Specification Manual Changes Version 2.4

1
Specification Manual Changes Version 2.4

• April 1, 2008 through September 30, 2008
  Discharges

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-08-02 SpecManCgs_PPT-jan
2

• The information included in this Power Point
  presentation reflects my reading and best
  professional interpretation of the Specifications
  Manual Release Notes Version 2.4, applicable to
  April 1, 2008 through September 30, 2008
  discharges.
• Please be aware that this may not necessarily be
  the same as CDACs interpretation. The only way
  to definitively assure correct abstraction of
  specific elements is to review QUEST responses or
  to post the question to Quest.
• Go to www.qualitynet.org and select Quest under
  Frequently Asked Questions in the lower left
  corner.
• If you post a new question you will receive an
  answer via email that you should retain should a
  conflict occur.

3
ALL Measures

• ICD population now referred to as the
• Initial Patient Population
• LOS gt 120 days will now be excluded from all
  measures
• Appendix H Table 2.6 (Positive Qualifiers) is
  removed
• If its not on the Negative Qualifiers Table
  consider it positive.

4
Admission Date

• Replace the Suggested Data Sources with the
  following Priority Order
• 
  
  1. Physician Orders
  
  
  
  2. Face Sheet
  
  
  
  
  
  3. UB-04 Field Location12.

5
Admission Date

• Observation Patients
• Abstract the date that the determination was
  made to admit to acute inpatient care and the
  order was written. Do not abstract the date the
  patient was admitted to observation.
  
  
  
  
• Surgical Patients
  
  
  If the admission order states the date the
  admission orders were written are effective for
  the surgery/procedure date, then the date of the
  surgery/procedure would be the admission date. If
  the medical record reflects that the admission
  order was written prior to the actual date the
  patient was admitted and there is no reference to
  the date of the surgery/procedure, then the date
  the order was written would be the admission
  date.

6
Comfort Measures Only

• To more clearly identify which patients belong in
  the admission measure sets for AMI, HF and PN and
  those who should remain in the discharge measure
  sets.
• Change values from Yes/No to Numeric 1 through 4
  

7
Comfort Measures Only

• 1 Day 0 or 1 The earliest day the
  physician/APN/PA documented comfort measures only
  was the day of arrival (Day 0) or day after
  arrival (Day 1).
• 2 Day 2 or after The earliest day the
  physician/APN/PA documented comfort measures only
  was two or more days after arrival day (Day 2).
• 3 Timing unclear There is physician/APN/PA
  documentation of comfort measures only during
  this hospital stay, but whether the earliest
  documentation of comfort measures only was on day
  0 or 1 OR after day 1 is unclear.
• 4 Not Documented/UTD There is no
  physician/APN/PA documentation of comfort
  measures only, or unable to determine from
  medical record documentation if there is
  physician/APN/PA documentation of comfort
  measures only during this hospital
• stay.

8
Comfort Measures Only

• Determine the earliest day the physician/APN/PA
  DOCUMENTED comfort measures only. Do not factor
  in when comfort measures only was actually
  instituted.
• E.g., Comfort Measures Only documented in a
  progress note on day 2 which may be linked to day
  0 or 1 (e.g., Discussed comfort care with family
  on arrival) Select 2 Day 2 or after.
• Consider Comfort Measures Only documentation in
  the discharge summary as documentation on the
  last day of the hospitalization, regardless of
  when the summary is dictated.
• CMO documented anywhere in the record on day of
  discharge / death NOW COUNTS. Select value 2.
• 
  
  
  

9
Comfort Measures Only



Add to inclusions Allow
natural death Palliative measures
10
ARB Prescribed at Discharge

• Add Exforge (Valsartan/Amlopidine) to the ARB
  list
• Appendix C Table 1.7

11
Contraindication to ASA at Discharge

• Clarification
• Coumadin on hold at discharge with a plan to
  restart is a contraindication to ASA at
  Discharge. Select Yes.

12
Contraindication to Beta-Blocker on Arrival at
Discharge

• To avoid including Aflutter as a heart block
  contraindication
• Delete Atrioventricular (AV) conduction
  described as 21 or 31 from the HB inclusions
  list .

13
Contraindication to Beta-Blocker to ASA on
Arrival

• Reduce false inclusions into the Beta Blocker
  Aspirin on Arrival measure.
• Pre-op or pre-procedure holds are now accepted as
  a contraindication. Say Yes. (Last revision
  post-op holds were recognized as
  contraindications).

14
Contraindication to Both ACE I and ARB at
Discharge

• "Significant" aortic stenosis is added to the
  inclusion list.

15
(All Contraindication data elements)

• Pharmacists are included in many drug related
  decision making processes and often write notes
  in the record communicating those decisions.
• Wherever it requires Physician/APN/PA
  documentation regarding medications or allergies
  CHANGE this to include pharmacists.

16
Discharge Status

• To remain consistent with the NUBC discharge
  status designations. NUBC delayed these changes
  from 10/1/07 to 4/1/08
• Add Allowable Value 70 Discharged/transferred
  to another Type of Health Care Institution not
  Defined Elsewhere in this Code List (See Code 05)
• Change Allowable Value 05 from
  Discharged/transferred to another Type of Health
  Care Institution not Defined Elsewhere in this
  Code List to Discharged/transferred to a
  Designated Cancer Center or Childrens Hospital
• Add Usage Note to Value 05 Transfers to
  non-designated cancer hospitals should use Code
  02. A list of (National Cancer Institute)
  Designated Cancer Centers can be found at

17
Initial ECG Interpretation

• Entire data element page has been revised "to
  simplify and streamline abstraction guidelines.
• Completely reworded for clarification

18
LVSD

• Establish a priority order
• Priority order
• Impression/Conclusion field on the Final Report
  of the most recent test
• Other fields on the Final Report of the most
  recent test
• Impression/Conclusion field on the Preliminary
  Report of the most recent test
• Other fields on the Preliminary Report of the
  most recent test
• Impression/Conclusion field on the Final Report
  of the second most recent test and so on.
  
  
  
  

19
LVSD

• If no test results are found in the chart look at
  documentation defining the test result (progress
  notes, etc).
• 1. Documentation defining the final results of
  the most recent test.
  
  
  2.
  Documentation defining the preliminary results of
  the most recent test.
  
  3.
  Documentation defining the final results of the
  2nd most recent test.
  
  
  
  4. Documentation defining the preliminary
  results of the 2nd most recent test.....
  
  
  
  

20
LVSD

• If you cannot determine which test is most
  recent (assume a test result is from prior to
  arrival "if timeframe is not specified or
  determinable") use both or all tests.
• Test reports take precedence over notes.
• Final results take precedence over preliminary
  results

21
LVSD

• If the information in your highest priority
  report(s) is/are conflicting
  
  
  1. Use the lowest calculated
  EF.
  
  
  
  
  2. Use the lowest
  estimated EF.
  
  
  
  3. Use
  narrative description from inclusion list A.
  
  
  
  4.
  Use narrative description from inclusion list B.
• OTHER RULES for conflicting info Use the
  impression/conclusion from a report over other
  areas on the report.

22
Pre-arrival Lipid Lowering Agent

• Test measure
• To remove patients on Lipid-lowering agents from
  Test Measure LDL Cholesterol Assessment
• A new data element that will change the
  population in the denominator for measure AMI -
  T1a.

23
Discharge Instructions Address Medications

• Currently When general references to laxatives,
  antacids, vitamins, food supplements, and herbs
  are made, which, by nature, allow the patient to
  choose their product of preference, specific
  names are not required (e.g., laxative of
  choice).
• As of Apr 1, 2008 discharges when general
  references to laxatives, antacids, vitamins, food
  supplements, and herbs are made, they do not have
  to be listed on the discharge instruction sheet
  at all.

24
Antibiotic Administration

• Name
• If an antibiotic is misspelled or abbreviated and
  supporting documentation identifies the
  antibiotic you may abstract that antibiotic name.
• This is a change from previous rulings. Currently
  the name, route, date and time must all be
  identified from the same source.

25
BC Collected After Arrival

• New Guideline
• When a blood culture is drawn but you are unable
  to determine if it was drawn before or after the
  admission order was written select value 2.

26
Chest X-Ray

• Change in allowable values
• Allowable Values
• Value 'Yes' becomes Value 1 - There is
  documentation the patient had a chest x-ray/CT
  scan the day of or the day prior to arrival or
  anytime during this hospital stay that included
  ANY Inclusion terms.
• Value 'No' becomes Values 2, 3 and 4.
  
  
  
• 2 - There is documentation the patient had a
  chest x-ray/CT scan the day of or the day prior
  to arrival or anytime during this hospital stay
  but NO Inclusion terms were found.
• 3 - The patient did not have a chest x-ray/CT
  scan on day of or the day prior to arrival or
  anytime during this hospital stay.
  
  
• 4 - (UTD) Unable to determine from medical record
  documentation if the patient had a chest x-ray/CT
  scan the day of or the day prior to arrival or
  anytime during this hospital stay OR if any
  Inclusion terms were found.

27
Chest X-Ray

• Suggested data sources are put in priority order
  
• 
  
  
  1. Chest x-ray
  report(s)
• 2. Chest CT scan report(s)
• 3. Other x-ray or CT scan with lung field
  findings
• 4. Physicians notes
• 5. History Physical

28
Healthcare Associated PN

• Wound Care within 30 days now includes
• Tracheostomy care
• Ventilator care
• Extended Care Facility now includes Inpatient
  Rehab Unit or Facility.

29
Identified Pneumonia Pathogen

• Name change to Identified Pathogen
• May now use any type of culture result
• Not limited to sputum or blood cultures

30
PN Diagnosis

• When a patient is seen in the ED but there is no
  ED paperwork in the record
• Look at the admission orders and the admission
  notes
• If see HP is found on either look at that as
  well.
• These are the only acceptable sources, it does
  NOT matter if they are timed.
• Select Value 1 if
• A PN diagnosis is found on any of the above
• The admission orders include a PN pathway
• The admission note refers to a PN pathway.

31
PN Diagnosis

• CHANGE to PN diagnosis must be found in one of
  the ONLY ACCEPTABLE SOURCES
• 
  
  1. Admitting notes
  
  
  
  
  2. admitting physician orders
  
  
  
  3. Consult note
  
  
  
  
  4. Physician
  admitting note
  
  
  
  5. May use the HP
  only if it is referred to in any of the above
  ("see HP").
• You no longer need to be concerned that the
  source is timed.

32
Pseudomonas Risk

• The requirement that Bronchiectasis be documented
  on admission to be considered a Pseudomonas Risk
  is relaxed to Bronchiectasis documented as a
  possible consideration (it's no longer limited to
  "on admission").

33
Risk Factors for Drug Resistant Pneumococcus

• Currently there are 6 risk factors for Drug
  Resistant Pneumococcus including
• The patient has an ICU stay any time during the
  hospitalization
• As of April 1, 2008 discharges the patient must
  be in the ICU within 24 hours of admission.

34
PN-3b

• Patients who had a blood culture drawn prior to
  arrival will no longer be included in this
  patient population. They currently automatically
  pass the measure.

35
PN Measures

• Patients discharged on the day of arrival will no
  longer be excluded from the PN-3b, PN-5 and PN-6
  measures.

36
Contraindication to Beta Blocker Peri-Op

• May say Yes if a practitioner OR A PHARMACIST
  documents a pulse lt 50.
• 
  
  
  Previous guidelines set the
  parameter at a pulse lt 60 and limited the
  acceptable sources to MD/APN/PA documentation.
  
  
  
  

37
Contraindication to VTE Prophylaxis

• Change Allowable Values
  
  
  
  
  
  From Yes / No to
• 1 - There is physician/APN/PA or pharmacist
  documentation ofcontraindications to mechanical
  VTE prophylaxis
• 2 - There is physician/APN/PA or pharmacist
  documentation ofcontraindications to
  pharmacological VTE prophylaxis
• 3 - There is physician/APN/PA or pharmacist
  documentation ofcontraindications to both
  mechanical and pharmacological VTE prophylaxis
• 4 - There is no physician/APN/PA or pharmacist
  documentation of contraindications to either
  mechanical or pharmacological VTE

38
Contraindication to VTE Prophylaxis

• May now review the record for Physician/ APN/PA
  OR PHARMACIST documentation of accepted
  contraindications.
• Consider mechanical and pharmacological
  contraindications separately.

39
Contraindication to VTE Prophylaxis

• Add the following inclusions for
  contraindications to MECHANICAL prophylaxis
• Bilateral amputee Patient refusal
  
  
  
  Bilateral lower
  extremity trauma

40
Contraindication to VTE Prophylaxis

• Add the following inclusions for
  contraindications to PHARMACOLOGICAL prophylaxis
  (incorporates data element Bleeding Risk)
  Active bleeding (gastrointestinal bleeding,
  cerebral hemorrhage, retroperitoneal
  bleeding) Bleeding risk GI bleed
  Hemorrhage Patient refusal Risk of bleeding
  Thrombocytopenia
  
  
  
  
  
  
• CAUTION Does not include history (Hx) of bleed)

41
Contraindication to VTE Prophylaxis

• For both mechanical and pharmacological
  prophylaxis exclude ORDERS to hold prophylaxis
  that are not implicitly linked to a reason.

42
Documented Bleeding Risk

• This data element is incorporated into
  Contraindication to VTE Prophylaxis
• Removed from all algorithms

43
Infection Prior to Anesthesia

• To clarify that HPs dated prior to arrival must
  reflect that an infection or a possible/suspected
  infection is current.
• To reduce false exclusions / clarification
• Refer ONLY to the inclusions listed on the data
  element page. DO NOT reference table 5.09 to
  cross reference with diagnosis codes.

44
Infection Prior to Anesthesia

• Changed. Relaxing a documentation requirement.
• Change inclusion "gross/extensive fecal
  contamination" to "fecal contamination".
  
  
  
  Any mention of fecal
  contamination and you may now say Yes - there is
  Physician/APN/PA documentation that the patient
  had an infection during this hospitalization
  prior to the principle procedure.

45
Intra-operative death

• The name of this data element has changed to
• PERI-OPERATIVE DEATH.
• The time period is extended to include surgical
  incision time through discharge from PACU.
  
  
  
  It
  haD previously been limited to time in the OR.

46
Joint Revision

• NEW DATA ELEMENT
• To exclude joint revisions from INF 1, 2 and 3 in
  the arthroplasty strata.
• Values
  
  
  
  Y (Yes) There is documentation that the
  patient had a joint revision.
• N (No) There is no documentation that the patient
  had a joint revision or unable to determine from
  medical record documentation.

47
Joint Revision

• If there is documentation that an antibiotic
  spacer was removed prior to joint replacement,
  select Yes.
• Other inclusions
  
  
  
  Artificial joint
  revision
• Removal of hardware
• Revision surgery
• Total joint revision
• Allowable sources are not limited.

48
Post-operative Infections

• Change inclusion "gross/extensive fecal
  contamination" to "fecal contamination".
  
  
  
  Any mention of fecal
  contamination and you may now say Yes - there is
  Physician/APN/PA documentation that the patient
  had an infection postoperatively following the
  principle procedure.
• Refer ONLY to the inclusions listed on the data
  element page. DO NOT reference table 5.09 to
  cross reference with diagnosis codes.

49
Vancomycin

• To ease abstraction burden
• Remove known colonization with from Value 2
  Physician/APN/PA documentation of known
  colonization with MRSA, so that it states
  "Physician/APN/PA documentation of MRSA".
• Clarification
• Plans to use Vancomycin prophylactically must be
  documented preoperatively by Physician/APN/PA or
  an Infection Control practitioner.
  
  
  You may now also use
  PHARMACIST documentation.

50
VTE Prophylaxis

• May accept mechanical prophylaxis placed on the
  patient any time from hospital arrival through 48
  hours after Surgery End Time.
• Data sources for MECHANICAL prophylaxis are no
  longer limited. Review the entire record for
  documented evidence that mechanical prophylaxis
  was ordered / applied.
• CAUTION Pharmacological prophylaxis is still
  limited to physician orders ONLY.
• Venous foot pumps are now acceptable for
  mechanical prophylaxis.

51
SCIP INF - 1

• The numerator includes only patients whose
  antibiotic is INITIATED within 1 hour prior to
  surgical incision (2 hours for Vancomycin or
  floroquinolones). It does not have to be infused
  within 1 hour prior to incision.

52
SCIP INF - 2

• Metronidazole monotherapy and Clindamycin
  monotherapy are now recommended for use in
  Hysterectomy patients with ß- lactam allergies.
• Previously both Metronidazole and Clindamycin had
  to be used in combination with other drugs.

53
SCIP INF - 3

• It is medically acceptable to continue urinary
  antibiotics for gt 24 hours post operatively.
• Patients whose ONLY post-op antibiotic is one of
  the Urinary Antiseptics listed in Appendix C
  Table 3.11 are excluded from Measure SCIP-INF 3
• If the only post-op antibiotic continued beyond
  24 hours after 'surgery end time' is a urinary
  antiseptic the patient will pass the measure.
• Urinary antiseptic meds are listed in Appendix C
  Table 3.11

54
SCIP VTE - 1 3

• Elective Spinal Surgery has been removed from the
  VTE measure populations.
• It is not medically indicated without additional
  risk factors.
• Venous Foot Pumps (VFP) are added as acceptable
  prophylaxis for
• Knee replacements.
• Hip replacements with documented contraindication
  to pharmacological prophylaxis.

55
Contact

• Beth McConville RN, BSN, CPHQ
• emcconville_at_maqio.sdps.org
• 781-419-2887