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Top 10 Specification Manual Changes for 2015 Quality Reporting

Posted by Revee White on Jan 27, 2015 9:00:00 AM

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There were big changes made to the 2015 Specification Manual for the Hospital Inpatient Quality Reporting program. The changes went into effect with discharges beginning Jan. 1, 2015.

We've detailed the top 10 Specification Manual changes.

10. The lists for diagnostic Venous thromboembolism (VTE) testing have been updated for the VTE Diagnostic Test (VTE 3-6) data element. This list is more specific to lower extremity VTEs and is located on page 1-412 in the 2015 Alphabetical Data Dictionary.  

9.  For Warfarin Administration (VTE-3), the timeframe has been changed.  It now only includes Warfarin given after the VTE diagnostic test.

8.  For Reason for Discontinuation of Parenteral Anticoagulation Therapy (VTE-3), the bullet that states if rivaroxaban (Xarelto) is ordered or administered during hospitalization or prescribed at discharge, select “yes” to reason for discontinuation.  It is now required to have an MD/PA/APN link to the discontinuation of therapy and starting Xarelto therapy.

7.  For VTE Present on Admission (VTE-6), there has been a bullet added that states if patients only have a history of VTE documented, select “no” to present on admission.

6.  Documentation of a Reason for Discontinuation of Parenteral Anticoagulation Therapy (VTE-3) must be on the same day or the day before the ORDER for discontinuation.  Any sources dated/timed after discharge are now excluded. Learn more here

5.  For Stroke Last Known Well (STK-4), if there is ANY documentation by a physician/PA/APN that the last known well time is unknown, answer “no” to last known well.

4.  For Stroke Last Known Well (STK-4), the hierarchy of sources has been removed, and now “Code Stroke” or stroke specific templates should be selected regardless of other dates and times documented in the record.

3.  For VTE Prophylaxis for both Hospital and ICU admission (VTE 1-2), it is now required to enter prophylaxis given BOTH the day of and the day after hospitalization.  

2.  New allowable sources for the Comfort Measures Only data element include consultation notes and the H&P.

1.    Both VTE Confirmed and VTE Diagnostic Test (VTE 3-6) have defined the timeframe for diagnostic testing to within FOUR days prior to arrival. 

For more information about changes to quality reporting in 2015, check out:

Hospital Quality Reporting Measures Snapshot
New Resources for Inpatient Psychiatric Facilities Quality Reporting
Quality Reporting in 2015: What does it look like?
8 Clinical Data Registries that Improve Patient Outcomes

As required and optional measures continue to change, Primaris, a core measures abstraction vendor, has the flexibility to absorb your hospital's abstraction changing needs. See the full list of core measures and registries we abstract. 

Download the 2015 Hospital Quality Reporting Measures Snapshot and Crosswalk below.

Download Crosswalk



Topics: quality reporting, core measures abstraction

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