Review of Specification Manual Changes in Version 2.3

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Review of Specification Manual Changes in
Version 2.3

• For discharges 10/01/2007 through 3/31/2008

This material was prepared by Masspro, the
Medicare Quality Improvement Organization for
Massachusetts, under contract with the Centers
for Medicare Medicaid Services (CMS), an agency
of the U.S. Department of Health and Human
Services. The contents presented do not
necessarily represent CMS policy.
8sow-ma-hosp-07-94 specman10.1.07_PPT-aug
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Waiver

• The content in the following presentation
  reflects our reading and best professional
  interpretation of the Specifications Manual
  Version 2.3.
• This may not necessarily be the same as CDACs
  interpretation. The only way to assure correct
  abstraction of specific elements is to post the
  question to Quest at www.qualitynet.org. You will
  receive an answer via email that you should
  retain for reference should a conflict occur.

3
Clinical Trial
General

• Collect for ALL measures.
• Definition Documentation that the patient was
  involved in a clinical trial during this hospital
  stay relevant to the measure set for this
  admission.
• Intent is to exclude patients involved in
  relevant trials from the measure sets. Include
• Evaluated for enrollment in a clinical trial
  after hospital arrival but was not accepted or
  refused.
• Newly enrolled in a clinical trial during the
  hospital stay.
• Enrolled prior to arrival and continued during
  hospital stay.
• Requires formal documentation of trial protocol
  or patient consent for participation within the
  medical record.
• Change to ONLY ACCEPTABLE SOURCES
• Clinical trial protocol
• Consent form for trial

4
Comfort Measures Only General

• Remove terminology suggesting the abstractor must
  verify that comfort measures were received.
• Replace the patient was receiving with of
  (i.e. Is there documentation of Comfort Measures
  Only?)
• Disregard
• CMO documentation when written on day of
  discharge except in discharge summary
• CMO referring to care planned for after discharge
• MD/APN/PA Referrals, recommendations and requests
  will suffice
• Recommendations for CMO (or synonyms)
• Order for hospice / palliative care consult
• Pt or family request for CMO (or synonyms)
• New inclusions
• Comfort only
• Hospice

5
Adult Smoking History AMI HF PN

• Sources are now extremely limited
• Review only ED record, HP, nurses admission
  assessment and nurses admission notes.
• Currently smokes (tobacco or unidentified
  product)
• Quit smoking less than one year ago
• If any one of the acceptable sources documents
  smoking within the year select Yes even if
  conflicting with other documentation.
• Disregard smoking history when the time frame is
  not defined then look for other documentation to
  determine your answer. If History of smoking is
  the ONLY documentation select No.

6
Discharge Status AMI HF PN

• CHANGE value 05
• From Discharged/transferred to another type of
  institution not defined elsewhere in this code
  list
• To Discharged/transferred to a designated cancer
  center of a childrens hospital
• ADD value 70
• Discharged/transferred to another type of
  institution not defined elsewhere in this code
  list
• Value 66 Discharge/Transfer to a CAH will now
  remove patients from all AMI, HF and PN measures.

7
Measure AMI T2 AMI HF

• Reduce LDL-c threshold for lipid lower medication
  from 130mg/dl to 100 mg/dl.
• Practitioner documentation of allergy is no
  longer required. Any documented evidence of
  allergy excludes the patient from the measure.

8
All Meds on Discharge AMI HF

• ACE I Prescribed at Discharge
• ARB Prescribed at Discharge
• Aspirin Prescribed at Discharge
• Beta-Blocker Prescribed at Discharge
• Lipid Lowering Agent Prescribed at Discharge
• Discharge Instructions Address Meds

9
All Meds on Discharge AMI HF

• On discharge when a medication start is delayed
  it is NOT considered a discharge med unless
  listed elsewhere as a discharge med. DISREGARD
  documentation that a med start is to be delayed
  and look for additional evidence that the med is
  a discharge med.
• If a med is listed only as a delayed start it
  does not need to be listed on the discharge med
  list.
• But if the delayed med is written on the
  discharge instruction sheet it is okay, it is not
  a mismatch.
• If a med is listed as a discharge med on only one
  of several lists select Yes.
• If a med is listed as a discharge med on one MD
  generated list and specifically discontinued on
  another consider this contradictory and select
  No.

10
Contraindication Elements AMI HF

• Contraindication to Aspirin at Discharge
• Contraindication to Aspirin on Arrival
• Contraindication to Beta-Blocker at Discharge
• Contraindication to Beta-Blocker on Arrival
• Contraindication to Both ACE I and ARB at
  Discharge

Post op or Post procedure order to hold the med
will now count as an other reason for not
prescribing it say Yes to the
contraindication data element.
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Contraindication to Beta-Blocker AMI HF

• Both On Arrival and At Discharge
• Findings of 2nd and 3rd degree heart block no
  longer need to be stated as ECG findings in order
  to count as a contraindication.
• Any documentation of a finding of 2nd or 3rd
  degree heart block without the presence of a
  pacemaker is a Yes to contraindication to
  beta-blocker data elements.
• High grade is added to the inclusion list for
  heart block.

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Contraindication to Both ACE I and ARB at
Discharge AMI HF

• Add to the inclusion list for aortic stenosis
• Moderate subaortic stenosis
• Severe subaortic stenosis
• Subaortic stenosis severity unknown
• It is clinically acceptable to treat subaortic
  stenosis as a contraindication to ACE I or ARB
  therapy.

13
Fibrinolytics and PCI AMI

• Fibrinolytic Administration Date
• Fibrinolytic Administration Time
• First PCI Date
• First PCI Time
• When the date or time is obviously in error and
  no other clarifying documentation exists select
  UTD.

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First PCI Date
AMI

• Reworded to be consistent with the First PCI Time
  data element.
• Change
• From do not include PCIs which were attempted
  but unsuccessful
• To Do not include PCIs which were attempted but
  not completed on at least one vessel. Include
  PCIs that are completed but unsuccessful in
  maintaining the flow of blood through the artery.
  May be described as failed complete.

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First PCI Time
AMI

• Lists of allowable terms have been expanded.
• Include Time of
• First balloon inflation
• First stent deployment
• First treatment of lesion
• Aspiration
• Suction
• Device pass
• Laser treatment
• Use earliest documented time.

16
Initial ECG Interpretation AMI

• Clarification
• If at least one source describes the LBBB as
  old or chronic or previously seen then
  disregard all LBBB findings.
• Change suggested data sources
• Add Physician/APN/PA documentation only
• Delete Ambulance record

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Reason for Delay in Fibrinolytics and PCI AMI

• MD/APN/PA documentation of a Cardiopulmonary
  arrest within 30 minutes of arrival for
  Fibrinolytics or within 90 minutes of arrival for
  PCI is now an acceptable reason for delay without
  language explicitly linking it to the delay.
• Documentation that the arrest occurred within
  30/90 minutes of arrival must be clear.
• Use the earliest arrest start time documented.

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Reason for Delay in Fibrinolytics and PCI AMI

• Inclusions
• Cardiac Arrest
• Cardiopulmonary Resuscitation (CPR)
• Code
• Defibrillation
• Endotracheal Intubation
• Respiratory Arrest
• Ventricular Fib (V-Fib)
• Exclusions
• Shocked
• Cardioversion

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Reason for Delay in Fibrinolytics and PCI AMI

• Pt/Family refusal of PCI/reperfusion/cath/transfer
  to cath lab is now an acceptable reason for
  delay without language explicitly linking it to
  the delay.

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Another Suspected Source of Infection PN

• Both suspected and diagnosed infections are
  acceptable.
• There does NOT need to be documentation linking
  the antibiotic to the infection/suspected
  infection.
• Change definition and allowable values from
  upon admission to within 24 hours.
• Remove nurses notes from the suggested data
  source must be practitioner documentation.
• No longer reference Table 5.09 for Inclusions,
  they are listed in the Data Element Page.

21
Antibiotic Administration Date PN

• Limit the antibiotic collection to just the first
  36 hours after arrival.
• Currently abstractors must abstract the
  antibiotics administered from arrival through 36
  hours and if no antibiotics are given during that
  time the abstractor must abstract the initial
  dose of antibiotic given after 36 hours.
• If all information (name/route/date/time) is not
  contained in one place select UTD.
• Either a signature or initials is required to
  signify the antibiotic was administered.
• The date of administration must be documented on
  each side of every page used as a data source. If
  this is not the case utilize UTD for the missing
  date.

22
Blood Culture Collected After Arrival PN

• Currently answering Yes if a blood culture was
  drawn at any time from arrival through discharge.
• NOW answer Yes for blood culture collected from
  arrival through 36 hours after arrival.
• Antibiotics are only being collected for the
  first 36 hours therefore
• If no blood cultures are collected within 36
  hours after arrival select
• Value 3 - No blood culture performed during this
  hospitalization or unable to determine from
  medical record documentation.

23
CXR
PN

• Remove old from the inclusions.
• If there are multiple interpretations of the
  CXR/CT scan and any contain abnormal findings
  that are not documented as chronic select
  Yes.

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Compromised
PN

• The inclusions have been separated into 2
  sections
• 3 month time frame
• No timeframe
• Add to inclusion list
• Any immunodeficiency syndrome
• Congenital / hereditary immunodeficiency
• Value 1 removed the list of compromising
  conditions and simply states A compromising
  condition (refer to inclusion list).

25
Influenza Vaccine Status PN

• To address concerns with vaccine delivery delays
  allowable value 6 has been changed
• An official memo from CMS allowing the use of
  value 6 is NO LONGER REQUIRED
• Choose value 6 if the vaccine has been ordered
  but has not been received due to
  manufacturing/distribution delays AND values 1
  through 5 are not selected.
• This data will now be collected October through
  MARCH
• If more than one value is true select the lowest
  number.

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Blood Cultures
PN

• Initial Blood Culture Collection Date and Time
• Concerned now only with blood culture collected
  within 36 hours of arrival.
• Disregard blood cultures drawn after the 36-hour
  time frame.
• Collect the time and date if there was an attempt
  to collect.

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Pneumonia Diagnosis ED / Direct Admit

• Add Value 4 UTD
• Value 3 will reflect that the final diagnosis was
  not pneumonia while value 4 reflects that no
  final diagnosis was documented selecting value
  4 will cause the case to fail all admission
  measures.

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Risk Factors for Drug Resistant Pneumococcus

• Change Patients over 65 to Patients 65 and
  over.
• History of Malignancy is not enough, there must
  be documentation the malignancy was present
  within the last three months.
• Any chronic systemic illness is more
  specifically defined as one of the following
  co-morbid conditions
• CHRONIC renal, heart, lung or liver disease or
  diabetes or asplenia or malignancy within the
  last three months.

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PN Antibiotic Recommendations Table

• Several changes please review
• PN-6, PN-6a, PN-6b Measure Information Pages
  (page 6)

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PN 5

• PN 5a is retired
• PN 5c
• Endorsed by NQF
• No longer a test measure
• Not yet required reporting for APU

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PN Diagnosis Codes

• The following have been removed and will no
  longer be part of the pneumonia population
• 482.81 PN due to anaerobes
• 487.0 Influenza with pneumonia

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SCIP All Measures

• Patients participating in clinical trials will be
  excluded from all of the SCIP measures
• The clinical trial must be relevant to the SCIP
  measure set
• The data element Laparoscope has been clarified
• Any procedure performed totally with a
  fiber-optic scope will be excluded
• Procedures labeled as hand-assisted or
  laparoscopically-assisted or performed with a
  hand port are not considered totally
  laparoscopic

33
SCIP Inf 1, 2, and 3 and VTE 1 and 2

• An exception was added for when a cystoscopy is
  performed prior to the Principal Procedure to
  allow the start time of the cystoscopy to be used
  for the Surgical Incision Time

34
SCIP Inf 1, 2, and 3

• Antibiotic administration information is to be
  abstracted from one source, the abstractor can no
  longer use supporting documentation to supply
  the missing information
• A signature or initials are required to abstract
  an antibiotic as administered
• Missing information should be entered as UTD
• For the data element Infection Prior to
  Anesthesia, changes were made to the
  Inclusion/Exclusion table
• The term acute abdomen has been added
• The Operative Report can no longer be used

35
SCIP Inf 1, 2, and 3

• The terms History of MRSA, MRSA colonization,
  and Viral infections have been added as
  exclusions to both infection data elements
  (Infection Prior to Anesthesia and Postoperative
  Infections)
• Postoperative Infections must be documented after
  incision and discharge summaries must be dated
  within 2 days to be used as a source
• The timeframe has been removed from the data
  element Oral Antibiotics and this data element is
  only used to prevent cases that get oral
  antibiotics prior to arrival from being excluded

36
SCIP Inf 1 and 3

• A note was added to the data element Other
  Surgeries to clarify that this data element is
  used to exclude patients that have a procedure
  with an incision and general anesthesia within 3
  days of the principal procedure
• The data element Other Surgeries was revised to
  cover an implanted pacemaker placed within 3 days
  (4 days for a cardiac surgery) of the principal
  procedure

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SCIP Inf 2

• Allowable values were added to the data element
  Vancomycin
• Patients undergoing valve surgery
• Patients transferred from another hospital after
  a 3-day stay
• Ertapenem is now acceptable for colon surgeries
• One dose is recommended
• Colon surgeries that receive oral antibiotics
  only, will no longer pass SCIP-Inf-2

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SCIP Inf 6 and 7

• Examples were added to provide direction for when
  more than one method of hair removal is
  documented in the medical record
• The timeframe for collecting the postoperative
  temperature was changed from one hour to 15
  minutes to more accurately reflect immediate
  postoperative temperature
• When two temperatures are recorded with the same
  time, abstract the higher value

39
SCIP VTE 1 and 2

• The timeframe for VTE Prophylaxis orders was
  changed, only collect prophylaxis ordered from
  hospital arrival to 48 hours after surgery
• The priority list for the data element Discharge
  Time, has been removed, any documentation of DC
  time is acceptable without one source taking
  priority over another
• Documentation of active bleeding is now
  acceptable for the data element Documented
  Bleeding Risk, but a time frame has been added
• arrival to 24 hours after Surgery End Time

40
SCIP VTE 1 and 2

• The data element Neuraxial Anesthesia has been
  clarified, if an epidural catheter is placed
  preoperatively for anesthesia or pain management
  postoperatively, the abstractor should select
  Yes
• A subarachnoid block is an inclusion and
  peripheral blocks are exclusions
• To be excluded with the data element Preadmission
  Warfarin, the patient should be on continuous
  therapy prior to admission
• If the warfarin was placed on hold greater than 7
  days prior to surgery, select No

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SCIP Card 2

• A new data element, Beta-Blocker During
  Pregnancy, has been created to exclude pregnant
  patients from this measure
• Beta-blockers that are listed as home or current
  medications should be abstracted as taken within
  24 hours prior to arrival unless there is
  documentation that they were not being taken
• Vital signs taken while the patient is on
  cardiopulmonary bypass should not be used when
  determining bradycardia (lt50bpm) for the data
  element Contraindication to Beta-Blocker-Periopera
  tive

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Specifications Manual Version 2.3

• www.qualitynet.org
• Got to Hospital tab
• Select Specifications Manual
• Select appropriate version
• http//www.qualitynet.org/dcs/ContentServer?cid11
  76726358615pagenameQnetPublic2FPage2FQnetTier3
  cPage

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Masspro Contacts

• Ed Donahue
• 781-419-2799
• Edonahue_at_maqio.sdps.org
• Beth McConville
• 781-419-2887
• Emcconville_at_maqio.sdps.org