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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:1- 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-CMDC2- 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.

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 20161. 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.

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 available

Patient Discharge DataPlusGestational Age at Delivery,And ParityFrom either:

Core Clinical Maternal dataORBirth Certificate data

Cases among the denominator who had cesarean delivery

Included 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 cesarean

Excluded Populations: None

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

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 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

All cesarean deliveries among the

Delivering women > 37 weeks who

Safe Deliveries Roadmap

Patient Discharge DataPlus

Cesarean delivery among the denominator defined by either Cesarean Delivery DRG, MS-DRG

Include: All deliveries, identified by DRG, MS-DRG or ICD-10 codes defined byDRG Codes: 370 Cesarean w cc, 371 Cesarean w/o cc, 372

December 23, 2015 (V1 effective starting with discharges 10/1/15) p. 2

Singleton Vertex (TSV) Cesarean Section Rate

denominator have not had a prior cesarean section.

Exclude: breech or transverse presentation, preterm births, fetal deaths, and multiple gestations

Measure Gestational age at DeliveryFrom either:Core Clinical Maternal dataORBirth Certificate data.When birth certificate data available add to exclusions: Previous c-section (# 57.7 on Birth Certificate)

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 cesarean

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&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 ccORICD-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 2016

3a.C-Section rate for Term Inductions of Labor in Nulliparous women >= 39 weeks gestation at delivery


Nulliparous women whose labor was induced with delivery >= 39 weeks gestation


Patient Discharge DataPlusGestational Age at deliveryandParityFrom either:Core Clinical Maternal data:ORBirth Certificate dataAndInduction of Labor (Y/N)

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:

Include all delivering women identified by DRG, MS-DRG or ICD-10 codes below withParity = 0Gestational 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&COR


from either Supplemental Maternal Data, internal data or chart review data

10D00Z0 Classical cesarean10D00Z1 Low cervical cesarean10D00Z2 Extraperitoneal cesarean

Delivery 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 ccORICD-10-CM Codes: See Joint Commission Appendix A: Table 11.01.1

3b.C-Section rate for Term Inductions of Labor in Multiparous women >= 39 weeks gestation at delivery


Multiparous women whose labor was induced with delivery >= 39 weeks gestation


Patient Discharge DataPlusGestational Age at deliveryandParityFrom either:Core Clinical Maternal dataORBirth Certificate dataAndInduction 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; 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 withParity >=1Gestational 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 ccORICD-10-CM Codes: See Joint Commission Appendix A:Table 11.01.1

4a.Number of Maternal admissions to ICU per all deliveries >= 20 weeks gestation

All maternal admissions to ICU anytime during delivery hospitalization among the denominator

Women with delivery at any gestational age >= 20 weeks gestation

SD Roadmap harmonized with Partnership for Patients ICU-related measure

Patient Discharge DataincludingBilling Revenue Code data (for ICU stay)PlusGestational age at deliveryFrom either:Core Clinical

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:

Include all delivering women identified by DRG, MS-DRG, or ICD-10 codes below withGestational 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


Maternal DataORBirth certificate data

ICU_days > 0

For WSHA-CMDC system: data in Maternal Supplemental Clinical DataORFor WSHA-QBS system: data from other internal hospital data source

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

ORDelivery ICD-10-CM codes:Joint Commission Appendix A: Table 11.01.1

4b.Number of maternal ICU days per 100 deliveries >= 20 weeks gestation

OPTIONAL

Number of ICU days among the denominator

Women with delivery at any gestational age >= 20 weeks gestation, calculated per 100 delivering women


Patient Discharge DataincludingBilling Revenue Code data (for ICU stay)PlusGestational age at deliveryFrom either:Core Clinical Maternal DataORBirth Certificate Data

Among 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

ORNumber of ICU days from Maternal Supplemental Clinical DataOROPTIONAL chart review via:WSHA-CMDC: secure chart review web interfaceORWSHA-QBS: other hospital chart review source

Calculated per 100 Discharges among the denominator

Include all delivering women identified by DRG, MS-DRG or ICD-10 codes below withGestational 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

ORMS-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

ORDelivery ICD-10 codes: Joint Commission Appendix A: Table 11.01.1

5a.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, Cryoprecipita

Women who delivered at >= 20 weeks gestational age

WSHA 2014 Partnership for Patients

Patient Discharge DataPlusGestational age at deliveryFrom either:Core Clinical Maternal DataORBirth Certificate Data

Among the denominator, number of patients with any ICD-10 Procedure code for specific transfusions identified by any of 28 ICD-10 codes:

30233H1 Transfusion of Nonautologous Whole Blood into Peripheral Vein, Percutaneous Approach

30233N1 Transfusion of Nonautologous Red Blood Cells into Peripheral Vein,

Include all delivering women identified by ICD-10 codes, DRG, or MS-DRG codes below withGestational Age >= 20 weeks at delivery

Delivery ICD-10 codes:Joint Commission Appendix A: Table 11.01.1ORDRG 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&COR


te) identified by ICD-10-CM procedure codes from among the denominator

Percutaneous Approach

30233P1 Transfusion of Nonautologous Frozen Red Cells into Peripheral Vein, Percutaneous Approach

30243H1 Transfusion of Nonautologous Whole Blood into Central Vein, Percutaneous Approach

30243N1 Transfusion of Nonautologous Red Blood Cells into Central Vein, Percutaneous Approach

30243P1 Transfusion of Nonautologous Frozen Red Cells into Central Vein, Percutaneous Approach

30253H1 Transfusion of Nonautologous Whole Blood into Peripheral Artery, Percutaneous Approach

30253N1 Transfusion of Nonautologous Red Blood Cells into Peripheral Artery, Percutaneous Approach

30253P1 Transfusion of Nonautologous Frozen Red Cells into Peripheral Artery, Percutaneous Approach

30263H1 Transfusion of Nonautologous Whole Blood into Central Artery, Percutaneous Approach

30263N1 Transfusion of Nonautologous Red Blood Cells into Central Artery, Percutaneous

MS-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 cc


Approach30263P1 Transfusion of

Nonautologous Frozen Red Cells into Central Artery, Percutaneous Approach

30233K1 Transfusion of Nonautologous Frozen Plasma into Peripheral Vein, Percutaneous Approach

30233L1 Transfusion of Nonautologous Fresh Plasma into Peripheral Vein, Percutaneous Approach

30243K1 Transfusion of Nonautologous Frozen Plasma into Central Vein, Percutaneous Approach

30243L1 Transfusion of Nonautologous Fresh Plasma into Central Vein, Percutaneous Approach

30253K1 Transfusion of Nonautologous Frozen Plasma into Peripheral Artery, Percutaneous Approach

30253L1 Transfusion of Nonautologous Fresh Plasma into Peripheral Artery, Percutaneous Approach

30263K1 Transfusion of Nonautologous Frozen Plasma into Central Artery, Percutaneous Approach

30263L1 Transfusion of Nonautologous Fresh Plasma into Central Artery, Percutaneous Approach

30233M1 Transfusion of Nonautologous


Plasma Cryoprecipitate into Peripheral Vein, Percutaneous Approach

30233R1 Transfusion of Nonautologous Platelets into Peripheral Vein, Percutaneous Approach

30243M1 Transfusion of Nonautologous Plasma Cryoprecipitate into Central Vein, Percutaneous Approach

30243R1 Transfusion of Nonautologous Platelets into Central Vein, Percutaneous Approach

30253M1 Transfusion of Nonautologous Plasma Cryoprecipitate into Peripheral Artery, Percutaneous Approach

30253R1 Transfusion of Nonautologous Platelets into Peripheral Artery, Percutaneous Approach

30263M1 Transfusion of Nonautologous Plasma Cryoprecipitate into Central Artery, Percutaneous Approach

30263R1 Transfusion of Nonautologous Platelets into Central Artery, Percutaneous Approach

5b.Total number of blood products transfused

Number of blood product units transfused from among the

Women who delivered at any gestational age >= 20 wks,


Patient Discharge Admin Data PlusGestational age at delivery

Among the denominatornumber of blood products transfused by each type and total: RBCs and FFP

Identified by either:

Include all delivering women identified by DRG, MS-DRG codes, or ICD-10-CM codes below withGestational Age >= 20 weeks at delivery

DRG Codes:370 Cesarean w cc, 371 Cesarean w/o cc, 372 Vaginal del


per 1,000 delivering women >= 20 weeks gestation

OPTIONAL

denominator calculated per 1000 delivering women

From either:Core Clinical Maternal DataORBirth Certificate DataPlusIf Revenue codes in PDD need supplemental backup: transfusionswith validation from hospital lab, blood bank, transfusion log bookORoptional chart review for blood transfusion data via WSHA-CMDC System Interface or WSHA-QBS: internal hospital chart review

Revenue code 0380 series for transfusion blood units/types and associated Service Unit –countsORHCPC 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 source

Calculated per 1000 cases in the denominator

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

ORMS-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

ORDelivery ICD-10 codes:Joint Commission Appendix A: Table 11.01.1

5c.Total number of massive blood transfusions (>= 4 units RBCs) per 1000 delivering women >= 20 weeks gestation

Number of delivering women who received >= 4 units of blood products (RBCs) per 1000 delivering women >= 20 weeks gestation

Women 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

Patient Discharge DataPlusGestational age at deliveryFrom either:Core Clinical Maternal DataORBirth Certificate DataPlusIf Revenue codes in PDD

Calculated 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,

Include all delivering women identified by ICD-10-CM codes, DRG, or MS-DRG codes below with Gestational Age >= 20 weeks at delivery

Delivery ICD-10 codes:Joint Commission Appendix A: Tables 11.01.1ORDRG 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


OPTIONALfor Patients Measure

need supplemental backup:back-up validation from hospital lab, blood bank, transfusion log bookoroptional chart review for blood transfusion data via WSHA-CMDC Interface or WSHA-QBS: internal hospital chart review

Platelets and Cryoprecipitate and associated Service Units per type >= 4 units (counts) per patient

ORFrom Maternal Supplemental Clinical File: >= 4 units transfused for RBCs, FFP, Platelets and Cryoprecipitate per patient

ORoptional hospital chart review via:WSHA-CMDC: secure web interfaceOrWSHA-QBS: other hospital chart review source

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

6a.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


Patient Discharge DataPlusGestational Age at DeliveryANDDate of newborn birthIdentified by either:Core Clinical Newborn and Maternal data

ORBirth certificate data

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 withGestational 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&C375 Vaginal del w OR proc except steril &/or D&C

ORVaginal 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 ccORICD-10-CM 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 cesarean


10D00Z1 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


Patient Discharge DataPlusGestational 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 >= 6 days

Include all women delivering by cesarean identified by DRG, MS-DRG or ICD-10-CM codes below withGestational 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 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 deliveries

Number of operative deliveries by forceps or vacuum from among the denominator

Number of vaginal deliveries


Patient Discharge Data

From among the denominatorOperative Assisted delivery with Instrument (forceps or vacuum)10D07Z3 Low forceps10D07Z4 Mid forceps10D07Z5 High forceps10D07Z6 Vacuum10D07Z8 Other specified or unspecified instrument

Include all women delivering vaginally identified by DRG, MS-DRG or ICD-10-CM codes

Vaginal 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&C

ORVaginal 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 cc

ORBy 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 716

Total rate per 100 with two subgroups:A.Severe rate per 100B.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 716Use 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 delivery

from either:

Core Clinical Maternal and Newborn data

ORbirth certificate dataOR

From among the denominatorTotal Complications per 100 in the denominatorAnd two sub categories-Severe and Moderate

(complications identified in hierarchical orderSEE 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

SEE APPENDICES FOR UNEXPECTED NEWBORN COMPLICATIONS COMPLETE LIST OF CODES AND DEFINITIONSFINALIZED APPENDICES PENDING FROM CMQCC IN JANUARY 2016

Include 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 illicit


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)

9a. For women with a diagnosis of Pre-eclampsia,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 Patients2014

Patient Discharge DataPlusBilling Revenue Code data (for ICU stay)PlusGestational Age at DeliveryFrom either:Core Clinical Maternal DataORBirth Certificate Data

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)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 11.01.01ORDelivery 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 period

9b.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 Measure

Patient Discharge DataIncludingBilling Revenue Code data (for ICU stay)PlusGestational Age at DeliveryFrom either:Core Clinical Maternal DataORBirth Certificate Data

Among 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

ORNumber of ICU_days from Maternal Supplemental Clinical Data FileOROPTIONAL hospital chart review via:WSHA-CMDC secure websiteORWSHA-QBS: hospital internal

Include all delivering women identified by DRG,MS-DRG or ICD-10-CM codes below, withGestational 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 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 ccORDelivery ICD-10-CM codes:Joint Commission Appendix A: Tables 11.01, 11.02, 11.03,


chart review or other data source

Calculated per 100 Discharges among the denominator

11.04AND with any diagnosis code for Preeclampsia, Severe preeclampsia, Eclampsia, or preeclampsia superimposed on pre-existing HTN014.00 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 period

9c.Rate of severe maternal morbidity for Delivering women with a diagnosis of Pre-eclampsia, Severe

Total number of women with Severe Maternal Morbidity from patients among the denominator

All delivering women with any diagnosis code for Preeclampsia

CMQCCPreeclampsiaCollaborative Measure

Hospital 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

Include all delivering women identified by DRG, MS-DRG, or ICD-10-CM codes below, withGestational Age >= 20 weeks at delivery

Delivery 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&C


Morbidity based on ICD-10 codes typical of an ICU admissionPENDING – CMQCC / Expected January 2016

SyndromePuerperal Cerebrovascular Disorder:Disseminated Intravascular Coagulation Syndrome: Postpartum Hemorrhage:Abruptio Placentae:ORProcedure 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 CODES

768 Vaginal del w OR proc except steril &/or D&C774 Vaginal del w cc, 775 Vaginal del w/o ccOR 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 HTN014.00 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 period

PENDING CMQCC ICD-10 DEFINITIONSPLEASE SEE APPENDIX WHEN AVAILABLE FOR DETAILED LIST OF SEVERE MATERNAL MORBIDITY WITH PREECLAMPSIA-ECLAMPSIA ICD-10-CM CODES

10. Those treated All women Roadmap Patient Cases with appropriate These denominator cases will initially be identified as in


Percent with Timely Treatment for delivering women with Severe Range BP at gestational age >= 20 weeks OPTIONAL

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.

giving birth >= 20 weeks with any diagnosis code and confirmation by chart review for severe range BP

Measure based on California CMQCC Pre-eclampsia Collaborative Measure

Discharge Data

PlusHospital 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 resource

medication administered within <= 60 minutes from confirmation of Severe BP measurementChart 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 interfaceOrWSHA-QBS: internal hospital chart review process

#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 >= 110

Chart review via:WSHA-CMDC: chart review with secure web interfaceOrWSHA-QBS: other hospital chart review source

11.Severe Maternal Morbidity for all deliveries >= 20 weeks gestationCMQCC and CDC – expected January 2016

CDC Measure (2015)

PENDING ICD-10 CODES FROM CMQCC and CDC IN JANUARY 2016

PENDING ICD-10 CODES FROM CMQCC and CDC IN 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.


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