Review of Specification Manual Changes

1
Review of Specification Manual Changes

• April 1, 2007 through Sept 30, 2007 discharges

Ed Donahue RN MBA CPHQ Hospital Quality
Advisor Masspro 781-419-2799 Edonahue_at_maqio.sdps.o
rg
Beth McConville RN BSN Hospital Quality
Advisor Masspro 781-419-2887 Emcconville_at_maqio.sdp
s.org
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-07-69 SpecManual-mar
2
April 1, 2007 discharges

• The following slides reflect our readings and
  best professional interpretations of the
  Specifications Manual Version 2.2. 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 post the
  question to Quest at www.qualitynet.org You will
  receive an answer via email that you should
  retain should a conflict occur.
• Although many of the Specification Manual changes
  will be reviewed here, the only way to insure
  awareness of all changes is to review the
  Specification Manual Release Notes.

3

• General Changes

• Mortality Measures
• Measure Information Forms (MIFs) are now
  found in the Specifications Manual. These MIFs
  discuss the 30 day risk adjustment for AMI, HF
  and PN.
• Section 10 - CMS Risk-Adjusted 30-Day
  Mortality Measures
• The Measure Population is now referred to as
  the ICD population.

4
UTD added to the Value options for the following
data elements

• ICD-9 Principle Procedure Date
• Arrival Date and Time
• Fibrinolytic Administration Date and Time
• First PCI Date and Time
• Antibiotic Administration Date and Time
• ICU Transfer or Admit w/in First 24 hours

• Initial Blood Culture Collection Date and Time
• Risk Factors for Drug Resistant Pneumococcus (add
  to No Value)
• Date of Infection
• Discharge Time
• Glucose POD 1 and POD 2
• Surgery Start Date
• Surgical Incision Time
• Temperature Value

5
ALL TOPICS

• Admission Date
• Adult Smoking Counseling

• The date and time admission orders are written.
• May now provide smoking cessation advise to
  CAREGIVERS.

6
AMI, HF, PN
DATA ELEMENT Adult Smoking History
CLARIFIED 4/1/07 discharges Review the entire
chart for all references to smoking.

• If product smoked is not identified assume it is
  cigarettes

7
ALL TOPICS

• Legibility
• Hispanic Ethnicity

• All documentation must be legible and complete.
• If one source is illegible continue to review the
  record.
• Exhaust all sources before selecting UTD due to
  illegibility.
• Collected for all CMS patients
• Not to be confused with data element Race.
  Answer BOTH.
• (clarification).

8
AMI

• ASA Received w/in 24 Hours Before or After
  Hospital Arrival

• May now assume patients on aspirin at home took
  their aspirin within 24 hours of arrival unless
  specifically documented otherwise. Select value
  Yes.
• May now infer patients who received aspirin
  prior to arrival did receive it within 24 hours
  before arrival unless specifically documented
  otherwise. Select value Yes.
• Both these scenarios require a No response
  through March 31, 2007 discharges.

9
AMI

• ALL AMI HF medication contraindication data
  elements
• Aspirin, Beta Blocker, ACE I / ARB

• Ordering practitioner crossing out the med order
  on a preprinted order sheet clearly implies a
  reason for not ordering the med. Select value
  Yes.
• In contrast, not checking a check box next to a
  med on a preprinted order sheet is NOT a clear
  implication of intent to not order the med as it
  may be an omission.

10
AMI

• Pre-arrival documentation is acceptable (transfer
  record, outpatient record or noted by hospital
  staff in the current record). It must be included
  in the permanent record that is sent to CDAC.
• Notation of Allergy/Sensitivity
• Hold or discontinuation WITH a reason
• Other (documented) reason intolerance to beta
  blockers, severe hypotension with Lopressor.

• ALL AMI HF medication contraindication data
  elements
• Aspirin, Beta Blocker, ACE I / ARB

11
AMI

• Contraindication_to Aspirin on Arrival
• Contraindication to Aspirin at Discharge

• Active bleeding is NO LONGER an automatic aspirin
  contraindication in and of itself.
• It may still be referenced as a Yes to
  Contraindication to Aspirin BUT ONLY as an other
  reason documented by physician/APN/PA for not
  prescribing aspirin on arrival. (i.e. Withheld
  aspirin due to GI bleeding).

12
AMI

• Contraindication to
• Beta Blocker on Arrival
• Contraindication to
• Beta_Blocker_at Discharge

• A hold / discontinuation of IV Beta Blocker does
  NOT count as a contraindication. This element is
  concerned with oral (long_term)_beta-blocker
  therapy.
• May now use telemetry and rhythm strips to
  identify 2nd and 3rd degree heart block in
  addition to ECGs.
• Consider a patient on a Beta Blocker if the
  beta-blocker was taken en-route to the hospital.
  Complete reversal of guideline for patients
  discharged through March 31 2007.

13
AMI

• Contraindication to both ACE and ARB at Discharge

• Documentation of a reason for not prescribing one
  class (either ACE I or ARB) may now be considered
  a reason for not prescribing the other class for
  the following five conditions ONLY
• Angioedema
• Hyperkalemia
• Hypotension
• Renal Artery Stenosis
• Worsening Renal Function / Renal Disease

Inclusions / Synonyms are listed in the data
element page
14
AMI

• Contraindication to both ACE and ARB at Discharge

• Hold / Discontinuation of IV ACEI does NOT count
  as a contraindication. This element is concerned
  with oral (long term) ACEI therapy.

15
AMI

• Beta Blocker Received within 24 hours of Hospital
  Arrival
• Beta Blocker Prescribed at Discharge

• Exclude eye drops

16
AMI

• Fibrinolytic Administration
• Fibrinolytic Administration Time
• Fibrinolytic Administration Date

• Refers to PRIMARY fibrinolytics.
• Fibrinolytics given during or after PCI are
  excluded.

17
AMI

• First PCI Time

• A timed reference to balloon, stent or other
  device without mention of inflation, deployment
  or other action IS acceptable to use as First PCI
  Time IF there is no specific reference to PCI
  time found in the chart.
• E.g. 1135 Voyager balloon. Infer this to be the
  time of use unless documentation suggests
  otherwise.

18
AMI

• Initial ECG Interpretation

• The following descriptions are NO LONGER
  EXCLUSIONS. They should be DISREGARDED (neither
  inclusion or exclusion look for other
  documentation)
• Age undetermined
• New
• Old
• Recent
• Sub Acute
• Previously seen
• Age not addressed (e.g.inferior MI) Newly added

19
AMI

• Initial ECG Interpretation

• ECG reports no longer need mention of leads (V1,
  V2, etc) to infer that it was a 12-lead. You may
  now infer an ECG report is referencing a 12-lead
  unless documentation indicates otherwise.
• Intraventricular conduction block is added as an
  EXCLUSION

20
AMI

• Reason for Delay in Fibrinolytic Therapy

• Systems reasons are NO LONGER acceptable.
• Examples of acceptable reasons
• Hold fibrinolytics to r/o bleed.
• Pt waiting for family before agreeing_to_Fibrinoly
  tic therapy.
• Patient arrived in cardiac arrest fibrinolytics
  delayed until stable.
• The delay in fibrinolytic therapy must be
  explicitly linked to the reason for the delay.

21
AMI

• Reason for Delay in PCI

• Systems reasons are NO LONGER acceptable.
• Examples of acceptable reasons
• Hold PCI. Obtain TEE to r/o aortic dissection
• SVG cath did not cross lesion, XMI_cath_successful
  ,_flow established after 30-minute delay.
• PCI delayed due to intermittent hypotension when
  crossing lesion.
• The delay in PCI therapy must be explicitly
  linked to the reason for the delay.

22
HF

• Discharge Instructions
• Discharge Instructions Address Meds

• An unchecked box for any component will be
  considered a NO.
• IF there is no discharge med list available in
  the record to compare to the discharge med list
  provided to the patient you may presume the
  discharge med list provided the patient is
  complete IF the physician/APN/PA name or initials
  is signed, stamped or typed on the form.

23
HF

• Discharge Instructions Address Symptoms Worsening
  
• LVF Assessment

• Decreased exercise tolerance and Fatigue are now
  included in the Inclusion list for Heart Failure
  Symptoms.
• If the MD/NP/PA defers LVSF assessment_to_another
  physician (after discharge) you MAY NO LONGER
  COUNT THIS as a reason for not assessing LVSF
  unless the reason for deferral is also noted.

24
PN / SCIP

• Antibiotic_Administration Date
• Antibiotic_Administration Time
• Antibiotic Administration Route

• If the infusion is interrupted (e.g. IV
  infiltrate) abstract the time the infusion was
  started.

25
PN

• Blood Culture Collected After Arrival

• Combined with data element Initial Blood Culture
  Collected in ED.
• Values changed from Yes / No
• to Numeric
• Initial Blood Culture collected in the ED
• Initial Blood Culture collected during this
  hospitalization but NOT in the ED.
• No Blood Culture collected during this
  hospitalization OR Unable to determine from the
  medical record.

26
PN

• Blood Culture Collected After Arrival

• If a patient has a BC drawn in the ED before an
  admission order is written select Value 1.
• If the patient has a BC drawn in the ED AFTER an
  admission order is written select value 2.
• The time admission orders are written is
  considered the Time of Admission.

27
PN

• Chest X-ray

• Change CXR indicates PN to Abnormal chest
  x-ray.
• Patients with Normal, Old or Chronic Chest x-ray
  results will be excluded from all PN measures.
• Specific findings (e.g. infiltrate, effusion)
  are no longer necessary to answer Yes.
• Includes x-rays and CT scans.

28
PN

• Compromised

• Remove Cystic Fibrosis (Patients with Cystic
  Fibrosis will now be excluded from ALL pneumonia
  measures).
• Add Significant Neutropenia as a Yes to
  Compromised.
• Absolute Granulocyte or Neutrophil count gt 1000
  OR
• MD/NP/PA documentation of significant or
  Marked neutropenia.

29
PN

• Diagnostic Uncertainty

• NEW DATA ELEMENT
• Used to determine if the practitioner identified
  clinical circumstances that would delay the
  diagnosis of PN.
• A Yes value will exclude the case from the PN-5b
  measure.
• Must be specifically documented by MD/APN/PA that
  the picture was questionable or unclear.

30
PN

• Identified_Pneumonia Pathogen

• NEW DATA ELEMENT
• Identifies patients with a positive diagnostic
  test for known pneumonia pathogen including
  within 24 hours of arrival
• Positive blood or sputum culture OR
• Positive urinary antigen test for Streptococcus
  pneumonia or Legionella pneumophilia OR
• Positive polymerase Chain Reaction (PCR) test for
  Legionella pneumophilia.

31
PN

• Identified_Pneumonia Pathogen

• NEW DATA ELEMENT
• A Yes value excludes the case from the Antibiotic
  Selection Measure.

32
PN

• Initial_Blood_Culture Collected in ED

• Remove data element.
• This was collected for PN 3b, replaced with Blood
  culture Collected After Arrival (see previous
  slide).

33
PN

• Pneumococcal_Vaccine Status

• Change Value 4 from received chemotherapy or
  radiation to currently receiving or received
  chemotherapy or radiation.
• Those patients receiving chemo or radiation
  therapy during the hospitalization will now also
  be excluded from the measure.

34
PN

• PN-1
• PN-3a
• PN-3b
• PN-5
• PN-6

• Four new exclusions
• Patients transferred to another acute care
  hospital or federal hospital on day of or day
  after arrival.
• Patients discharged on day of arrival
• Patients who expired on day of or day after
  arrival.
• Patients who left against medical advice on day
  of or day after arrival.

35
PN

• PN-6

• Piperacillin is NO LONGER a recommended
  antipseudomonal beta-lactam.

36
SCIP

• SCIP Inf-1
• SCIP Inf-2
• SCIP Inf-3
• SCIP Inf-4
• SCIP Inf-7

• The following terms have been added to the
  inclusion list for the data elements Infection
  Prior to Anesthesia and Postoperative Infections
• Necrotic
• Ischemic
• Infarcted Bowel
• Gangrene
• Lung Infiltrates

37
SCIP

• SCIP Inf-1
• SCIP Inf-2
• SCIP Inf-3

• Antibiotics are collected from arrival through
  the first 48 hours postoperatively
• (72 hours for CABG or Other Cardiac Surgery)
• Antibiotic Administration Route is now being
  collected for SCIP Inf-3, as well as SCIP Inf-1
  and SCIP Inf-2, and the values 4, 5, 6, 7, 8, and
  9 are now retired
• If all the routes are missing or invalid, the
  case will be excluded from these measures

38
SCIP

• SCIP Inf-2

• The data element Vancomycin has been clarified to
  require physician documentation for allowable
  values 2 8
• Documentation by an Infection Control
  Practitioner is acceptable
• Inclusions and Exclusions were added to clarify
  hospitalizations and nursing home stays for value
  3 and 4

39
SCIP

• SCIP Inf-6

• The data element Preoperative Hair Removal now
  allows the abstractor to select all the methods
  documented
• Patients whose method of hair removal could not
  be determined will be removed as an exclusion
  from this measure

40
SCIP

• SCIP CARD-2

• Beta-blockers used on a PRN basis and eye drops
  with beta-blocker activity should not be
  considered for the data elements Beta Blocker
  Current Medication or Beta Blocker Perioperative

41
SCIP

• SCIP VTE-1
• SCIP VTE-2

• The data element VTE Laparoscope has been changed
  to Laparoscope
• Procedures performed entirely by laparoscope will
  be excluded from all SCIP measures
• Patients who receive neuraxial anesthesia or have
  a documented bleeding risk may pass the measure
  if appropriate prophylaxis is ordered

42
Q A
43
CONTACT INFORMATION
Ed Donahue RN MBA CPHQ Hospital Quality
Advisor Masspro 781-419-2799 Edonahue_at_maqio.sdps.o
rg
Beth McConville RN BSN m Hospital Quality
Advisor Masspro 781-419-2887 Emcconville_at_maqio.sdp
s.org
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-07-69 SpecManual-mar