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Carediscovery quality measures –release v

CareDiscovery Quality Measures –Release v9.2
Holly Lockwood, Product Support, BSN, MBA Truven Health Analytics Inc. All Rights Reserved.

 Release date will be Monday June 20, 2016  Aligns with the National Hospital Inpatient Quality Reporting Measures Specifications Manual v5.1 discharges from 07-01-16 (3Q16) through 12-31-16 (4Q16)  Aligns with the specification manual for OP v9.0 For use in submitting data for encounters from 01/01/16 through 06/30/16.
 Specifications Manual for Joint Commission National Quality Measures (v2016A-1) Discharges 07-01-16 (3Q16) through 12-31-16 (4Q16)  CDQM users must review the specifications manuals and IPPS/OPPS Final rules. Slides are current as of June 9, 2016. Truven Health Analytics Inc. All Rights Reserved.

OP measure changes (none) IP measure changes Appendix Changes Truven Health Analytics Inc. All Rights Reserved.

OQR Program Changes
 Not a lot of OP changes for July
 OP-Web – OP-33 measure - External Beam Radiotherapy (EBRT) for
Bone Metastases – abstraction begins with January 1, 2016 discharges. Eight data elements (already available)  Hospitals will self-report OP-33 via the CMS web based tool annually starting in 2017. Truven Health Analytics Inc. All Rights Reserved.

External Beam Radiotherapy for Bone Metastases
OP – 33, Web-Based
 Description: Percentage of patients, regardless of age, with a
diagnosis of painful bone metastases and no history of previous radiation who receive EBRT with an acceptable fractionation scheme.  Numerator Statement: All patients with painful bone metastases,
and no previous radiation to the same anatomic site who receive EBRT with any of the following recommended fractionation schemes: 30Gy/10fxns, 24Gy/6fxns, 20Gy/5fxns, and 8Gy/1fxn. The data for the numerator may be found in the consultation and office visit notes, outpatient treatment center record, and problem/diagnosis list.  Denominator Statement: All patients with painful bone metastases
and no previous radiation to the same anatomic site who receive EBRT. The data for the denominator may be found in the consultation and office visit notes, outpatient treatment center record, and other-treatment summaries. Truven Health Analytics Inc. All Rights Reserved.

External Beam Radiotherapy for Bone Metastases
OP – 33, Web-Based
 Denominator Criteria (Eligible Cases): All patients, regardless of
age & Bone metastases diagnosis (ICD-10-CM): C79.51, C79.52
AND CPT or HCPCS: 77261, 77262, 77263
 Denominator Exclusions:
 Documentation of medical reason(s) including:  Previous radiation treatment to the same anatomic site  Patients with femoral axis cortical involvement greater than 3 cm in  Patients who have undergone a surgical stabilization procedure  Patients with spinal cord compression, cauda equina compression, or Truven Health Analytics Inc. All Rights Reserved.

External Beam Radiotherapy for Bone Metastases
OP – 33, Web-Based
OP EBRT Measure Data
See CMS Fact Sheets for additional guidance
Truven Health Analytics Inc. All Rights Reserved. Truven Health Analytics Inc. All Rights Reserved. Truven Health Analytics Inc. All Rights Reserved. Highlighted Inpatient Changes by Measure Set
 SEP (12 - 48)  Global –ED/IMM (49-50)  VTE (51 – 54)  STK (55 - 70)  SUB/TOB (73 - 84)  PC & HBIPS (85 - 94)  IPF PPS (95 – 98) Truven Health Analytics Inc. All Rights Reserved. Highlighted Inpatient Changes by Measure Set
 Removed AMI, SCIP, CAC, VTE 1,2,3, STK 1,2,3,5,6,8,10, IMM-1 with 1/1/16 discharges. VTE no VTE removed after 4Q15 dc's. Algorithm, MIF, Initial Population, Sampling section changes  VTE-5 & 6 new reference added based on the environmental scan.
 STK 4 updates the selected reference for FDA labeling instructions.
 Change data element name from: Administrative Contraindication to Care to: Administrative Contraindication to Care, Severe Sepsis, Administrative Contraindication to Care, Septic Shock  Added new data elements for Septic Shock: Initial Hypotension & Documentation of Septic Shock Truven Health Analytics Inc. All Rights Reserved. MIF Changes IP
 SEP 1 –many changes due to data elements being removed and
added. Changes to MIF, algorithm, etc.
 TOB-1, 2 & 3 - Denominator exclusion was changed from =< 3 days
length of stay to =< 1 day length of stay to increase the denominator population. The time frame to complete the tobacco use screen was changed based on recommendations from TOB Advisory Panel  Numerator Statement Change to: The number of patients who were
screened for tobacco use status within the first day of admission.
Truven Health Analytics Inc. All Rights Reserved. Release Note supplement v5.1 out 4-14-16 – SEP-1
 Rationale: A supplement to the Release Notes to include verbiage
that was omitted from original Release Notes  Description of Changes: SEP-1 Algorithm:
 Change first Discharge Disposition right branch to "= 1, 2, 3, 4, 5, 6, 7"
and branch continuing down to "= 8."  Change calculation to "Sepsis Discharge Time (in minutes) = Discharge
Date and Discharge Time – Severe Sepsis Presentation Date and Severe Sepsis Presentation Time" and the following decision box to "Sepsis Discharge Time."  Change second Discharge Disposition right branch to "= 1, 2, 3, 4, 5, 6,
7" and branch continuing down to "= 8."  Change calculation to "Shock Discharge Time (in minutes) = Discharge
Date and Discharge Time – Septic Shock Presentation Date and Septic Shock Presentation Time" and the following decision box to "Shock Discharge Time." Specifications Manual for National Hospital Inpatient Quality Measures Discharges 07-01-2016 (3Q16) through 12-31-16 (4Q16) Truven Health Analytics Inc. All Rights Reserved. Administrative Contraindication to Care, Septic Shock
(SEP-1)
Definition: Documentation of refusal of blood draw, fluid
administration, or vasopressor administration prior to or within 6 hours
following presentation of septic shock.
Suggested Data Collection Question: Did the patient or surrogate
decision-maker decline consent for blood draw, fluid administration, or
vasopressor administration prior to or within 6 hours following
presentation of septic shock?
 1 (Yes) There is documentation by a physician/APN/PA that the patient or decision-maker has refused either blood draw, fluid administration, or vasopressor administration prior to or within 6 hours following presentation of septic shock. Truven Health Analytics Inc. All Rights Reserved. Administrative Contraindication to Care, Septic Shock
(SEP-1)
Allowable Values Continued:
 2 (Yes) There is a witnessed consent form for either blood draw, fluid administration, or vasopressor administration that is marked "refused" prior to or within 6 hours following presentation of septic shock.  3 (No) There is no physician/APN/PA documentation or witnessed consent form that the patient or decision-maker has refused either blood draw, fluid administration, or vasopressor administration prior to or within 6 hours following presentation of septic shock. Notes for Abstraction: Only acceptable sources are
physician/APN/PA documentation or a witness- signed consent form
marked "refused."
• Consent forms either signed or unsigned by the patient or decision-maker that are marked "refused" and witnessed by a physician, APN, PA or other hospital personnel, are acceptable. Truven Health Analytics Inc. All Rights Reserved. Administrative Contraindication to Care, Septic Shock
(SEP-1)
Notes for Abstraction: Documentation of refusal of blood draw, fluid
administration, or vasopressor administration that is present prior to or
within 6 hours following presentation of septic shock can be used.
Sources: Consultation reports, H&P, Physician/APN/PA notes &
Witnessed consent forms
Truven Health Analytics Inc. All Rights Reserved. Administrative Contraindication to Care, Severe Sepsis
(SEP 1)
Definition, Question and Allowable Values –Add the language "prior
to or within 6 hours following presentation of severe sepsis?" at the
end.
Truven Health Analytics Inc. All Rights Reserved. Broad Spectrum or Other Antibiotic Administration
Selection (SEP-1)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Broad Spectrum or Other Antibiotic Administration
Time (SEP-1)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Capillary Refill Examination Date & Time (SEP-1)
Definition, Question and Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Capillary Refill Examination Performed (SEP-1)
Question and Notes for Abstraction Changes:
Inclusions: Add Peripheral perfusion
Truven Health Analytics Inc. All Rights Reserved. Cardiopulmonary Evaluation Date, Performed & Time
(SEP-1)
Cardiopulmonary Evaluation Date had Definition, Question and
Notes Changes add word documented:
Cardiopulmonary Evaluation Performed Changes:
Truven Health Analytics Inc. All Rights Reserved. Central Venous Oxygen Measurement, Date & Time
(SEP-1)
Definition, Values and Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Central Venous Oxygen Measurement, Date & TIME
(SEP-1)
Definition, Values and Notes for Abstraction Changes & add VS
flow sheet to sources for CVO Measurement Time
Truven Health Analytics Inc. All Rights Reserved. Crystalloid Fluid Administration (SEP-1)
Definition and Question Changes:
Allowable Value Changes:
Truven Health Analytics Inc. All Rights Reserved. Crystalloid Fluid Administration (SEP-1)
Notes For Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Crystalloid Fluid Administration (SEP-1)
Notes For Abstraction Changes & additional Sources:
Inclusions Add:
Truven Health Analytics Inc. All Rights Reserved. Crystalloid Fluid Administration Date & Time (SEP-1)
Definition and Question Changes
Notes For Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Directive for Comfort Care or Palliative Care, Septic
Shock & Directive for Comfort Care or Palliative Care,
Severe Sepsis (SEP-1)
Definition Change to Add a section- Palliative Care is the
identification, prevention, and treatment of suffering by means of
assessment of the physical, psychosocial, intellectual, and spiritual
needs of the patient with a goal of supporting and optimizing the
patient's quality of life. Palliative care ensures a partnership between
practitioner, patient, and family to provide support in decision making at
any stage in the patient's care.
Allowable Value Changes:
Truven Health Analytics Inc. All Rights Reserved. Directive for Comfort Care or Palliative Care, Septic
Shock (SEP-1)
Notes for Abstraction Changes:
Inclusion Guidelines for Abstraction add new bullet:
 Palliative care Truven Health Analytics Inc. All Rights Reserved. Documentation of Septic Shock (SEP 1)
Definition & Question:
Allowable Values and Notes for Abstraction:
Truven Health Analytics Inc. All Rights Reserved. Initial Hypotension (SEP 1)
Definition & Question:
Truven Health Analytics Inc. All Rights Reserved. Initial Lactate Level Collection, Date (SEP-1)
Inclusion Guidelines for Abstraction Changes (collection and
Date) :
Initial Lactate Level Collection Date/Time Notes changes:
Truven Health Analytics Inc. All Rights Reserved. Initial Lactate Level Collection Result (SEP-1)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Passive Leg Raise Exam Date & Time (SEP-1)
Question Change:
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Passive Leg Raise Exam Date (SEP-1)
Question Change:
Allowable Value Changes:
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Peripheral Pulse Evaluation Date (SEP-1)
Definition and Question changes similar to prior slides:
Notes for Abstraction Changes:
 Change in second bullet: ‘must' to ‘may'  Change in third bullet: ‘done' to ‘documented' Truven Health Analytics Inc. All Rights Reserved. Peripheral Pulse Evaluation Performed (SEP-1)
Question changes similar to prior slides:
Allowable Value Changes:
Notes for Abstraction: inserted word Documented
Truven Health Analytics Inc. All Rights Reserved. Peripheral Pulse Evaluation Time (SEP-1)
Definition and Question changes:
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Truven Health Analytics Inc. All Rights Reserved. Allowable Value Changes (not to value 4):
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Repeat Lactate Level Collection, Date & Time (SEP-1)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Septic Shock Present (SEP-1)
Notes for Abstraction Changes
Inclusions Guidelines for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Septic Shock Presentation Date, Time (SEP-1)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Severe Sepsis Present (SEP-1)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Skin Examination Date, Performed, Time (SEP-1)
Definition and Question had clarifying language added:
Notes for Abstraction Changes (Date& Time):
Inclusions for Abstraction Skin Exam Performed: add Mottled
Truven Health Analytics Inc. All Rights Reserved. Vasopressor Administration, Date, Time (SEP-1)
Allowable Value Changes:
Truven Health Analytics Inc. All Rights Reserved. Vasopressor Administration, Date, Time (SEP-1)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Vital Signs Performed (SEP-1)
 Clarifies the requirements for the vital signs review  Notes for Abstraction Changes to the second bullet:  Vital signs review is done to assess overall status. The review must include temperature, pulse (also referred to as heart rate), respirations, and systolic and diastolic blood pressure reading. Truven Health Analytics Inc. All Rights Reserved. Arrival Date & Time (ED-1, STK-4)
Notes for Abstraction Changes: add sub bullet and changes to 6th
bullet shown at bottom
Truven Health Analytics Inc. All Rights Reserved. Influenza Vaccination Status (IMM-2)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Reason for No Administration of VTE Prophylaxis (VTE-
6)
Definition, Question and Allowable Value add pharmacist:
Exclusion Guidelines for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. VTE Confirmed (VTE-5,6)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. VTE Diagnostic Test (VTE 5,6)
 Inclusion Guidelines for Abstraction: Diagnostic testing includes
the following: THIS LIST IS ALL INCLUSIVE
Truven Health Analytics Inc. All Rights Reserved. VTE Prophylaxis Status (VTE 6)
Notes for Abstraction Changes:
Inclusion Guidelines for Abstraction:
Truven Health Analytics Inc. All Rights Reserved. STK Changes
 Adding STK to the TJC manual –changes throughout  STK 6 had MIF and algorithm changes.  Removal of Aspirin(9) and GCS(4) from VTE Prophylaxis. See notes for changes to these data elements.
 References have been updated to reflect current evidence. (tPA, etc.) Truven Health Analytics Inc. All Rights Reserved. Arrival Date & Time (STK records)
Notes for Abstraction Changes Date:
Notes for Abstraction Changes Time:
Truven Health Analytics Inc. All Rights Reserved. STK Data Element Changes
 Antithrombotic Therapy Administered by End of Hospital Day 2
 Atrial Fibrillation/Flutter- Removed an exception that not longer
 Date Last Known Well – added to code stroke forms to inclusions
and modified exclusions to Stroke Education Form & Core Measure Form  Education Addresses Activation of Emergency Medical System-
Notes changes Educational material must address activation of the emergency medical system (EMS) if signs or symptoms of stroke or transient ischemic attack (TIA) occur.
Truven Health Analytics Inc. All Rights Reserved. Date Last Known Well (STK 4)
Inclusion Guidelines for Abstraction -Add Code STK Form
Truven Health Analytics Inc. All Rights Reserved. STK Data Element –Education (STK 8)
 Education Addresses Follow-up After Discharge- Notes changes
 If it does not include STK follow up = No Educational material must address follow-up after discharge If documentation reflects that educational material regarding follow-up after discharge was given to the patient/caregiver, select "Yes", even if a copy of the material is not present  Education Addresses Medication Prescribed at Discharge -
Abstraction is a two-step process:  1. Compile a list of all of the medications being prescribed at discharge, based on available medical record documentation.
 2. Check list of discharge medications against the written discharge instructions given to ensure that the discharge instructions addressed all of the discharge meds prescribed.
Truven Health Analytics Inc. All Rights Reserved. STK Data Element –Education (STK 8)
 Education Addresses Risk Factors for Stroke- Individual risk
factors that are not mentioned in the context of education provided on the risk factors for stroke, do not count.  Educational material which addresses risk factors for transient ischemic attack (TIA) is acceptable.
 Education Addresses Warning Signs and Symptoms of Stroke-
Educational material must address what to do if warning signs or symptoms of stroke or transient ischemic attack (TIA) are noted.
 If the medical record contains documentation of education that does not include stroke and warning signs and symptoms, select "No Truven Health Analytics Inc. All Rights Reserved. STK Data Element Changes
 Elective Carotid Intervention - When documentation indicates that
the carotid intervention is elective admitting orders to obtain informed consent for a carotid procedure; pre-operative testing completed prior to admission; surgical orders for carotid endarterectomy dated prior to arrival select "Yes."  If sent by the physician or transferred for intervention select yes.
 IV OR IA Thrombolytic (t-PA) Therapy Administered at This
Hospital or Within 24 Hours Prior to Arrival- Notes changed
 If there is documentation that the patient received IV or IA thrombolytic (t- PA) therapy and mechanical thrombectomy at this hospital or within 24 hours prior to arrival, select "Yes."  If there is documentation that the patient received mechanical thrombectomy only with no IV or IA thrombolytic (t-PA) given, select "No." Truven Health Analytics Inc. All Rights Reserved. Elective Carotid Intervention (STK-4)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. STK Data Element Changes
 Last Known Well- Select "Yes" if BOTH a date and time Last Known
Well are documented. Select "No" if there is ANY physician/APN/PA documentation that Last Known Well is "UNKNOWN."  If the Time Last Known Well is clearly greater than 2 hours prior to hospital arrival AND no time is documented, select "No."
 Reason for Extending the Initiation of IV Thrombolytic – added to
notes that If "other" reasons are not mentioned in the context of IV thrombolytics, do not make inferences. Added examples and changes to Exclusion Guidelines.
 Reason for No VTE Prophylaxis – Hospital Admission - Updated
flow of bullets in notes. Added new sub bullet- "No VTE Prophylaxis", "No VTE Prophylaxis needed" [no reason given].
Truven Health Analytics Inc. All Rights Reserved. STK Data Element Changes
 Reason for Not Administering Antithrombotic Therapy by End of
Hospital Day 2 – Definition changed to: Reason for not
administering antithrombotic therapy by end of hospital day 2.
 Other reasons documented by physician/APN/PA or pharmacist.
 Notes Changes: documentation of a hold on antithrombotics or
discontinuation that occurs the day of or day after hospital arrival constitutes a "clearly implied" reason for not administering antithrombotic therapy by end of hospital day 2. A hold/discontinuation of all P.O. medications counts if an antithrombotic was on order at the time of the notation. NPO is NOT a reason for not administering antithrombotic therapy without explicit documentation that no antithrombotic medication should be given.
 Refer to Appendix C, Table 8.2 do not use T 2.6 Truven Health Analytics Inc. All Rights Reserved. Reason for Extending the Initiation of IV Thrombolytic
(STK-4)
Notes for Abstraction Changes: Added Examples
Exclusion Guidelines for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Reason for Not Initiating IV Thrombolytic (STK-4)
Definition & Notes Changes to add language:
Notes for Abstraction Changes: "other" reasons are not mentioned
in the context of IV thrombolytics, do not make inferences below are
unacceptable ex. to select no:
Exclusion Guidelines for Abstraction add: Delay in hospital arrival
greater than 2 hours
Truven Health Analytics Inc. All Rights Reserved. Reason for Not Prescribing
Antithrombotic/Anticoagulation Therapy at Discharge
(STK 2 & 3)
 Reason for Not Prescribing Antithrombotic/Anticoagulation
Therapy at Discharge –Definition Remove: Hemorrhagic stroke
 Notes for Abstraction -Reasons for not prescribing antithrombotic therapy at hospital discharge must be documented with one exception: Patient/family refusal of any form of antithrombotic therapy (e.g., "ASA refused," "Patient refusing antithrombotic therapy") may be documented by a nurse.
 Inclusion Guidelines: None Refer to Appendix C, Table 8.2  Exclusion Guidelines: Antithrombotic medication allergy described Truven Health Analytics Inc. All Rights Reserved. Reason for Oral Factor Xa Inhibitor (STK 1)
 Change is to accept pharmacist documentation for the reason for Oral Factor Xa Inhibitor.
 Question Change:  Notes for Abstraction Change: The only acceptable reasons are
identified in the list of inclusions. No other reasons will be accepted  Suggested Data Sources Change "PA" to "PA or PHARMACIST"
Truven Health Analytics Inc. All Rights Reserved. Time Last Known Well (STK-4)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Time Last Known Well (STK-4)
Notes for Abstraction Changes:
Exclusions:
Truven Health Analytics Inc. All Rights Reserved. Appendix A Changes
 Appendix A & C table changes due to measure sets being removed  Appendix A & C tables designated as "Reserved for Future Use" and "Retired" are being removed to simplify the index.
 Table 8.3: Carotid Intervention Procedures adds ICD-10-PCS codes equivalent to ICD-9-CM procedure code 39.22 aortic-subclavian-carotid-bypass. Add several  Table 12.9: Influenza will remove the use of ICD-10 codes that are non-specific to influenza vaccination.
 Table 13.1: Alcohol Dependence remove several codes as they do not reflect a current alcohol use or substance use disorder.
 Table 13.2: Drug Dependence remove F1921 Other psychoactive substance dependence, in remission Truven Health Analytics Inc. All Rights Reserved. Appendix C Medication Table Changes
 Table 5.0 - Antibiotic Monotherapy, Sepsis revised to  remove Amoxicillin/clavulanate and Augmentin as it is only available orally and the measure requires IV antibiotics.  remove Tequin and gatifloxacin since IV formulations have been removed from the market due to safety reasons.
 Table 5.1 - Antibiotic Generic/Trade Name Crosswalk, Sepsis revised to add Cefotan and Cefotetan at the request of the measure steward.  Table 9.1: FDA-Approved Tobacco Cessation Medications inadvertently left off the table have been added.  Nicorette lozenge  Wellbutrin  Appendix H Updates Also- Table 2.1, T 2.3 & T 2.7 Truven Health Analytics Inc. All Rights Reserved. Alcohol Use Status (all SUB)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Alcohol Use Status (all SUB)
Notes for Abstraction Changes Continued:
Truven Health Analytics Inc. All Rights Reserved. Brief Intervention (SUB-2)
Truven Health Analytics Inc. All Rights Reserved. Brief Intervention (SUB-2)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Tobacco Use Status (all TOB)
Allowable Value Changes:
Truven Health Analytics Inc. All Rights Reserved. Tobacco Use Status (all TOB)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Tobacco Use Status (all TOB)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Prescription for Tobacco Cessation Medication (TOB-3
& 4)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Reason for No Tobacco Cessation Medication at
Discharge (TOB-3) & During the Hospital Stay (TOB-2)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Referral for Outpatient Tobacco Cessation Counseling
(TOB 3 & 4)
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. Tobacco Use Treatment FDA-Approved Cessation
Medication (TOB-2)
Question & allowable values removed: "within the first three days
after admission"
Notes for Abstraction Changes:
Exclusion Guidelines: None
Truven Health Analytics Inc. All Rights Reserved. Tobacco Use Treatment Practical Counseling (TOB-2)
Question & Allowable Values removed: "within the first three days
after admission"
Notes for Abstraction Changes:
Truven Health Analytics Inc. All Rights Reserved. PC and HBIPS Changes
Truven Health Analytics Inc. All Rights Reserved. Truven Health Analytics Inc. All Rights Reserved.  Hospital-Based Inpatient Psychiatric Services (HBIPS) - retired HBIPS-4, HBIPS-6 and HBIPS-7  Removed the word "Core" from the title of manual and other manual sections as appropriate  Perinatal Care (PC) - removed clinical trial from all measures, and risk adjustment from PC-02  The PDF updated Feb. 2016: A typographical error for Gestational Age in the PC-03 algorithm picture has been corrected. The weeks value was revised from ">=24 and <32" to ">=24 and <34".
Truven Health Analytics Inc. All Rights Reserved.  Advanced Certification Heart Failure (ACHF) and Advanced Certification Heart Failure Outpatient (ACHFOP) measure sets are added to the TJC Manual.
 Stroke (STK) measure set is added to the TJC Manual-see prior  Sampling Sections: Remove all references to SCIP, AMI, and CAC measure sets, and HBIPS-4, HBIPS-6 and HBIPS-7 measures. Include STK in the examples in the content as one of the measure sets presented in the manual.  The name of the manual changed from "Specifications Manual for Joint Commission National Quality Core Measures" to "Specifications Manual for Joint Commission National Quality Measures." Truven Health Analytics Inc. All Rights Reserved. PC Changes
 Clinical trial was removed to align with the eCQM version- algorithm & other changes throughout.
Truven Health Analytics Inc. All Rights Reserved. PC Data Element Changes
 Admission to NICU- Clarification was added to address admissions
for observation.
 Exclusive Breast Milk Feeding- Clarification added to help identify
actual feedings the newborn received in order to determine exclusive breast milk feeding. If the newborn received IV fluids this is the same as a medication and not a feeding. Sources changed.
 Labor -Clarification was added for acceptable documentation for
labor. Notes changed to indicate documentation of labor should be abstracted at face value. Clarified documentation of regular contractions with or without cervical change.  Excluded- Prodromal is not an acceptable descriptor for labor Truven Health Analytics Inc. All Rights Reserved. PC Data Element Changes
 Number of Previous Live Births -Clarification was added for using
parity from the EHR and use of GTPALGTPAL documentation alone does not indicate previous live births. Parity may be used for the number of previous deliveries resulting in a live birth if zero is documented. If parity in the EHR is "one" and includes delivery for the current hospitalization, abstract zero.
 Term Newborn - notes added to determine if the newborn was term.
Gestational age should be rounded off to the nearest completed week, not the following week.  an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.  In cases when there is conflicting documentation, e.g., both term and a gestational age of 36 weeks are documented, the gestational age takes precedence.
Truven Health Analytics Inc. All Rights Reserved. Patient Status at Discharge (HBIPS 5)
Definition: Documentation in the medical record of the patient's status
at the time the patient left the hospital-based inpatient psychiatric care
setting
Question: What was the patient's status at the time the patient left the
hospital-based inpatient psychiatric care setting?
Allowable Values:
Truven Health Analytics Inc. All Rights Reserved. Patient Status at Discharge (HBIPS 5)
Notes for Abstraction, sources:
Truven Health Analytics Inc. All Rights Reserved. HBIPS Data Element Changes
 Appropriate Justification for Multiple Antipsychotic Medications-
Revisions were made to reflect the retirement of HBIPS-6 and HBIPS-7.
 Number of Antipsychotic Medications Prescribed at Discharge –
Remove continuing care plan from sources  NEW: Patient Status at Discharge -added due to the retirement of
HBIPS-4, 6 and 7 and the removal of the data element Patient Referral to Next Level of Care Provider in order to exclude patients who were discharged from the psychiatric care setting Truven Health Analytics Inc. All Rights Reserved. Appendix A - ICD-10 & C (meds) Code Tables JC
Manual
 Addition of STK measure set and tables to TJC Manual.
 ICD-10-CM diagnosis codes were removed from Table 11.10.1 and Table 11.10.2, since these codes are not specifically used to include or exclude cases from PC-04.
 Appendix C – Medication Tables  Table 10.0 was updated to include new antipsychotic medications.
 Appendix D- Glossary updates since measures sets removed from CMS' Hospital Inpatient Quality Reporting program and The Joint Commission's Flexible ORYX® performance reporting requirements beginning with 1/1/2016 discharges.
Truven Health Analytics Inc. All Rights Reserved. Truven Health Analytics Inc. All Rights Reserved. Truven Health Analytics Inc. All Rights Reserved.  For facilities participating in the IPF-PPS program, note that 4Q 2015 IPF-PPS data (HBIPS/SUB/TOB) will be entered into QualityNet in July of 2016 tentatively, as this data is submitted annually and not quarterly.  CMS removed HBIPS 6 and HBIPS 7 & then adopted the two new transition measures. (next slides) Truven Health Analytics Inc. All Rights Reserved. IPFQR Transition Measures & Changes
 Transition Record measures & Metabolic Screening measure: Inpatient Psychiatric Facilities (IPFs) were originally required to begin collecting these measures starting July 1, 2016.
The revised date for the beginning of measure collection is now January 1, 2017 and will apply to the Fiscal Year (FY) 2019 payment determination. IPFs will be required to report all four quarters of data or face a payment reduction. Reporting periods for all other measures remain unchanged.
 There will be data elements: View the Inpatient Psychiatric Facilities Program Manual for details.
 Effective January 1, 2016, HBIPS-4, HBIPS-6 and HBIPS-7 were no longer required by CMS or TJC. Truven Health Analytics Inc. All Rights Reserved. IPFQR Transition Measures
The Inpatient Psychiatric Facility Prospective Payment System (IPF-PPS) will be requiring three new chart abstracted measures to meet the CMS reporting requirements for the IPFQR Program.
These measures are:  Transition Record with Specified Data Elements - the percentage of patients discharged from an IP facility, or caregivers, who received a transition record with specified elements at the time of discharge  Timely Transmission of Transition Record - -the percentage of patients discharged from an inpatient facility for whom a transition record was transmitted to the health care setting designated for follow-up care within 24 hours of discharge.  Screening for Metabolic Disorders –awaiting further details from CMS Truven Health Analytics Inc. All Rights Reserved. Truven Health Analytics Inc. All Rights Reserved. Truven Health Analytics Inc. All Rights Reserved. New Functionality and Enhancements
 Sepsis Sub-Measures – updated the Truven Sepsis sub-measures
to the new specifications for July discharges  Errors and Warnings – additional errors and warnings added to
Sepsis cases per CMS requirements  National Provider ID – NPI now required to be numeric only, error
will indicate if it has alpha characters as CMS now rejects cases with a non-numeric NPI  Expedite data loader – for clients using the Expedite module
improvements have been made to the tool that loads the HL7 data, due to this change only data from March 21, 2016 and forward will be available.
Truven Health Analytics Inc. All Rights Reserved.  Log on to Product Support Web Site ill direct you to the CareDiscovery Quality Measures Customer Portal.
 Please see our Advantage Community for bulletins or notices at Advantage Community -  For complete regulatory requirements, always refer to the appropriate specifications manuals according to discharge dates published by CMS and TJC. It is your facility's responsibility to comply with core measures requirements as regulated by CMS and TJC. The specifications manuals are available via the resource tab of the CareDiscovery Quality Measures application under Resources.
Also you may reveal the manual by clicking on the abstraction question within the CDQM application.
Analytics recommends that you examine the specifications manuals carefully when revised versions are published and determine how the changes may affect your facility.
Truven Health Analytics Inc. All Rights Reserved. Truven Health Analytics Inc. All Rights Reserved.

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