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Appendix H Miscellaneous Tables Release Notes: Inclusion Table Table 1.1 Bleeding Inclusion Table Version 1.0 Gastrointestinal (GI) Genitourinary (GU) Intracranial Other Types of Bleeding • anemia due to • in urine, • cerebral hemorrhage or • bleeding which occurred gastrointestinal unless noted only as bleeding as a result of trauma or bleeding laboratory or • hemorrhagic injury ONLY if medical • bleeding diverticulum dipstick finding cerebrovascular intervention required • bleeding from a peptic, • hematuria described accident (CVA) • epistaxis ONLY if gastric, esophageal, or as gross • hemorrhagic infarct of medical intervention duodenal ulcer the brain required • bleeding from colon • intracerebral • hematoma requiring • bleeding from gastritis Pulmonary bleeding/hemorrhage transfusion, stoppage of • bleeding hemorrhoid • bloody tinged • intracranial heparin or other ONLY if medical sputum bleeding/hemorrhage anticoagulant (e.g., intervention required • bloody sputum • ruptured intracranial Integrilin, Eptifibatide, Coumadin, Levonox), or • blood in vomitus, • coughing up blood surgical intervention emesis, or stool • hemoptysis • subarachnoid • coffee ground emesis hemorrhage (SAH) (e.g., incision and • esophageal bleeding • subdural hematoma drainage) varices • post-procedure bleeding • hematemesis noted as abnormal or which required medical • hematochezia intervention • heme/guaiac positive vomitus, emesis, or • retinal hemorrhage/ bleeding stool • retroperitoneal (bleeding • hemoccult/occult into the abdomen) positive vomitus, emesis, or stool • vaginal bleeding, abnormal and • lower gastrointestinal nonmenstrual bleeding (LGI bleed,

LGIB)

• Mallory-Weiss Tear • melena • rectal bleeding (bright red blood [BRB] per rectum [BRBPR]) • upper gastrointestinal bleeding (UGI bleed, UGIB)

Specifications Manual for National Appendix H-1 Hospital Quality Measures

Release Notes: LVF Assessment Inclusion Table Version 1.0 Table 1.2 LVF Assessment Inclusion Table (cath) Nuclear Medicine Left Ventricular Echocardiogram (echo) with Left Tests Function (LVF) Ventriculogram (LV gram) • 2-D • adenosine • cardiac cath with • akinesis • cardiac ultrasound myocardial mention of LVF • biventricular failure • Doppler color flow perfusion stress test • cardiac/coronary • contractility mapping with mention of angiogram with LV • diastolic dysfunction • M-mode echo LVF gram • diastolic function • transesophageal • cardiac blood pool • cardiac/coronary • diastolic impairment echocardiogram (TEE) imaging angiogram with • dyskinesis • Cardiolite scan with mention of LVF • ejection fraction (EF) mention of LVF • cardiac/coronary • endstage cardiomyopathy • gated blood pool arteriogram with LV • hypocontractility imaging study gram • hypokinesis gated heart study cardiac/coronary • • • left ventricular diastolic arteriogram with • gated dysfunction ventriculogram mention of LVF • left ventricular diastolic • multiple gated • left ventriculogram function acquisition scan • left ventricular (MUGA) dysfunction (LVD) • radionuclide • left ventricular ejection ventriculography fraction (LVEF) Sestamibi scan with • • left ventricular systolic mention of LVF dysfunction (LVSD) • technetium scan • left ventricular systolic with mention of function (LVSF) LVF • systolic dysfunction • thallium stress test • systolic function with mention of LVF • wall motion study

Specifications Manual for National Appendix H-2 Hospital Quality Measures

Release Notes: Moderate/Severe Systolic Dysfunction Inclusion Table Version 1.0

Table 1.3 Moderate/Severe Systolic Dysfunction Inclusion Table

Note: Moderate/severe biventricular heart failure and endstage cardiomyopathy are also inclusions.

Contractility described Ejection fraction (EF) Hypokinesis described as: described as: as: • abnormal • abnormal • diffuse • compromised • compromised • generalized • decreased • decreased • global • depressed • depressed • involving the entire left • hypocontractility • impaired • impaired • low • low • poor • poor • reduced • reduced • very low • very low

Left ventricular Left ventricular Left ventricular dysfunction (LVD) ejection fraction function (LVF) described as: (LVEF) described as: described as: • marked • abnormal • abnormal • moderate • compromised • compromised • moderate-severe • decreased • decreased • severe • depressed • depressed • significant • impaired • impaired • substantial • low • low • the severity is not • poor • poor specified • reduced • reduced • very severe • very low • very low

Left ventricular Left ventricular Systolic dysfunction Systolic function systolic dysfunction systolic function described as: described as: (LVSD) described as: (LVSF) described as: • marked • abnormal • marked • abnormal • moderate • compromised • moderate • compromised • moderate-severe • decreased • moderate-severe • decreased • severe • depressed • severe • depressed • significant • impaired • significant • impaired • substantial • low • substantial • low • the severity is not • poor • the severity is not • poor specified • reduced specified • reduced • very severe • very low • very severe • very low

Specifications Manual for National Appendix H-3 Hospital Quality Measures

Table 1.4 - retired Release Notes: LVSD Notes Table Version 1.0 Table 1.5 LVSD Notes Table NUMERIC EFs • When the severity of systolic dysfunction is not • The numeric EF may be documented as a specified in the test report or other documentation percentage (%), whole number, or decimal. Convert (e.g., “LVD”), the inference is being made that the all decimals to percentages (e.g., 0.40 = 40). The degree of systolic dysfunction is clinically significant value should be between 5 and 80. – that is, the systolic dysfunction is moderate or severe • If the EF is documented as less than (<) or greater in degree. than (>) a given number, use the value one whole • The Moderate/Severe Systolic Dysfunction Inclusion number below or above the given number. E.g., Table is limited to moderate/severe systolic “EF< 40%” – Use 39%; “EF>40%” – Use 41%. dysfunction terms most commonly found in medical • If the EF is not documented as a whole number, record documentation. Abstractors may need to round fractions to the nearest whole number (e.g., exercise judgment in determining how to abstract 39.5% = 40%, 39.4% = 39%). terms that are not covered in the inclusion and • If both calculated and estimated values are exclusion lists (e.g., “mildly reduced EF” = ‘No’). It is documented on an LVF assessment test report, use recommended that organizations establish a systemic the calculated value. way of tracking such decisions so that future cases • If the EF is documented as a range, use the midpoint with similar terms can be abstracted in a consistent and consider this an estimated value. E.g., LVEF of manner. “35-45%.” Use 40% as an estimated EF value. • The LVF inclusion terms from the LVF Assessment • If the EF is documented as “about 40%” or variable should not automatically be considered “approximately 40%”, use 40% and consider this an synonyms of the LVF inclusion terms in the estimated value. Moderate/Severe Systolic Dysfunction Inclusion Table (e.g., Diastolic dysfunction is an inclusion for LVF in the LVF Assessment variable. “Impaired LVF” is an inclusion for LVSD. “Impaired diastolic dysfunction” should not be considered LVSD.). • When there are two or more documented LVFs, use the LVF closest to discharge (or closest to hospital arrival, if ONLY pre-arrival LVFs are documented). • The intent of this variable is to capture the most recent known LVF. In cases where there are no LVF results documented from a recent LVF assessment test, but there is an LVF documented from an earlier time period, use that earlier LVF, as it is the most recent known LVF. E.g., MUGA was done in the hospital and there are no LVF results documented (no numeric EF, no qualitative description), but an echo from 3 months prior to arrival showed an EF of 35% - Select “Yes” for LVSD). • If unable to determine which LVF is closest to discharge (or closest to arrival, in the case where only pre-arrival LVFs are documented), or if there is conflicting documentation, select “Yes” if any of the documented LVFs is an EF less than 40% or a narrative description consistent with moderate or severe systolic dysfunction. In the following examples, “Yes” should be selected: o EF 50% per MUGA report from previous hospital stay included in chart, “Recent echo showed moderate LVD” per consultation report.

Specifications Manual for National Appendix H-4 Hospital Quality Measures

NUMERIC EFs o “EF 35%” per echo report, “Echo indicates normal systolic function” per progress note. o “Moderate LV dysfunction with EF 45%” noted on MUGA report. o Findings of “reduced EF” and “mild left ventricular dysfunction” are noted on MUGA report. o Echo findings noted as “global hypokinesis” and “EF 44%” in discharge summary. o “Echo last March showed preserved systolic function” per consultation report, “LVSD” noted in history section of H&P. o “Patient admitted with known LVSD” per H&P, “Hx mild biventricular heart failure” per consultation report.

Specifications Manual for National Appendix H-5 Hospital Quality Measures

Tables 1.6-1.8 - Retired Release Notes: Performed During Stay (SIP) Version 1.0

Table 1.9 Surgery Performed During Stay (SIP) Inclusion/Exclusion Table for Surgical Procedures Procedure Inclusions Exclusion CABG Surgery Coronary Bypass Any surgery other than CABG performed on the vessels of the heart • Operations on structures adjacent to the heart • /PTCA valves, such as papillary muscles or chordae • tendineae • Pacemaker insertion • Repair of septal defects • Percutaneous procedures, such as • Replacement or repair of aortic mitral percutaneous valvuloplasty (bicuspid), tricuspid or pulmonary valve • Surgery on the vessels of the heart • Valvotomy • Valvuloplasty Colon Surgery • Cecectomy • Diagnostic endoscopy, sigmoidoscopy, • Closure of fistula of large intestine colonoscopy or laparoscopy not involving • Colostomy (temporary, permanent, delayed incision, excision, resection or opening) of the large intestine • Complete or partial proctectomy • Endoscopic or open biopsy of the large • Excision of lesion or tissue of large intestine intestine • Exteriorization of intestine • Endoscopic polypectomy • Hemicolectomy • Incision, excision, resection of the small • Isolation of a segment of large intestine intestine or duodenum • Large-to-small and small-to-large intestinal • Small-to-small anastomosis anastomosis • Loop colostomy • Polypectomy (by open approach only) • Resection of rectum • Revision of large-to-small or small-to-large intestinal anastomosis • Sigmoidectomy Hip Arthroplasty Partial or total hip replacement • Any other procedure involving the hip, such as repairs or reduction and fixation of fractures or dislocations • Partial or total revision of hip replacement Hysterectomy • Abdominal hysterectomy (including subtotal, None total, supracervical or radical) • Vaginal hysterectomy (including radical or laparoscopically assisted [LAVH])

Knee Arthroplasty Partial or total knee replacement • Any other procedure involving the knee, such as repairs or reduction and fixation of fractures or dislocations. • Revision of knee replacement

Specifications Manual for National Appendix H-6 Hospital Quality Measures

Surgery Performed During Stay (SIP) cont. Inclusion/Exclusion Table for Surgical Procedures Procedure Inclusions Exclusion Vascular • Resection of vessel with anastomosis (, • Any repair of aneurysm which does not Surgery: abdominal and only): involve excision of a part of the vessel with Abdominal arteries: reconnection (e.g., by coagulation, suturing, Blood Vessel o Celiac wiring, or wrapping) or replacement. Resection o Gastric • Any resection or repair which does not Definition: This o Hepatic involve the vessels listed above category includes o Iliac • Clipping of aneurysm procedures which o Mesenteric involve excision of o Renal part of a vessel o Splenic lesion and may o Umbilical include Abdominal veins: reconnection o Iliac (anastomosis) or o Portal surgical repair and o Renal replacement of the o Splenic excised section. o Inferior Vena Cava These procedures • Resection of vessel with replacement are often performed (abdominal aorta, lower limb arteries and to repair . veins only): Lower limb arteries: o Femoral (common) o Popliteal o Saphenous o Tibial • Repairs of unruptured aneurysms with replacement of the excised section (abdominal, aorta, lower limb arteries and veins only). • Repairs of unruptured aneurysms with reconnection (anastomosis), aorta, abdominal arteries and veins only). • Angiectomy with replacement of the excised section (abdominal aorta, lower limb arteries and veins only). • Angiectomy with reconnection (anastomosis) (aorta abdominal arteries and veins only). • Excision of aneurysm (arteriovenous) with replacement (abdominal aorta, lower limb arteries, and veins only). • Excision of aneurysm (arteriovenous) with anastomosis (aorta, abdominal arteries and veins only). • Excision of blood vessel lesion with replacement of the excised section (abdominal, aorta, lower limb arteries and veins only). • Excision of blood vessel lesion, NOS (aorta only).

Note: Includes both ruptured and unruptured aneurysms.

Specifications Manual for National Appendix H-7 Hospital Quality Measures

Surgery Performed During Stay (SIP) cont. Inclusion/Exclusion Table for Surgical Procedures Procedure Inclusions Exclusion Vascular or thromboendarterectomy Surgery (cont.): performed on any blood vessel other than those listed above. Thrombo- endarterectomy: This category includes of the aorta, femoral or popliteal arteries, or any combination thereof, with or without , patch graft or thrombectomy.

Vascular Shunt or • Aorta-iliac-femoral bypass (any combination • Peritoneovenous shunt Bypass of these vessels (e.g., aorto-femoral or ilio- • /bypass/shunting of any femoral bypass) vessel other than those listed above. • Intra-abdominal vascular shunt or bypass (involving the aorta, iliac, superior mesenteric, celiac, common hepatic or renal arteries) • Peripheral vascular shunt or bypass (involving the axillary, brachial, femoral, peroneal, tibial, or popliteal arteries) • Vascular bypass, not otherwise specified (NOS)

Specifications Manual for National Appendix H-8 Hospital Quality Measures

Release Notes: DVT Prophylaxis Inclusion Table Version 1.0 Table 2.0 DVT Prophylaxis Inclusion Table

Ambulation Post-op Coumadin/warfarin Elastic stockings Factor Xa Inhibitor

• Include any orders for ambulation for the post- op period, even if written prior to surgery. • Any order for ambulation to be initiated after surgery should be included. The order does not have to specify that the ambulation is being ordered for DVT prophylaxis. Synonyms/Inclusions Synonyms/Inclusions Synonyms/Inclusions Synonyms/Inclusions • Activity as tolerated • Anisindione • Ace wraps • Arixtra • Ambulatory • Barr Warfarin Sodium • Anti- stockings • fondaparinux sodium • Ambulatory with • Coumadin • Anti-thrombosis stockings assist/assistive device • Dicumarol • Elastic support hose • Bathroom privileges • Jantoven • Graduated compression (BRP) with assist • Liquamar elastic stockings • Bathroom privileges • Marevam • Jobst stockings (without • Miradon • Stockinettes documentation that • Panwarfin • Surgical hose assistance is needed) • Warfarin • TED hose • Contact guard • Thromboguard assistance (CGA) • White hose • Independent activity • Thrombosis stockings • OOB to BR (out of bed to bathroom) • Standby assistance (SBA) • Up ad lib • Up as tolerated • Up in room/hall • Up in room/hall with assist • Up to bathroom with assistance • Up to bathroom independently • Up with assistance

Specifications Manual for National Appendix H-9 Hospital Quality Measures

DVT Prophylaxis Inclusion Table (cont.)

Low Dose Low Molecular Weight Inferior Vena Cava (IVC) Intermittent Pneumatic Unfractionated Heparin Heparin (LMWH) Filter Compression Device (IPC) (LDUH) • Include only Heparin • LMWH • IVC filter • IPC given by the subcutaneous (SQ, Subcut, SC, SubQ route).

Synonyms/Inclusions Synonyms/Inclusions Synonyms/Inclusions Synonyms/Inclusions • Calciparine • Ardeparin • Bird's Nest filter • AE pumps • HEP • Dalteparin • Filter insertion (anti-embolic pumps) • Heparin • Danaparoid • Greenfield filter • A-V impulse system • Heparin Calcium • Enoxaparin • Inferior vena cava filter • Athrombic pumps • Heparin Na • Fragmin • IVC clip • Compression booties • Heparin Sod • Innohep • IVC filter • DVT boots • Heparin Sodium • Lovenox • IVC interruption • EPC boots/cuffs/ • Heparin Sodium Inj. • Normiflo • Umbrella stockings • Heparin Sodium Inj. • Orgaran • Vena caval cross-clamp • Flotron boots Pork • Tinzaparin • Vena caval filter • Flotron • Heparin Subcu/SQ/ • Flowtron boots SC/SubQ • Foot pump • Impulse pump • Intermittent pneumatic compression stockings • IPC • KCI stockings • Kendall AV impulse • Kendall boots • Leg pumpers • PAS (Pulsatile anti- embolic stockings) • Plantar venous plexus pump • Plexiboots • Plexipulse • Pneumatic intermittent impulse compression device • Pneumoboots • SC boots • SCD boots • Sequential compression device • Sequential pneumatic hose • Sequential TEDS • Thrombus pumps • Venodyne boots • Venous foot pump

Specifications Manual for National Appendix H-10 Hospital Quality Measures