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-CMDC
2-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 forInduction of Labor, 2)updatednational measure specificationsfor two maternal blood transfusion-related measures, 3) Pending national finalization of ICD-10 code specifications for Primary TSV C-section(AHRQ), Unexpected Newborn Complications (CMQCC), Pre-eclampsia with Severe Maternal Morbidity (CMQCC), Severe Maternal Morbidity per All Deliveries >= 20 wks (a New Roadmap Outcome measure based on CMQCC and CDC measure)
Induction of Labor Measures
New Required Supplemental Data Field “Induced” (Yes / No).The addition of a clinical “Induced” data element will enable continued calculation of the two outcome measures for CS Rates forTerm Inductions of Labor in Multiparous and Nulliparous Women >= 39 Week.
Transfusion Measures
Two of the Optional Safe Deliveries Roadmap Transfusion measures have been aligned with national measures from CMS and Joint Commission. Changes have occurred nationally to the blood product types captured for these measures. Washington State Safe Deliveries Roadmap is making changes to these two measures to align with the national measures.
1.CMS OB Adverse Event Measure (original measure defined by CMS in 2014): Total number of blood products transfused per 1,000 delivering mothers >= 20 wks. This measure has been changed to focus on RBC and FFP units only (platelets and cryoprecipitate packs will no longer counted because of variations in these unit volumes)
2.Joint Commission Maternal Sentinel Event-Massive Blood Transfusion >= 4 units (deliveries >= 20 wks): This measure is now focused on RBCs only (FFP, platelets and cryoprecipitate packs will Not be included per this Joint Commission Maternal Sentinel Event definition)
Draft measure specifications provided in this document for two measures (finalized versions expected January 2016)
- Primary TSV Cesarean Delivery (#2) (AHRQ)
- Unexpected Newborn Complications (#8) (CMQCC)
- 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 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 dataavailable / PatientDischarge Data
Plus
Gestational Age at Delivery,
And Parity
From either:
Core Clinical Maternal data
OR
Birth 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 cesarean
10D00Z1 Low cervical cesarean
10D00Z2 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 weeks
NOTE: SEE JOINT COMMISSION CODE TABLE APPENDICES FOR COMPLETE LIST OF CODES
When birth certificate data available add to exclusions “Planned Birth Place, if different” = Home or Freestanding Birth Center (item 4b on Birth Certificate) and “mother was transferred to hospital for higher level of care for maternal or fetal indications for delivery” (item 45 on Birth Certificate)
2.
Primary Term Singleton Vertex (TSV) Cesarean Section Rate / All cesarean deliveries among the denominator / Delivering women 37 weeks who have not had a prior cesarean section.
Exclude: breech or transverse presentation, preterm births, fetal deaths, and multiple gestations / Safe Deliveries Roadmap Measure / Patient Discharge Data
Plus
Gestational age at Delivery
From either:
Core Clinical Maternal data
OR
Birth Certificate data.
When birth certificate data available add to exclusions: Previous 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 by
DRG codes:
370 Cesarean w cc,
371 Cesarean c/o cc
OR
MS-DRG codes:
765 Cesarean w cc/mcc
766 Cesarean w/o cc/mcc
OR
ICD-10 Cesarean Delivery Procedure Codes:
10D00Z0 Classical cesarean
10D00Z1 Low cervical cesarean
10D00Z2 Extraperitoneal cesarean / Include: 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&C
OR
MS-DRG codes: 765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc, 767 Vaginal del w sterilization &/or D&C, 768 Vaginal del w OR proc except steril &/or D&C, 774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
ICD-10 codes from Joint Commission Appendix A: Table 11.01.1
Exclude cases with:
-Gestational Age < 37 weeks at delivery
-Any listed ICD-10-CM diagnosis code for contraindication to vaginal delivery: abnormal presentation, breech, preterm, fetal death, or multiple gestation (see Appendix for detail on ICD-10 codes)
- Any listed ICD-10-CM diagnosis code for Previous Cesarean delivery (034.21 Maternal care for scar from previous cesarean delivery)
When WA birth certificate data available add to exclusions: History of previous cesarean delivery (field #57.7 on Birth Certificate)
SEE “TWO APPENDIX DOCUMENTS FOR PRIMARY TERM SINGLETON VERTEX CESAREAN RATE” FOR COMPLETE LIST OF CODES
FINALIZED APPENDICESPENDING CLARIFICATIONS FROM AHRQ IN 2016
3a.
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 gestation / Safe Deliveries Roadmap / Patient Discharge Data
Plus
Gestational Age at delivery
and
Parity
From either:
Core Clinical Maternal data:
OR
Birth Certificate data
And
Induction of Labor (Y/N) from either Supplemental Maternal Data, internal data or chart review data / Discharges among the denominator with either:
DRG, MS-DRG, or
ICD-10-CM procedure codes for Cesarean delivery
DRG codes:
370 Cesarean w cc
371 Cesarean c/o cc
OR
MS-DRG codes:
765 Cesarean w cc/mcc
766 Cesarean w/o cc/mcc
OR
ICD-10 Cesarean Delivery Procedure Codes:
10D00Z0 Classical cesarean
10D00Z1 Low cervical cesarean
10D00Z2 Extraperitoneal cesarean / Include all delivering women identified by DRG, MS-DRG or ICD-10 codes below with
Parity = 0
Gestational Age >= 39 weeks at delivery
Induction of Labor (based on supplemental Maternal Data from internal electronic or manual data) until ICD 10 code for Induction of Labor added nationally sometime later in 2016
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc, 372 Vaginal del w cc, 373 Vaginal del w/o cc, 374 Vaginal del w sterilization &/or D&C, 375 Vaginal del w OR proc except steril &/or D&C
OR
Delivery MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc,
767 Vaginal del w sterilization &/or D&C
768 Vaginal del w OR proc except steril &/or D&C
774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
ICD-10-CM Codes: See Joint Commission Appendix A: Table 11.01.1
3b.
C-Section rate for Term Inductions of Labor in Multiparous women >= 39 weeks gestation at delivery / All cesarean deliveries among the denominator / Multiparous women whose labor was induced with delivery >= 39 weeks gestation / Safe Deliveries Roadmap / Patient Discharge Data
Plus
Gestational Age at delivery
and
Parity
From either:
Core Clinical Maternal data
OR
Birth Certificate data
And
Induction of Labor (Y/N) from either Supplemental Maternal Data, internal data or chart review data / Discharges among the denominator with either:
DRG or MS-DRG codes for Cesarean delivery; or
Any listed ICD-10-CM procedure codes for Cesarean delivery
Cesarean Delivery DRG codes:
370 Cesarean w cc
371 Cesarean c/o cc
OR
Cesarean Delivery MS-DRG codes:
765 Cesarean w cc/mcc
766 Cesarean w/o cc/mcc
OR
ICD-10 Cesarean Delivery Procedure Codes:
10D00Z0 Classical cesarean
10D00Z1 Low cervical cesarean
10D00Z2 Extraperitoneal cesarean / Include all delivering women identified by DRG, MS-DRG or ICD-10 codes below with
Parity >=1
Gestational Age >= 39 weeks at delivery
Induction of Labor (based on supplemental Maternal Data from internal electronic or manual data) until ICD 10 code for Induction of Labor added nationally sometime later in 2016
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc, 372 Vaginal del w cc, 373 Vaginal del w/o cc, 374 Vaginal del w sterilization &/or D&C, 375 Vaginal del w OR proc except steril &/or D&C
OR
Delivery MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc,
767 Vaginal del w sterilization &/or D&C
768 Vaginal del w OR proc except steril &/or D&C
774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
ICD-10-CM Codes: See Joint Commission Appendix A:Table 11.01.1
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 Data
including
Billing Revenue Code data (for ICU stay)
Plus
Gestational age at delivery
From either:
Core Clinical Maternal Data
OR
Birth certificate data / Discharges among the denominator who had an ICU admission during their stay as identified by either:
Any Revenue Charge code in Accommodations 0200 series (ICU) from PDD
OR IF REVENUE CODES NEED SUPPORT FROM SUPPLEMENTAL DATA:
ICU_days > 0
For WSHA-CMDC system: data in Maternal Supplemental Clinical Data
OR
For WSHA-QBS system: data from other internal hospital data source / Include all delivering women identified by DRG, MS-DRG, or ICD-10 codes below with
Gestational Age >= 20 weeks at delivery
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc, 372 Vaginal del w cc, 373 Vaginal del w/o cc, 374 Vaginal del w sterilization &/or D&C, 375 Vaginal del w OR proc except steril &/or D&C
OR
MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc,
767 Vaginal del w sterilization &/or D&C,
768 Vaginal del w OR proc except steril &/or D&C,
774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
Delivery ICD-10-CM codes:
Joint Commission Appendix A: Table 11.01.1
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 / 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
OR
Birth Certificate Data / Among the denominator
number of maternal ICU days as identified by either:
Number of unit charge codes associated with Revenue code in Accommodations 0200 series (ICU) from PDD
OR
Number of ICU days from Maternal Supplemental Clinical Data
OR
OPTIONAL chart review via:
WSHA-CMDC: secure chart review web interface
OR
WSHA-QBS: other hospital chart review source
Calculated per 100 Discharges among the denominator / Include all delivering women identified by DRG, MS-DRG or ICD-10 codes below with
Gestational Age >= 20 weeks at delivery
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc,372 Vaginal del w cc, 373 Vaginal del w/o cc, 374 Vaginal del w sterilization &/or D&C, 375 Vaginal del w OR proc except steril &/or D&C
OR
MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc,
767 Vaginal del w sterilization &/or D&C,
768 Vaginal del w OR proc except steril &/or D&C,
774 Vaginal del w cc, 775 Vaginal del w/o cc
OR
Delivery ICD-10 codes: Joint Commission Appendix A: Table 11.01.1
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, Cryoprecipitate) identified by ICD-10-CM procedure codes from among the denominator / Women who delivered at >= 20 weeks gestational age / WSHA 2014 Partnership for Patients / Patient Discharge Data
Plus
Gestational age at delivery
From either:
Core Clinical Maternal Data
OR
Birth 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, 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 Approach
30263P1 / 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
/ Include all delivering women identified by ICD-10 codes, DRG, or MS-DRG codes below with
Gestational Age >= 20 weeks at delivery
Delivery ICD-10 codes:
Joint Commission Appendix A: Table 11.01.1
OR
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o c,372 Vaginal del w cc, 373 Vaginal del w/o cc, 374 Vaginal del w sterilization &/or D&C, 375 Vaginal del w OR proc except steril &/or D&C
OR
MS-DRG codes:
765 Cesarean w cc/mcc, 766 Cesarean w/o cc/mcc
767 Vaginal del w sterilization &/or D&C,
768 Vaginal del w OR proc except steril &/or D&C,
774 Vaginal del w cc, 775 Vaginal del w/o cc
5b.
Total number of blood products transfused per 1,000 delivering women >= 20 weeks gestation
OPTIONAL / Number of blood product units transfused from among the denominator / Women who delivered at any gestational age >= 20 wks, calculated per 1000 delivering women / Safe Deliveries Roadmap / Patient Discharge Admin Data Plus
Gestational age at delivery
From either:
Core Clinical Maternal Data
OR
Birth Certificate Data
Plus
If Revenue codes in PDD need supplemental backup: transfusions
with validation from hospital lab, blood bank, transfusion log book
OR
optional chart review for blood transfusion data via WSHA-CMDC System Interface or WSHA-QBS: internal hospital chart review / Among the denominator
number of blood products transfused by each type and total: RBCs and FFP
Identified by either:
Revenue code 0380 series for transfusion blood units/types and associated Service Unit –counts
OR
HCPC charge code for type and associated Service Units counts
OR
From Maternal Supplemental Clinical File: number of units transfused for RBCs, FFP, Platelets and Cryoprecipitate
OR
OPTIONAL chart review via:
WSHA-CMDC: secure chart review web interface
OR
WSHA-QBS: other hospital chart review source
Calculated per 1000 cases in the denominator / Include all delivering women identified by DRG, MS-DRG codes, or ICD-10-CM codes below with
Gestational Age >= 20 weeks at delivery
DRG Codes:
370 Cesarean w cc, 371 Cesarean w/o cc, 372 Vaginal del w cc, 373 Vaginal del w/o cc, 374 Vaginal del w sterilization &/or D&C, 375 Vaginal del w OR proc except steril &/or D&C