The Joint Commission

Section 3: Measure Exclusions (HAP/CAH)

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Last updated: Mar 04, 2024 by Patty Craig
Joint Commission Guide for Data Entry of Chart-Abstracted Measures for Hospitals (HAP/CAH)
- Version 2023: Discharges 01-01-23 (1Q2023) through 12-31-23 (4Q2023)
- Version 2024: Discharges 01-01-24 (1Q2024) through 12-31-24 (4Q2024); March 2024

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Introduction

This section of the manual describes the denominator exclusion questions asked by the Direct Data Submission Platform (DDSP) for each chart-abstracted measure used for accreditation purposes. These questions capture the counts of the number of cases excluded from the measure population by receiving a measure category assignment of ‘B’ (Not in Measure Population) when processed through the measure algorithm. The information in this section is intended to assist hospitals in their preparation for data entry of their aggregate data into the DDSP.

These exclusion counts will be used by the DDSP to verify all cases are accounted for based upon the Initial Patient Population and Sample Size that are entered. Cases which are not accounted for by the entered data will be assumed to have received a measure category assignment of ‘X’ (Data Are Missing) or ‘Y’ for a continuous variable or ratio measure (UTD Allowable Value Does Not Allow Calculation of the Measure) and will be counted as such by the DDSP.

Measure Algorithm Logic

Unlike eCQMs, chart-abstracted measure algorithms process patient data in a top-down manner. This means that once a case is processed to a measure category assignment (i.e., ‘B’, ‘D’, ‘E’, ‘Y’, or ‘X’), the case stops being executed against the algorithm.

The Joint Commission acknowledges that a case may be applicable to multiple measure exclusions and that hospitals performing analysis would typically evaluate all the reason(s) a case was excluded. However, for DDSP purposes, each excluded case is to be only counted in the Measure Exclusion question which assigns the measure category assignment of ‘B’.

The cases in the Table below depict the data element and allowable value that causes it to be excluded from the algorithm and the associated Measure Exclusion to include the case in.

Note:  Compare the below measure algorithm for PC-05 to this table when reviewing. The case for this example had a Length of Stay <= 120 days, no ICD-10-CM Other Diagnosis Code on Table 11.21, and no ICD-10-PCS Principal or Other Procedure Code on table 11.22, which means the case was not excluded in the algorithm above the below questions.

Case #

Discharge Disposition

Term Newborn

Admission to NICU

Counted in Measure Exclusion

1

1

1

N

Not counted as a measure exclusion, case will not be assigned a measure category assignment of ‘B’

2

3

1

Y (Documentation that newborn was admitted to NICU)

Number of cases excluded for being admitted to the NICU?

3

2

2 (Documentation that newborn was not term or >= 37 weeks)

Y

Number of cases excluded for not being at term; or with a Gestational Age < 37 weeks or =UTD?

4

4 (Acute Care Facility)

2

N

Number of cases excluded for being transferred to another hospital?

5

6 (Expired)

2

Y

Number of cases excluded for expiring within the hospital?

The below measure algorithm is an example of how Measure Exclusions questions are determined:

 

Measure Exclusions

Below are the measure exclusions questions for each chart-abstracted measure. Help Text is provided to assist in determining exactly what to count for each exclusion question. The questions and help text have been derived from the appropriate version of the Measure Information Forms. In some cases, a measure contains exclusion questions that are only applicable for a portion of the year (e.g., IMM-2).

ED-1: Median Time from ED Arrival to ED Departure for Admitted ED Patients

Note:  ED-1 Measure Exclusions are entered based on the Overall Measure. They are not entered for each stratum.

How many patients were excluded for

Help Text

Number of cases excluded for not being seen in the ED or unable to determine?

There is no documentation the patient received care in a dedicated emergency department of the facility, OR unable to determine from medical record documentation.

 

ED-2: Admit Decision Time to ED Departure Time for Admitted Patients

Note:  ED-2 Measure Exclusions are entered based on the Overall Measure. They are not entered for each stratum.

How many patients were excluded for

Help Text

Number of cases excluded for not being seen in the ED or unable to determine?

There is no documentation the patient received care in a dedicated emergency department of the facility, OR unable to determine from medical record documentation.

HBIPS-2: Hours of physical restraint use

HBIPS-2: Hours of physical restraint use

No exclusion questions

HBIPS-3: Hours of seclusion use

HBIPS-3: Hours of seclusion use

No exclusion questions

 

HBIPS-5: Patients discharged on multiple antipsychotic medications with appropriate justification

Note:  HBIPS-5 Measure Exclusions are entered based on the Overall Measure. They are not entered for each stratum.

Retired as of 12/31/2023 Discharges

HBIPS-5: Patients discharged on multiple antipsychotic medications with appropriate justification

Note:  HBIPS-5 Measure Exclusions are entered based on the Overall Measure. They are not entered for each stratum.

Retired as of 12/31/2023 Discharges

How many patients were excluded for

Help Text

Number of cases excluded due to a Length of Stay <= 3 days?

Length of Stay (in days) = Discharge Date minus (-) Admission Date

Number of cases excluded because they expired during hospital stay?

The patient expired during the hospital stay.

*Number of cases with a psychiatric diagnosis excluded because they were not patients in an inpatient psychiatric care setting?

Documentation in the medical record that the patient was receiving care primarily for a psychiatric diagnosis but was NOT in an inpatient psychiatric setting, i.e., a psychiatric unit of an acute care hospital or a free-standing psychiatric hospital.

Number of cases excluded due to an unplanned departure resulting in discharge?

Documentation in the medical record of the patient's status at the time the patient left the hospital-based inpatient contains one of the following:

  1. the patient eloped and was discharged

  2. the patient failed to return from leave and was discharged

  3. the patient has not yet been discharged from the hospital

  4. the patient was transferred/discharged from the inpatient psychiatric unit in an acute care or critical access hospital to another level of care, (i.e., medical unit), at the same acute care or critical access hospital and subsequently discharged from that level of care psychiatric care setting

The intent of this exclusion is to identify and exclude patients with an unplanned departure resulting in discharge.

  1. Patients who discharge or transfer to another level of care in the same hospital are excluded from the measure population since they have not yet been discharged from the hospital.

  2. Patients who are discharged from the psychiatric setting are included in the measure population.

Number of cases excluded for being discharged on <= 1 antipsychotic medications?

The number of routinely scheduled antipsychotic medications prescribed to the patient at discharge as documented in the medical record.

* The “Number of cases with a psychiatric diagnosis excluded because they were not patients in an inpatient psychiatric care setting?” measure exclusion question is required for all hospitals because HBIPS-5 allows patients into the measure if the data element Psychiatric Care Setting is missing. This occurs to support hospitals unable to set the value of this data element before manual data abstraction has occurred.

  • Hospitals that can pre-set this data element before the Initial Population is executed will enter a zero.

  • Any hospital unable to pre-set this data element will need to answer the Measure Exclusion question based on how they manually abstracted the data for their patients.

 

IMM-2: Influenza Immunization

Note: IMM-2 is a seasonal measure and only reported for the 1st and 4th quarters. While organizations may use this measure for cases discharged during the 2nd or 3rd quarters, their measure results are not be reported to The Joint Commission. This includes Measure Exclusion data.

How many patients were excluded for

Help Text

Number of cases excluded due to being less than 6 months of age at admission?

The Patient Age (in months) = Admission Date minus (-) Birthdate

 

To calculate, use the month and day portion of Admission Date and Birthdate to yield the most accurate age. Only cases with a valid Admission Date and Birthdate should be processed against the measure algorithm.

Number of cases excluded for having an organ transplant during the current hospitalization?

Patients with an ICD-10-CM Principal or Other Procedure Codes as defined in Appendix A, Table 12.10, Organ Transplant During Current Hospitalization.

Number of cases excluded for being discharged to an acute care facility?

The patient was discharged (on the day of discharge) to an acute care facility.

Number of cases excluded for leaving Against Medical Advice (AMA)?

The patient left the facility Against Medical Advice (AMA).

Number of cases excluded because the patient expired during hospital stay?

The patient expired during the hospital stay.

Number of cases excluded because a vaccination was indicated, but supply had not been received by the hospital?

Patients for whom vaccination was indicated, but supply had not been received by the hospital due to problems with vaccine production or distribution.

 

OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients

How many patients were excluded for

Help Text

Number of cases excluded for expiring within the hospital?

The patient expired while within the hospital.

Number of cases excluded for leaving Against Medical Advice (AMA)?

The patient left the facility Against Medical Advice (AMA).

Number of cases excluded for not being able to determine the Discharge Code?

Discharge Code is not documented or unable to be determined (UTD).

 

OP-23: Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients Who Received Head CT or MRI Scan Interpretation Within 45 minutes of ED Arrival

How many patients were excluded for

Help Text

Number of cases excluded for expiring within the hospital?

The patient expired while within the hospital.

Number of cases excluded for leaving Against Medical Advice (AMA)?

The patient left the facility Against Medical Advice (AMA).

Number of cases excluded for not being able to determine the Discharge Code?

Discharge Code is not documented or unable to be determined (UTD).

Number of cases excluded for not having a head CT or MRI scan ordered in the ED?

There is no documentation a head CT or MRI scan was ordered by the physician/APN/PA during the emergency department visit.

Number of cases excluded for not having the date and time of Last Known Well?

There is no documentation that the date and time of Last Known Well was witnessed or reported, or Unable to Determine from medical record documentation.

Number of cases excluded for having Last Known Well > 120 minutes?

Last Known Well (in minutes) = Outpatient Encounter Date and Arrival Time minus (-) Date Last Known Well and Time Last Known Well.

PC-01: Elective Delivery

How many patients were excluded for

Help Text

Number of cases excluded for conditions possibly justifying elective delivery prior to 39 weeks gestation?

Patients with an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.07, Conditions Possibly Justifying Elective Delivery, are to be counted.

Number of cases excluded for Gestational Age < 37 or >= 39 weeks or =UTD?

Gestational Age is the weeks of gestation completed at the time of delivery. This is the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation, irrespective of whether the gestation results in a live birth or a fetal death.

Number of cases excluded for a history of a prior stillbirth?

Documentation that the patient had a prior history of stillbirth.

 

PC-02: Cesarean Birth (through 6/30/2023 Discharges)

How many patients were excluded for

Help Text

Number of cases excluded for multiple gestations and other presentations?

Patients with an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.09, Multiple Gestations and Other Presentations, are to be counted.

Number of cases excluded for an outcome of delivery other than a single live birth?

Patients without an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.08, Outcome of Delivery, are to be counted.

Number of cases excluded for Gestational Age < 37 weeks or =UTD?

Gestational Age is the weeks of gestation completed at the time of delivery. This is the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation, irrespective of whether the gestation results in a live birth or a fetal death.

Number of cases excluded for a history of previous live births?

Documentation that the patient experienced a live birth prior to the current hospitalization.

 

PC-02: Cesarean Birth (starting with 7/1/2023 Discharges)

How many patients were excluded for

Help Text

Number of cases excluded for multiple gestations and other presentations?

Patients with an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.09, Multiple Gestations and Other Presentations, are to be counted.

Number of cases excluded for an outcome of delivery other than a single live birth?

Patients without an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.08, Outcome of Delivery, are to be counted.

Number of cases excluded for Gestational Age < 37 weeks or =UTD?

Gestational Age is the weeks of gestation completed at the time of delivery. This is the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation, irrespective of whether the gestation results in a live birth or a fetal death.

Number of cases excluded for a history of previous births?

Documentation that the patient experienced a birth >= 20 weeks gestation regardless of the outcome (i.e. parity > 0) prior to the current hospitalization.

 

PC-05: Exclusive Breast Milk Feeding (through 12/31/2023 Discharges)

How many patients were excluded for

Help Text

Number of cases excluded due to a Length of Stay > 120 days?

Length of Stay (in days) = Discharge Date minus (-) Admission Date

Number of cases excluded for galactosemia?

Patients with an ICD-10-CM Other Diagnosis Code as defined in Appendix A, Table 11.21, Galactosemia, are to be counted.

Number of cases excluded for parenteral nutrition?

Patients with an ICD-10-CM Principal or Other Procedure Codes as defined in Appendix A, Table 11.22, Parenteral Nutrition, are to be counted.

Number of cases excluded for expiring within the hospital?

The patient expired while within the hospital.

Number of cases excluded for patients being discharged to an acute care facility?

The patient was discharged to an acute care facility.

Number of cases excluded because patient was discharged to another hospital?

The patient was discharged (on the day of discharge) to another health care facility.

Number of cases excluded for not being at term; or with a Gestational Age < 37 weeks or =UTD?

There is documentation that the newborn was not at term or < 37 completed weeks of gestation at the time of birth. Gestational Age is the weeks of gestation completed at the time of delivery. This is the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation, irrespective of whether the gestation results in a live birth or a fetal death.

Number of cases excluded for being admitted to the NICU?

There is documentation that the newborn was admitted to the Neonatal Intensive Care Unit (NICU) at this hospital at any time during the hospitalization.

PC-05: Exclusive Breast Milk Feeding (starting with 1/1/2024 Discharges)

How many patients were excluded for

Help Text

Number of cases excluded for galactosemia?

Patients with an ICD-10-CM Other Diagnosis Code as defined in Appendix A, Table 11.21, Galactosemia, are to be counted.

Number of cases excluded for parenteral nutrition?

Patients with an ICD-10-CM Principal or Other Procedure Codes as defined in Appendix A, Table 11.22, Parenteral Nutrition, are to be counted.

Number of cases excluded for expiring within the hospital?

The patient expired while within the hospital.

Number of cases excluded for patients being discharged to an acute care facility?

The patient was discharged to an acute care facility.

Number of cases excluded because patient was discharged to another hospital?

The patient was discharged (on the day of discharge) to another health care facility.

Number of cases excluded for not being at term; or with a Gestational Age < 37 weeks or =UTD?

There is documentation that the newborn was not at term or < 37 completed weeks of gestation at the time of birth. Gestational Age is the weeks of gestation completed at the time of delivery. This is the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation, irrespective of whether the gestation results in a live birth or a fetal death.

Number of cases excluded for not being able to determine if they were term or their Gestational Age and their birthweight < 3000g or =UTD?

The documentation for a newborn being at term or < 37 weeks of gestations at time of birth cannot be determined from medical record documentation, so a UTD is documented. Birthweight is the weight (in grams) of a newborn at the time of delivery. Whether entered in pounds or grams within the hospital's software, all birth weights must be converted to grams prior to measure evaluation.

Number of cases excluded for being admitted to the NICU?

There is documentation that the newborn was admitted to the Neonatal Intensive Care Unit (NICU) at this hospital at any time during the hospitalization.

PC-06: Unexpected Complications in Term Newborns

How many patients were excluded for

Help Text

Number of cases excluded for congenital malformations or genetic diseases; pre-existing fetal conditions; or maternal drug use exposure in-utero?

Patients with an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A on Table 11.30 (Congenital Malformations), Table 11.31 (Fetal Conditions), or Table 11.32 (Maternal Drug Use) are to be counted. A patient with codes on multiple of these tables is to be counted only once.

Number of cases excluded for a birthweight < 2500g or =UTD?

Birthweight is the weight (in grams) of a newborn at the time of delivery. Whether entered in pounds or grams within the hospital's software, all birth weights must be converted to grams prior to measure evaluation.

Number of cases excluded for not being at term; or with a Gestational Age < 37 weeks?

There is documentation that the newborn was not at term or < 37 completed weeks of gestation at the time of birth. Gestational Age is the weeks of gestation completed at the time of delivery. This is the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation, irrespective of whether the gestation results in a live birth or a fetal death.

Number of cases excluded for not being able to determine if they were term or their Gestational Age and their birthweight < 3000g?

The documentation for a newborn being at term or < 37 weeks of gestations at time of birth cannot be determined from medical record documentation, so a UTD is documented. Birthweight is the weight (in grams) of a newborn at the time of delivery. Whether entered in pounds or grams within the hospital's software, all birth weights must be converted to grams prior to measure evaluation.

 

SDOH-1: Screening for Social Drivers of Health (starting with calendar year 2024)

How many patients were excluded for

Help Text

Exclusions, if any, will be provided later this year.

 

 

SDOH-2: Screen Positive Rate for Social Drivers of Health (starting with calendar year 2024)

How many patients were excluded for

Help Text

Exclusions, if any, will be provided later this year.

 

SUB-2: Alcohol Use Brief Intervention Provided or Offered and
SUB-2a: Alcohol Use Brief Intervention

How many patients were excluded for

Help Text

Number of cases excluded due to being less than 18 years of age at admission?

The Patient Age (in years) = Admission Date minus (-) Birthdate

 

To calculate, use the month and day portion of Admission Date and Birthdate to yield the most accurate age. Only cases with a valid Admission Date and Birthdate should be processed against the measure algorithm.

Number of cases excluded with a Length of Stay <= 1 day

Length of Stay (in days) = Discharge Date minus (-) Admission Date

Number of cases excluded for having Comfort Measures Only documented?

Comfort Measures Only refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort. It includes attention to the psychological and spiritual needs of the patient and support for both the dying patient and the patient's family. Comfort Measures Only is commonly referred to as “comfort care” by the general public. It is not equivalent to a physician order to withhold emergency resuscitative measures such as Do Not Resuscitate (DNR).

Number of cases excluded because the patient refused screening for Alcohol Use Status during the hospital stay?

Within the first day of admission (by end of Day 1) the patient refused screening for Alcohol Use Status during the hospital stay

Number of cases excluded due to a score on the validated alcohol screen indicative of no or low risk of alcohol related problems?

Within the first day of admission the patient was screened for Alcohol Use with a validated tool and the score indicated no or low risk of alcohol related problems.

Number of cases being excluded because patient could not be screened for alcohol use due to cognitive impairment?

Within the first day of admission (by end of Day 1) the patient was not screened for alcohol use because of cognitive impairment.

SUB-2a only: 

Number of cases excluded due to screening on a non-validated tool?

Within the first day of admission the patient was screened for Alcohol Use with a non-validated tool.

SUB-2a only:

Number of cases excluded due to screening not done or UTD?

Within the first day of admission the patient was not screened for Alcohol Use or UTD.

 

SUB-3: Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge

How many patients were excluded for

Help Text

Number of cases excluded due to being less than 18 years of age at admission?

The Patient Age (in years) = Admission Date minus (-) Birthdate

To calculate, use the month and day portion of Admission Date and Birthdate to yield the most accurate age. Only cases with a valid Admission Date and Birthdate should be processed against the measure algorithm.

Number of cases excluded with a Length of Stay <= 1 day?

Length of Stay (in days) = Discharge Date minus (-) Admission Date

Number of cases excluded for having Comfort Measures Only documented?

Comfort Measures Only refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort. It includes attention to the psychological and spiritual needs of the patient and support for both the dying patient and the patient's family. Comfort Measures Only is commonly referred to as “comfort care” by the general public. It is not equivalent to a physician order to withhold emergency resuscitative measures such as Do Not Resuscitate (DNR).

Number of cases being excluded because patient could not be screened for alcohol use due to cognitive impairment?

Within the first day of admission (by end of Day 1) the patient was not screened for alcohol use because of cognitive impairment.

Number of cases excluded for patients being discharged to an acute care facility?

The patient was discharged (on the day of discharge) to an acute care facility.

Number of cases excluded for leaving Against Medical Advice (AMA)?

The patient left the facility Against Medical Advice (AMA).

Number of cases excluded because patient was discharged to another healthcare facility?

The patient was discharged (on the day of discharge) to another healthcare facility.

Number of cases excluded because they expired during hospital stay?

The patient expired during the hospital stay.

Number of cases excluded for being discharged to home or another healthcare facility for hospice care?

Patient discharged to hospice at home or at another healthcare facility.

Number of cases excluded for not having a procedure code for alcohol dependence, drug dependence or alcohol and drug treatment procedures?

Patients without an ICD-10-CM Principal or Other Procedure Codes as defined in Appendix A, Table 13.1, Alcohol Dependence; 13.2, Drug Dependence; and 13.3, Alcohol and Drug Treatment Procedures, are to be counted.

Number of cases excluded because the patient's home is not in the United States, released to a court hearing and did not return, or discharged to jail/law enforcement?

Patient's home is not in the United States, they are released to a court hearing and did not return, or they were discharged to jail/law enforcement?

 

TOB-2: Tobacco Use Treatment Provided or Offered and
TOB-2a: Tobacco Use Treatment 

Retired as of 12/31/2023 Discharges

How many patients were excluded for

Help Text

Number of cases excluded due to being less than 18 years of age at admission?

The Patient Age (in years) = Admission Date minus (-) Birthdate
To calculate, use the month and day portion of Admission Date and Birthdate to yield the most accurate age. Only cases with a valid Admission Date and Birthdate should be processed against the measure algorithm.

Number of cases excluded with a Length of Stay <= 1 day?

Length of Stay (in days) = Discharge Date minus (-) Admission Date

Number of cases excluded for having Comfort Measures Only documented?

Comfort Measures Only refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort. It includes attention to the psychological and spiritual needs of the patient and support for both the dying patient and the patient's family. Comfort Measures Only is commonly referred to as “comfort care” by the general public. It is not equivalent to a physician order to withhold emergency resuscitative measures such as Do Not Resuscitate (DNR).

Number of cases being excluded because patient could not be screened for tobacco use due to cognitive impairment?

Within the first day of admission (by end of Day 1) the patient was not screened for tobacco use because of cognitive impairment.

Number of cases excluded because the patient refused the tobacco use screening?

Within the first day of admission (by end of Day 1) the patient refused screening for Tobacco Use Status during the hospital stay.

Number of cases excluded because the patient is a former tobacco user?

Documentation within the first day of admission (by the end of Day 1) that the patient is a former tobacco user.

Number of cases excluded because the patient has never used tobacco?

Documentation within the first day of admission (by the end of Day 1) that the patient never used tobacco.

 

Tobacco use includes all forms of tobacco including cigarettes, smokeless tobacco products, pipe, and cigars. A tobacco use screen should identify the type of tobacco product used, the volume used, and the time frame of use.

TOB-2a only: Number of cases excluded due to Tobacco Use Status unknown?

Tobacco use status is unknown.

 

TOB-3: Tobacco Use Treatment Provided or Offered at Discharge

How many patients were excluded for

Help Text

Number of cases excluded due to being less than 18 years of age at admission?

The Patient Age (in years) = Admission Date minus (-) Birthdate
To calculate, use the month and day portion of Admission Date and Birthdate to yield the most accurate age. Only cases with a valid Admission Date and Birthdate should be processed against the measure algorithm.

Number of cases excluded with a Length of Stay <= 1 day?

Length of Stay (in days) = Discharge Date minus (-) Admission Date

Number of cases excluded for having Comfort Measures Only documented?

Comfort Measures Only refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort. It includes attention to the psychological and spiritual needs of the patient and support for both the dying patient and the patient's family. Comfort Measures Only is commonly referred to as “comfort care” by the general public. It is not equivalent to a physician order to withhold emergency resuscitative measures such as Do Not Resuscitate (DNR).

Number of cases being excluded because patient could not be screened for tobacco use due to cognitive impairment?

Within the first day of admission (by end of Day 1) the patient was not screened for tobacco use because of cognitive impairment.

Number of cases excluded because the patient refused or Tobacco Use Status unknown during the hospital stay?

Within the first day of admission (by end of Day 1) the patient:

  1. Refused screening for tobacco use during the hospital stay.

  2. Tobacco use status is unknown.

Number of cases excluded because the patient is a former tobacco user?

Documentation within the first day of admission (by the end of Day 1) that the patient is a former tobacco user.

Number of cases excluded because the patient has never used tobacco?

Documentation within the first day of admission (by the end of Day 1) that the patient never used tobacco.

 

Tobacco use includes all forms of tobacco including cigarettes, smokeless tobacco products, pipe, and cigars. A tobacco use screen should identify the type of tobacco product used, the volume used, and the time frame of use.

Number of cases excluded for patients being discharged to an acute care facility?

The patient was discharged (on the day of discharge) to an acute care facility.

Number of cases excluded for leaving Against Medical Advice (AMA)?

The patient left the facility Against Medical Advice (AMA).

Number of cases excluded because patient was discharged to another healthcare facility?

The patient was discharged (on the day of discharge) to another healthcare facility.

Number of cases excluded because they expired during hospital stay?

The patient expired during the hospital stay.

Number of cases excluded for being discharged to home or another healthcare facility for hospice care?

Patient discharged to hospice at home or at another healthcare facility.

Number of cases excluded because the patient's home is not in the United States, released to a court hearing and did not return, or discharged to jail/law enforcement?

Patient's home is not in the United States, they are released to a court hearing and did not return, or they were discharged to jail/law enforcement?

 

VTE-6: Hospital Acquired Potentially-Preventable Venous Thromboembolism

How many patients were excluded for

Help Text

Number of cases excluded for not having a VTE or Obstetrics-VTE OTHER diagnosis?

Patients without an ICD-10-CM Other Diagnosis Codes as defined in Appendix A, Table 7.03 or 7.04, Venous Thromboembolism (VTE) or Obstetrics - VTE (Venous Thromboembolism), are to be counted.

Number of cases excluded for having VTE present at admission?

Documentation by a physician/APN/PA that VTE was diagnosed or suspected on arrival to the day after admission.

Number of cases excluded for having Comfort Measures Only documented?

Comfort Measures Only refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort. Documentation by a physician/APN/PA any time during the hospital stay or timing unclear is to be counted. Only the terms listed in Inclusion Guidelines for Abstraction are accepted.

Number of cases excluded for being enrolled in a clinical trial studying VTE?

Documentation that during this hospital stay the patient was enrolled in a clinical trial in which patients with the same condition as the measure set were being studied (i.e., VTE).

*Number of cases excluded because VTE was not confirmed by diagnostic testing?

A diagnosis of new/acute VTE [deep vein thrombosis (DVT) and/or pulmonary embolism (PE)] in a defined location was not confirmed by diagnostic testing on the day of arrival or anytime during the hospitalization.

 

Confirmation of a new/acute VTE requires documentation by a physician/APN/PA based upon a diagnostic test performed on the day of arrival or anytime during the hospitalization. Acceptable VTE locations and VTE diagnostic tests are defined in Inclusion Guidelines for Abstraction.

Number of cases excluded with reasons for not administering mechanical and pharmacological prophylaxis?

Documentation by a physician/APN/PA or pharmacist why mechanical AND pharmacological VTE prophylaxis were not administered on the day(s) between arrival and the day before the VTE Diagnostic Test order date. Both mechanical and pharmacological prophylaxis must be addressed.

*The two data elements VTE Diagnostic Test and VTE Confirmed are used to answer this Measure Exclusion question. While two separate data elements are required in the algorithm to derive the answer, the clinical exclusion “VTE was not confirmed by diagnostic testing” requires VTE Diagnostic Test = ‘N’ and/or VTE Confirmed = ‘N’.

 

Continue to the next section: Section 4: Aggregate Data Element Tool

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