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  2. CQM-6916

How is stillborn captured for CMS1028/PC-07

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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    • Karen McLaughlin
    • 667.217.6550
    • Medisolv
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      Thank you for your question about CMS1028/PC-07 Severe Obstetric Complications. The description of the denominator in the header is “Inpatient hospitalizations for patients delivering stillborn or live birth with >= 20 weeks, 0 days gestation completed” to ensure that stillborn deliveries are not discounted when one thinks about the measure. Delivering a stillborn puts the patient at greater risk of SMM than a live birth, so we do not exclude those cases.

      The intent of the measure is to capture anyone with a delivery encounter that is 20 or more weeks gestation, regardless of the outcome. The "Delivery Procedures" value set includes only procedures being performed and procedure codes do not specify the outcome of the delivery. Neither stillborn nor live birth (outcomes) are addressed in the logic.
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      Thank you for your question about CMS1028/PC-07 Severe Obstetric Complications. The description of the denominator in the header is “Inpatient hospitalizations for patients delivering stillborn or live birth with >= 20 weeks, 0 days gestation completed” to ensure that stillborn deliveries are not discounted when one thinks about the measure. Delivering a stillborn puts the patient at greater risk of SMM than a live birth, so we do not exclude those cases. The intent of the measure is to capture anyone with a delivery encounter that is 20 or more weeks gestation, regardless of the outcome. The "Delivery Procedures" value set includes only procedures being performed and procedure codes do not specify the outcome of the delivery. Neither stillborn nor live birth (outcomes) are addressed in the logic.
    • CMS1028v2
    • Capturing stillborn is not an option with the current value sets for this measure. How does this factor into the logic since nothing other than the Denominator description addresses stillborn including value sets?

      The specifications for 2024 state that the Denominator includes "Inpatient Hospitalizations for patients delivering stillborn or live birth with >=20 weeks, 0 days gestation completed. There are no codes in any of the value sets that we could find for stillborn. How is this being captured in the logic?

            JLeflore Joelencia Leflore
            kmclaughlin@medisolv.com Karen McLaughlin
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