmhg). Persistent Hyptensin Ratinale: The Persistent Hyptensin data element is being updated with clarifying guidance. Change third bullet pint t: Hyptensive BPs btained within the perating rm (OR), interventinal radilgy, during active delivery, r prcedural/cnscius sedatin shuld nt be used. Add new sixth bullet pint: If ne r mre bld pressures were dcumented within the time frame and persistent hyptensin is unable t be determined but a vaspressr was administered, select Value 1. Change eighth bullet pint t: Dcumentatin f a term that represents r is defined by an SBP <90 mmhg r MAP <65 mmhg is acceptable in place f an abnrmal value when dcumented as nrmal fr Specificatins Manual fr Hspital Inpatient Quality Measures Page 4

6 the patient, due t a chrnic cnditin, due t a medicatin, r due t an acute cnditin that has a nn-infectius surce/prcess. Example: Hyptensin (Systlic bld pressure <90 mmhg). Remve: Acceptable crystallid fluids are identified in the Crystallid Fluid Administratin data element. If the end time f the target rdered vlume f crystallid fluids cannt be determined, select Value 3. If crystallid fluids were administered but at a vlume less than the target rdered vlume, chse Value 4. Reasn fr N Administratin f VTE Prphylaxis Ratinale: The data element is being updated t prvide additinal guidance fr the abstractr. Change under secnd bullet pint, third sub-bullet pint t: Fr patients receiving anticagulant therapy, including cntinuus IV heparin infusin, between arrival and the day befre the VTE diagnstic test rder date, select Yes. Disregard IV heparin administered t flush/maintain patency f a line r dialysis equipment and IV heparin administered during an interventinal prcedure, e.g., cardiac cath. Remve furth bullet pint: If the VTE Diagnstic Test was perfrmed the day f r the day after arrival, select Yes. Referral fr Addictins Treatment Ratinale: The data element is being updated t prvide abstractin guidance regarding dcumentatin related t patient referrals and appintments fr addictins treatment. Change t: If a patient is referred t an addictins treatment prvider that des nt schedule appintments and the patient was given a specific date and time t present fr addictins treatment, select Value 1. If the patient des nt have a residence in the USA, Value 4 must be selected. A referral t Alchlics Annymus (AA) r similar mutual supprt grups des nt meet the intent f the measure. Select Value 5. Select Value 5 if: it cannt be determined that a referral fr addictins treatment was made r; it is unclear that the absence f the referral was due t a patient refusal r because the referral was nt ffered. Specificatins Manual fr Hspital Inpatient Quality Measures Page 5

7 Referral fr Outpatient Tbacc Cessatin Cunseling Ratinale: The data element is being updated t prvide abstractin guidance regarding dcumentatin related t patient referrals and appintments fr addictins treatment. Change t: If a referral is made t a Quitline, defined as a telephne cunseling in which at least sme f the cntact is initiated by the Quitline cunselr t deliver tbacc use interventins, select Value 1. If the patient directly calls the Quitline during the hspitalizatin, dcumentatin must reflect that staff was present during the call t verify that an appintment was set. If a patient is referred t an utpatient tbacc cessatin cunseling prvider that des nt schedule appintments and the patient was given a specific date and time t present fr cunseling, select Value 1. If the patient is prvided with cntact infrmatin fr e-health r internet smking cessatin prgrams which tailr prgram cntent t the tbacc user s needs (by cllecting infrmatin frm the tbacc user and using algrithms t tailr feedback r recmmendatins, permitting the user t select frm varius features including extensive infrmatin n quitting, tbacc dependence, and related tpics) select Value 2. Nte that if Value 2 is selected, the case will nt pass the measure. Value 2 can be used as part f an internal perfrmance imprvement activity in rder t determine if any type f referral was made rather than n referral. If a referral fr utpatient tbacc cessatin cunseling was ffered during the hspitalizatin and the patient refused, select Value 3. It des nt need t be ffered again at discharge. If the patient des nt have a residence in the USA, Value 4 must be selected. If the patient is prvided with self-help materials that are nt tailred t the patient s needs and d nt prvide a structured prgram, select Value 5. Select Value 5 if: it cannt be determined that a referral fr utpatient cessatin cunseling was made r; it is unclear that the absence f the referral was due t a patient refusal r because the referral was nt ffered. If the patient refused practical cunseling (Tbacc Use Treatment Practical Cunseling) during the hspitalizatin, a referral fr utpatient tbacc cessatin cunseling must still be ffered at the time f discharge. Select Value 5 if a referral fr utpatient cunseling was nt ffered at the time f discharge. Severe Sepsis Present Ratinale: The Severe Sepsis Present data element is being updated with new guidance. Change under secnd bullet pint, eighth bullet pint under C t: INR >1.5 r aptt >60 sec Specificatins Manual fr Hspital Inpatient Quality Measures Page 6

8 Release Ntes Versin 5.6 If the suggested data surce shws the patient was given an anticagulant medicatin in Appendix C Table 5.3, an elevated INR r aptt level shuld nt be used as rgan dysfunctin. Physician/APN/PA dcumentatin is nt required. If nly the fllwing is given, the elevated INR r aptt level shuld be used: Heparin flushes Change furth bullet pint t: Dcumentatin f a term that represents r is defined by a SIRS criteria r sign f rgan dysfunctin is acceptable in place f an abnrmal value when dcumented as nrmal fr the patient, due t a chrnic cnditin, due t a medicatin, r due t an acute cnditin that has a nn-infectius surce/prcess. Examples include but are nt limited t: Tachypnea (Respiratin >20 per minutes) Tachycardia, RVR (Heart rate >90) Leukpenia (White bld cell cunt <4,000) Leukcytsis (White bld cell cunt >12,000) Thrmbcytpenia (Platelet cunt <100,000) Hyptensin (Systlic bld pressure <90 mmhg) Change seventh bullet pint t: SIRS criteria r a sign f rgan dysfunctin btained within the perating rm (OR), interventinal radilgy, during active delivery, r prcedural/cnscius sedatin shuld nt be used. Septic Shck Present Ratinale: The Septic Shck Present data element is being updated with clarifying guidance. Change a under third bullet pint t: a. Severe Sepsis Present AND Persistent Hyptensin evidenced by: In the hur after the cnclusin f the target rdered vlume f Crystallid Fluid Administratin, tw cnsecutive dcumented hyptensive bld pressure readings. Change furth and fifth bullet pint t: Fr evaluatin f bld pressure parameters t establish whether r nt hyptensin persists after crystallid fluid administratin, begin abstracting at the time that crystallid fluid administratin cncludes (refer t the Persistent Hyptensin data element); abstract fr the time perid that fllws fr the next hur nly. Hyptensive BPs btained within the perating rm (OR), interventinal radilgy, during active delivery, r prcedural/cnscius sedatin shuld nt be used. Change ninth bullet pint t: Dcumentatin f a term that represents r is defined by a SBP <90 mmhg r MAP <65 mmhg is acceptable in place f an abnrmal value when dcumented as nrmal fr the patient, due t a chrnic cnditin, due t a medicatin, r due t an acute cnditin that has a nn-infectius surce/prcess. Specificatins Manual fr Hspital Inpatient Quality Measures Page 7

9 VTE Cnfirmed Ratinale: The data element is being updated t prvide additinal guidance fr the abstractr. Inclusin Guidelines fr Abstractin Add new bullet pint: Infrarenal IVC Exclusin Guidelines fr Abstractin Add new bullet pints: Amnitic fluid emblism / embli Cement emblism / embli VTE Diagnstic Test Ratinale: The data element is being updated t prvide additinal guidance fr the abstractr. Inclusin Guidelines fr Abstractin Change secnd bullet pint t: Venus Ultrasund f lwer extremities Add new bullet pint: CT pulmnary angigram (CTPA) / CTPA Scan / CT pulmnary emblism (CTPE) VTE Present at Admissin Ratinale: The data element is being updated t prvide additinal guidance fr the abstractr. Change t: The time frame fr this data element includes any dcumentatin dated frm hspital arrival t the day after admissin. It is nt necessary t review dcumentatin utside f this timeframe t answer this data element. Dcumentatin f suspicin r a diagnsis f a pulmnary emblism (PE) r venus thrmbemblism (VTE) in a cnfirmed lcatin is acceptable. Only accept terms identified in the list f inclusins. NOTE: It is nt necessary fr a VTE Diagnstic Test t be linked with the physician/apn/pa dcumented diagnsis f PE r VTE. Acceptable Examples: A patient arrived n 10/1/20xx with shrtness f breath. On 10/2/20XX, there is physician dcumentatin that a PE is suspected, select Yes. Results f a venus Dppler perfrmed the day after admissin are psitive fr VTE in the cmmn femral vein, select Yes. Specificatins Manual fr Hspital Inpatient Quality Measures Page 8

10 Release Ntes Versin 5.6 Results f a Dppler are psitive fr an acute nncclusive LLE thrmbus n the day after admissin, select Yes. Day f admissin physician includes PE n the prblem list, select Yes. Patient admitted with a diagnsis f left ppliteal deep vein thrmbus, select Yes. Patient arrived n 01/05/20XX with dcumentatin frm an utside transferring hspital indicating vascular ultrasund was perfrmed n 01/02/20XX and psitive fr VTE, select Yes. Physician dcuments in H&P n day f admissin, DVT right lwer extremity, select Yes. Unacceptable Examples: H&P n day f admissin ntes that the patient has an cclusin f the subclavian vein. Subclavian vein is nt a defined lcatin, select N. A patient arrives t the hspital emergency department with C/O severe headache. Differential diagnsis n the day f arrival includes cerebral venus thrmbsis (CVT) versus SAH, select N. Physician admitting nte dcuments DVT prphylaxis under the treatment plan, select N. Patient admitted with a diagnsis f left upper extremity deep vein thrmbus, select N. Patient has a CT chest with IV cntrast n the day f arrival t R/O PE and test results are negative and received by 2359 the day after admissin, select N. An rder fr a VTE diagnstic test is acceptable ONLY if it is explicitly dcumented that VTE/PE is the reasn fr the test. Only accept terms identified in the list f inclusins. If an acceptable test is rdered fr a PE r VTE indicatin and results are dcumented as negative by 2359 the day after admissin, then suspicin f PE r VTE has been ruled ut. Select N. Acceptable Examples: A patient presents t the hspital emergency department with a chief cmplaint f pain and swelling in the right calf. A vascular ultrasund f the lwer extremities is rdered t R/O DVT, select Yes. UNLESS results are negative and received by 2359 the day after admissin. Bilateral venus Dppler f the lwer extremities is rdered n the day after admissin fr redness and swelling left calf, select Yes. A patient arrives n 06/01/20XX. Admitting diagnsis is fever. On 06/02/20XX patient admitted and physician dcuments if cugh cntinues may require evaluatin fr PE. On 06/03/20XX, CTA chest is rdered and psitive fr PE. Select Yes. Unacceptable Examples: Physician rders a bilateral lwer extremity arterial duplex n the day after admissin. Arterial duplex is nt an acceptable test. Select "N" fr VTE Present n Admissin. Patient presents t the emergency rm with cmplaints f pain all ver after sustaining a fall. ED MD rders multiple tests including a CT f the chest with IV cntrast. ED MD dcuments fall as the reasn fr the test. N mentin f PE/VTE, select N. Specificatins Manual fr Hspital Inpatient Quality Measures Page 9

11 Release Ntes Versin 5.6 A patient is admitted after a mtr vehicle accident. On arrival, a CT f the abd/pelvis with IV cntrast was dne t R/O internal injuries. N mentin f PE/VTE, select N. Bilateral venus Dppler f the lwer extremities is rdered n the day f arrival fr redness and swelling left calf. Results returned the same day dcument n acute VTE in left cmmn femral vein r ppliteal vein, select N. Patients wh are under treatment and receiving anticagulatin therapy fr PE/VTE at the time f hspital arrival, select Yes. Examples: Patient admitted 04/30/20XX. Physician dcuments n 04/30/20XX that Cumadin was started n 04/20/20XX fr a recently diagnsed PE, select Yes. Patient presents with a dcumented diagnsis f PE n the day f arrival. Cumadin placed n hld t evaluate fr GI bleed, select Yes. Patients n anticagulatin therapy fr anther cnditin (e.g., atrial fibrillatin, mitral valve replacement) at the time f hspital arrival, select Yes. Examples: Patient with a histry f strke and taking dabigatran as a hme medicatin prir t arrival, select YES. H&P dcuments chrnic VTE. Taking Cumadin, select Yes. EXCEPTION: Patient n apixaban prir t arrival fr a histry f atrial fibrillatin. Apixaban discntinued n arrival fr surgery the day after admissin, select N. Fr patients with nly a past histry f VTE dcumented, select N. Example: Prblem list includes PE 199X, select N. If the patient was admitted and had surgery n day f r day after hspital admissin r ICU admissin and there was n dcumentatin f diagnsed/suspected VTE prir t surgery, the VTE is nt cnsidered present n admissin. Select N. Disregard diagnstic prcedures perfrmed, e.g., cardiac catheterizatin, endscpy, ERCP. Inclusin Guidelines fr Abstractin VTE Cnfirmed Add new bullet pint: Infrarenal IVC Inclusin Guidelines fr Abstractin VTE Diagnstic Test Change secnd bullet pint t: Venus Ultrasund f lwer extremities Add new bullet pint: CT pulmnary angigram (CTPA) / CTPA Scan / CT pulmnary emblism (CTPE) Specificatins Manual fr Hspital Inpatient Quality Measures Page 10

12 SECTION 2 Measurement Infrmatin Subsectin 2.1 Severe Sepsis and Septic Shck (SEP) (n updates) Subsectin 2.2 Venus Thrmbemblism (VTE) VTE Data Element List Ratinale: The VTE Data Element List is being updated t remve data elements nt cllected by The Jint Cmmissin, the current measure steward. Remve rws in their entirety: First Name Last Name Patient Identifier Physician 1 Physician 2 Pstal Cde Sample Size Requirements Quarterly Sampling Ratinale: This dcument is being updated t remve the references t CMS. Remve frm first paragraph and under Quarterly Sampling sectin: the CMS Clinical Warehuse r Subsectin 2.4 Glbal Initial Patient Ppulatin (ED, IMM, TOB, SUB) (n updates) Subsectin 2.5 Emergency Department (ED) ED-1: Algrithm Ratinale: This dcument is being updated t align with fiscal year (FY) 2019 Inpatient Prspective Payment System (IPPS) final rule and the remval f ED-1 frm the Hspital IQR Prgram. Remve the fllwing ntes and decisin bx: Fr Overall Measure (ED-1a) Fr The Jint Cmmissin Only ff f the Case Will Be Rejected decisin pint Stp here fr CMS. CONTINUE fr The Jint Cmmissin decisin pint Nte: X is fr The Jint Cmmissin Only Specificatins Manual fr Hspital Inpatient Quality Measures Page 11

13 Subsectin Preventin Immunizatin (IMM) IMM Data Element List Ratinale: The IMM Data Element List is being updated t remve data elements nt cllected by The Jint Cmmissin, the current measure steward. Remve rws in their entirety: First Name Last Name Patient Identifier Physician 1 Physician 2 Pstal Cde Substance Use (SUB) (n updates) Tbacc Treatment (TOB) (n updates) SECTION 3 Missing and Invalid Data (n updates) SECTION 4 Ppulatin and Sampling Specificatins (n updates) SECTION 9 Data Transmissin Transmissin Overview (n updates) Transmissin Alphabetical Data Dictinary (n updates) Hspital Clinical Data XML File Layut Data Elements Inf Ratinale: Updates are being made t align with the specificatins manual alphabetical data dictinary. Change Retired r Deleted Data Elements Effective 07/01/2019 Discharges sectin t: N elements retired r deleted. Hspital Initial Patient Ppulatin Data XML File Layut (n updates) SECTION 10 CMS Outcme/Inpatient Web-Based Measures Subsectin 10.1 CMS Outcme Measures (n updates) Subsectin 10.2 Inpatient Web-Based Measures (n updates) Specificatins Manual fr Hspital Inpatient Quality Measures Page 12

14 APPENDICES Appendix A ICD-10 Cde Tables (Wrd and Excel) (n updates) Appendix C Medicatin Tables (Wrd and Excel) Table 5.2: Vaspressrs fr Septic Shck Ratinale: Table 5.2 is being updated t include Giapreza (angitensin II), an injectin recently apprved by the U.S. Fd and Drug Administratin t increase bld pressure in adults with septic r ther distributive shck. Add rw under Generic Name and crrespnding Brand Name clumns: Angitensin II t left clumn Giapreza t right clumn Appendix D Glssary f Terms (n updates) Appendix E Overview f Measure Infrmatin Frm and Flwchart Frmats (n updates) Appendix F Measure Name Crsswalk (n updates) Appendix G Resurces (n updates) Appendix H Miscellaneus Tables Table 2.6 Ratinale: Table 2.6 is being remved as it is n lnger utilized fr any f the measure sets. Remve in its entirety: Table 2.6: Qualifiers and Mdifiers Table Appendix P Preview Sectin (n updates) Specificatins Manual fr Hspital Inpatient Quality Measures Page 13