The PC-07 measure requires the use of Present on Admission (POA) indicators for both numerator logic and risk adjustment.

A recent review of ORYX Performance Measurement data submitted to Joint Commission via the Direct Data Submission Platform (DDSP) for CY2024, indicates that some hospitals reported a rate of zero (0) per 10,000 delivery hospitalizations for the eCQM PC-07 Severe Obstetric Complications, and/or inconsistently provide Present-On-Admission (POA) Indicator values for all patient encounters. Failure to include POA Indicator values for Severe Maternal Morbidity (SMM) diagnosis codes lead to inaccurate PC-07 rate calculations and negatively affect risk adjustment for PC-07.

The document provides guidance on improving data quality for the PC-07 Severe Obstetric Complications measure reported to Joint Commission, emphasizing the critical role of Present-On-Admission (POA) indicators in accurately identifying Severe Maternal Morbidity complications during delivery hospitalizations and ensuring proper risk adjustment. It details the POA values used in numerator logic and risk adjustment, explains the relevant value sets and indicators, and notes the importance of including POA data to avoid inaccurate rate calculations and performance measure scores for hospitals.

The PC-07 measure requires the use of Present on Admission (POA) indicators for both numerator logic and risk adjustment.

1. Numerator Logic:
   This section evaluates delivery encounters with Severe Maternal Morbidity (SMM) diagnosis or procedure codes, excluding blood transfusions. For these encounters, POA values are required to determine whether the complication diagnosis was present at time of inpatient admission. Specifically, the logic looks for POA Indicator values where EncounterDiagnoses.code is in the SMM diagnosis value set.

2. Risk Variable Adjustment:
   This section includes approximately 30 risk variables that assess various diagnosis codes. POA Indicator values are also required here to determine whether a diagnosis qualifies as a risk factor. While these risk variables do not directly affect the numerator or denominator, they are essential for accurate risk adjustment, which ultimately impacts your hospital’s performance score.

PC-07: Additional information for Mapping Present on Admission (POA) indicators

In addition to clinical electronic health record data, the Severe Obstetric Complications measure uses Present on Admission (POA) indicators (e.g., POA = U) as found in billing/claims system within the measure criteria. Some organizations have elected to map the present-on-admission (POA) Indicator to claims data, finding this approach tends to provide more consistent results. Be sure to map these indicators to the appropriate value sets for this measure.  The POA Indicator is intended to differentiate conditions present at the time of admission from those conditions that develop during the hospital stay.

Value set "Present On Admission is Yes or Exempt" (2.16.840.1.113762.1.4.1110.63)

POA Indicator of Y = yes (Diagnosis was present at the time of the inpatient admission)

POA Indicator of 1 = Unreported/Not used. Exempt from POA reporting

Value set "Present on Admission is No or Unable To Determine" (2.16.840.1.113762.1.4.1029.370)

POA Indicator of N = no (Diagnosis was not present at the time of the inpatient admission)

POA Indicator of W = clinically undetermined

POA Indicator of U = documentation insufficient to determine if the condition was present at the time of inpatient admission

How to Review Uploaded PC-07 QRDA I Documents for POA Information and Edit Warnings

Use the steps below to identify and review if an inpatient encounter includes Severe Maternal Morbidity (SMM) Diagnosis or Risk Adjustment Variables codes and review warnings related to missing Present on Admission (POA) indicators

Two Ways to Review Encounter Diagnoses Data with POA Information

1. Stylesheet View

2. XML View

Steps to Access Data Accuracy, Filtering for POA Edit Warnings and Reviewing the Document

1. Log in to the DDSP application

2. From the eCQM Submission menu, select Data Accuracy

3. The Data Accuracy page will open
   For details, see: eCQM Data AccuracyPreview

Filtering for POA Edit Warnings

5. On the QRDA Documents Errors/Warnings bar chart, click one of these Data Accuracy Labels:

• “POA is missing for SMM Diagnosis”

• “POA is missing for Risk variable”

6. Alternatively:

• In the Select Type section, choose Warning to display all warnings for that HCO

• Click the relevant POA warning label

Reviewing the Document

After filtering, the Active Documents section lists all documents with the selected warning(s).

7. Select a document from Active Documents

8. Click the Magnifying Glass icon to open the Source Viewer

For details, see: eCQM Source ViewerPreview

There are two ways to review Encounter Diagnosis and POA information:

1. Stylesheet View (Default)

• Opens by default in Source Viewer.

New Feature:

If code belongs to any of the ValueSet below, the ValueSet name will be displayed next to the code

• Severe Maternal Morbidity (SMM) Diagnosis ValueSet

• Risk Adjustment Variables ValueSets

Steps:

After Stylesheet View opens,  

• In the Patient Data Section, locate the Encounter Performed Template where the code belongs to the ValueSet:
  Encounter Inpatient (OID: 2.16.840.1.113883.3.666.5.307)

• All Encounter Diagnoses appear in the Attributes and Extension column.

• For each Encounter diagnosis code:

  • If the code belongs to Severe Maternal Morbidity Diagnoses ValueSet
    (OID: 2.16.840.1.113762.1.4.1029.255) →
    “SMM – Severe Maternal Morbidity Diagnoses” will display next to the code.

  • If the code belongs to any Risk Adjustment Variables ValueSet
    (e.g., Anemia – OID: 2.16.840.1.113762.1.4.1029.323) →
    “Risk Variable – Anemia” will display next to the code.

• Check if POA value is listed for each diagnosis.

If missing, it corresponds to a warning that verified in the XML view.

• Please check the sample screenshot of the Stylesheet View below for reference.

Open

2. XML View

• Select QRDA I Errors / Warnings to see all errors/warnings.

• To verify a POA warning:

  • Click the warning - Clicking on the warning in the sub-menu takes to the corresponding XML section in the right-hand view.

  • Entry section of the Encounter performed template with the missing POA with the Encounter Diagnosis code will be highlighted.

• Use Prev and Next buttons to navigate multiple occurrences.

  • Please check the sample screenshot of the QRDA I Errors / Warnings below for reference.

Open