WU Health & Medical Modification of Internal Data Questions

Data Content & Standards. C. Data Governance 2. Construct and maintain the standardization of data dictionaries to meet the needs of the enterprise

I. .Data Content & Standards. C. Data Governance. 3. Demonstrate compliance with internal and external data dictionary requirements

Using a word document, please answer the questions listed below by reviewing the attached documents.

2018 Data Dictionary Document (Please research the document and answer the 5 questions below)

2017 Data Dictionary Document (Please research the document and answer the 5 questions below)

Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk)
Appendix A-10:
Data Dictionary for
MassHealth Specific Measures
RY2017
Technical Specifications Manual for
MassHealth Acute Hospital Quality Measures
(Version 10.0)
Effective with Q3-2016 discharges (07/01/16)
RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0)
Effective with Q3-2016 discharges (07/01/16)
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Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk)
Enhancements to Data Dictionary (v 10.0)
This Appendix contains the f ull set of clinical and administrative data element def initions to supplement the
maternity and care coordination measures technical specif ications outlined under Section 3 of this manual. It
also includes def initions f or all patient identif ier administrative data elements required in the MassHealth
Crosswalk Files to supplement the MassHealth Payer Files f or the nationally reported hospital quality
measures data.
This version of the data dictionary contains changes to def initions f or existing data elements and introduces
new data elements ef f ective with Q3-2016 data. These changes are summarized in table below.
Change to
Data Element
Existing
Add New
Retired:
Updates to Data Dictionary (version 10.0)
Maternity and Newborn Measures
Care Coordination Measures
(MAT-3, 4, 5)
(CCM-1, 2, 3)
(NEWB-1, 2)
• Admission to the NICU
• Exclusive Breast Milk Feeding
• Labor
• Number of Previous Live Births
• Prior Uterine Surgery
• Term Newborn
• N/A
•
•
•
•
•
•
•
•
•
Clinical Trial
• N/A
Advance Care Plan
Current Medication List
Discharge Diagnosis
Medical Procedures and Tests
Reason for Admission
Reconciled Medication List
Studies Pending at Discharge
Transmission Date
N/A
All MassHealth Records
• Admission Date
• Provider ID
• N/A
• N/A
Effective as
of Q3-2016
All updates to existing and/or new data elements are shown in underlined italic font on the table of contents
and throughout this data dictionary. The table of contents also shows which data element corresponds to the
specif ic measure it is being collected f or and the page number locator.
Data Dictionary Format and Terms
This data dictionary contains detailed inf ormation necessary f or def ining and f ormatting the collection of all
data elements, as well as the allowable values f or each data element that uses the f ollowing f ormat:
• Data Element Name: A short phrase identif ying the data element.
• Collected For: Identif ies the measure(s) requiring that data element to be collected.
• Definition: A detailed explanation of the data element.
• Suggested Data Collection Question: The wording f or a data element question in a data abstraction tool.
• Format: Length: The number of characters or digits allowed f or the data element.
• Type: The type of inf ormation the data element contains (e.g., numeric, alphanumeric, date, character, or
time).
• Occurs: The number of times the data element occurs in a single episode of care record.
• Allowable Values: A list of acceptable responses f or this data element.
• Notes for Abstraction: Notes to assist abstractor in the selection of appropriate value f or a data element.
• Suggested Data Sources: Source document f rom which data may be identif ied such as administrative or
medical record. Please note the data sources listed are not intended to ref lect a comprehensive list.
• Guidelines for Abstraction: Notes to assist abstractors in determining how data element
inclusions/exclusions should be answered.
RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0)
Effective with Q3-2016 discharges (07/01/16)
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Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk)
Adherence to data dictionary def initions provided in this EOHHS manual are necessary to ensure that data
element abstraction is accurate and reliable. This data dictionary should be used in conjunction with Section 6
(Table 6.1) of this EOHHS manual f or a list of the data elements that are subject to data validation scoring.
RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0)
Effective with Q3-2016 discharges (07/01/16)
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Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk)
Data Dictionary Table of Contents
Field Name
Page
#
Collected for
ADMIT-DATE
5
All MassHealth Records
ADMNICU
6
NEWB-1, NEWB-2
ADVCAREPLN
7
CCM-2
BIRTHDATE
9
All MassHealth Records
BORNFAC
10
NEWB-2
CMO
11
NEWB-2
CONTINFOHRDY
12
CCM-2
CONTINFOSTPEND
13
CCM-2
MEDLIST
14
CCM-2
DISCHARGE-DATE
15
All MassHealth Records
PRINDXDC
16
CCM-2
DISCHGDISP
17
All MassHealth Records
DVTP
20
MAT-5
EPISODE-OF-CARE
21
All MassHealth Records
ETHNICCODE
22
All MassHealth Records
EXBRSTFD
24
NEWB-1
FIRST-NAME
25
All MassHealth Records
GESTAGE
26
MAT-3, MAT-4, NEWB-2
ETHNIC
28
All MassHealth Records
Hospital Bill Number
HOSPBILL#
29
All MassHealth Records
ICD-10-CM Other Diagnosis Codes
OTHERDX#
30
All MassHealth Records
ICD-10-PCS Other Procedure Codes
OTHERPX#
31
All MassHealth Records
ICD-10-PCS Other Procedure Dates
OTHERPX#DT
32
All MassHealth Records
ICD-10-CM Principal Diagnosis Code
PRINDX
33
All MassHealth Records
ICD-10-PCS Principal Procedure Code
PRINPX
34
All MassHealth Records
ICD-10-PCS Principal Procedure Date
PRINPXDATE
35
All MassHealth Records
Data Element
Admission Date
Admission to the NICU
Advance Care Plan
Birthdate
Born in this Facility
Comf ort Measures Only
Contact Inf ormation 24hrs/ 7 days
Contact Inf ormation f or Studies Pending
Current Medication List
Discharge Date
Discharge Diagnosis
Discharge Disposition
DVT Prophylaxis f or Cesarean Delivery
Episode of Care
Ethnicity
Exclusive Breast Milk Feeding
First Name
Gestational Age
Hispanic Indicator
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Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk)
Field Name
Page
#
Collected for
Labor
ACTLABOR
36
MAT-3
Last Name
LAST-NAME
38
All MassHealth Records
MHRIDNO
39
All MassHealth Records
PROCTEST
40
CCM-2
NPI
42
All MassHealth Records
BILISCRN
43
NEWB-2
PARITY
44
MAT-4
Patient Identif ier
PATIENT-ID
46
All MassHealth Records
Patient Instructions
PATINSTR
47
CCM-2
Payer Source
PMTSRCE
48
All MassHealth Records
Plan f or Follow Up Care
PLANFUP
50
CCM-2
POSTAL-CODE
52
All MassHealth Records
PPFUP
53
CCM-2
PRIORUTSURG
55
MAT-3
PROVIDER-ID
56
All MassHealth Records
PROVNAME
57
All MassHealth Records
MHRACE
58
All MassHealth Records
INPTADMREAS
60
CCM-2
RECONMEDLIST
61
CCM-1
SAMPLE
63
All MassHealth Records
SEX
64
All MassHealth Records
STUDPENDDC
65
CCM-2
Term Newborn
TRMNB
66
NEWB-1
Transition Record
TRREC
68
CCM-2
Transmission Date
TRDATE
70
CCM-3
Data Element
MassHealth Member ID
Medical Procedures and Tests & Summary of
Results
National Provider ID
Newborn Bilirubin Screening
Number of Previous Live Births
Postal Code
Primary Physician/ Health Care Prof essional
f or Follow Up Care
Prior Uterine Surgery
Provider ID
Provider Name
Race
Reason for Inpatient Admission
Reconciled Medication List
Sample
Sex
Studies Pending at Discharge
RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0)
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Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk)
Data Element Name:
Admission Date
Collected For:
All MassHealth Records
Definition:
The month, day, and year of admission to acute inpatient care.
Suggested Data
Collection Question:
What is the date the patient was admitted to acute inpatient care?
Format:
Length:
Type:
Occurs:
10 – MM-DD-YYYY (includes dashes)
Date
1
Allowable Values:
MM
=
DD
=
YYYY =
Month (01-12)
Day (01-31)
Year (2000 – 9999)
Notes for Abstraction:
The intent of this data element is to determine the date that the patient was
actually admitted to acute inpatient care. Because this data element is critical in
determining the population for many measures, the abstractor should NOT
assume that the claim inf ormation f or the admission date is correct. If the
abstractor determines through chart review that the date is incorrect, for
purposes of abstraction, she/he should correct and override the downloaded
value.
For patients who are admitted to Observation status and subsequently
admitted to acute inpatient care, abstract the date that the determination
was made to admit to acute inpatient care and the order was written. Do
not abstract the date that the patient was admitted to Observation.
Example:
Medical record documentation reflects that the patient was admitted to
observation on 04-05-20xx. On 04-06-20xx the physician writes an order to
admit to acute inpatient effective 04-05-20xx. The Admission Date would be
abstracted as 04-06-20xx; the date the determination was made to admit to
acute inpatient care and the order was written.
The admission date should not be abstracted from the earliest admission order
without regards to substantiating documentation. If documentation suggests that
the earliest admission order does not reflect the date the patient was admitted to
inpatient care, this date should not be used.
Example:
Preoperative orders dated 4-6-20xx with an order to admit Inpatient.
Postoperative orders, dated 5-1-20xx, state to admit to acute inpatient. All other
documentation supports that the patient presented to the hospital for surgery on
5-1-20xx. The admission date would be abstracted as 5-1-20xx.
If there are multiple inpatient orders, use the order that most accurately reflects
the date that the patient was admitted.
For newborns that are born within this hospital, the Admission Date would be the
date the baby was born.
Suggested Data Sources:
Guidelines for Abstraction:
Inclusion
None
PRIORITY ORDER FOR THESE SOURCES
Physician orders
Face sheet
Exclusion
Admit to observation
Arrival date
RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0)
Effective with Q3-2016 discharges (07/01/16)
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Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk)
Data Element Name:
Admission to NICU
Collected For:
NEWB-1, NEWB-2
Definition:
Documentation that the newborn was admitted to the Neonatal Intensive
Care Unit (NICU) at this hospital any time during the hospitalization.
Suggested Data
Collection Question:
Format:
Allowable Values:
Was the newborn admitted to the NICU at this hospital at any time during the
hospitalization?
Length: 1
Type: Alphanumeric
Occurs: 1
Y (Yes)
N (No)
Notes for Abstraction:
There is documentation that the newborn was admitted to
the NICU at this hospital at any time during the
hospitalization.
There is no documentation that the newborn was admitted to
the NICU at this hospital at any time during the
hospitalization or unable to determine f rom medical record
documentation.
A NICU is def ined as a hospital unit providing critical care services which is
organized with personnel and equipment to provide continuous lif e support
and comprehensive care f or extremely high-risk newborn inf ants and those
with complex and critical illness (source: American Academy of Pediatrics).
Names of NICUs may vary f rom hospital to hospital. Level designations and
capabilities also vary f rom region to region and cannot be used alone to
determine if the nursery is a NICU.
If the newborn is admitted to the NICU f or observation or transitional care,
select allowable value “no”. Transitional care is def ined as a stay of 4 hours
or less in the NICU. There is no time limit for admission to observation.
If an order to admit to the NICU is not f ound in the medical record, there must
be supporting documentation present in the medical record indicating that the
newborn received critical care services in the NICU in order to answer yes.
Examples of supporting documentation include, but are not limited to the
NICU admission assessment and NICU f low sheet.
If your hospital does not have a NICU, you must always select Value “No”
regardless of any reason a newborn is admitted to a nursery.
Suggested Data Sources:
Guidelines for Abstraction:
Inclusion
None
Nursing notes
Discharge summary
Physician progress notes
Exclusion
None
RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0)
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Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk)
Data Element Name:
Advance Care Plan
Collected For:
CCM-2
Definition:
An Advance Care Plan ref ers to a written statement of patient instructions or
wishes regarding future use of life sustaining medical treatment. This data
element may also be called advance directive, living will, healthcare proxy, DNR,
power of attorney.
A transition record that included documentation of an Advance Care Plan or a
documented reason for not providing an advance care plan.
Suggested Data
Collection Question:
Does the Transition Record include documentation of an Advance Care Plan?
Format:
Length: 1
Type: Alphanumeric
Occurs: 1
Allowable Values:
Y (Yes)
The transition record includes documentation of an Advance Care Plan
or a documented reason for not providing an advance care plan.
N (No)
The transition record does not include documentation of an Advance Care
Plan or a documented reason for not providing an advance care plan.
Notes for Abstraction:
The presence of an advance care plan must be documented on the transition record
f or all patients 18 years and over.
A checkbox or documentation of the presence of an advance directive, health
care proxy, power of attorney, DNR or Full Code status etc must be
documented.
If there is no advance care plan, a reason must be documented.
A documented reason for not providing an advance care plan includes:
• The care plan was discussed but the patient did not wish or was not able to
name a health care proxy
• The patient was not able to provide an advance care plan
• Documentation as appropriate that the patient’s cultural and/ or spiritual
belief s preclude a discussion of advance care planning as it would be
viewed as harmf ul to the patient’s beliefs and thus harmful to the physician
patient relationship
• The patient was < 18 years of age (calculated from Date of Birth and Admission Date) • Patient ref usal of advance care plan information or decision for an advance care plan, select Y(Yes) Documentation in the medical record that there is no advance care plan without a reason does not meet the requirement. The physician decision not to address the Advance Care Plan topic with the patient does not meet the requirement. In the event the patient is transferred to another site of care and the advance care plan information is provided to the next site of care, this data element may be documented as Y(Yes). Documentation of Y(Yes) also applies to patients discharged and admitted within the same site. RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 8 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) A copy of an Advance Care Plan document within the medical record does not meet the requirement. The Transition Record must have documentation of an Advance Care Plan. Suggested Data Sources: Transition Record Discharge Instructions Guidelines for Abstraction: Inclusion Advance Care Directives Power of Attorney Health care proxy Do Not Resuscitate – DNR etc Living Will Documentation of code status: Full Code Exclusion Patients < 18 years of age RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 9 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) Data Element Name: Birthdate Collected For: All MassHealth Records Definition: The month, day, and year the patient was born. NOTE: Patient’s age (in years) is calculated by Admission Date minus Birthdate. The algorithm to calculate age must use the month and day portion of admission date and birthdate to yield the most accurate age. Suggested Data Collection Question: What is the patient’s date of birth? Format: Length: Type: Occurs: 10 – MM-DD-YYYY (includes dashes) Date 1 Allowable Values: MM = DD = YYYY = Month (01-12) Day (01-31) Year (1880 – 9999) Notes for Abstraction: Because this data element is critical in determining the population for many measures, the abstractor should NOT assume that the claim information for the birthdate is correct. If the abstractor determines through chart review that the date is incorrect, for purposes of abstraction, she/he should correct and override the downloaded value. If the abstractor is unable to determine the correct birthdate through chart review, she/he should default to the date of birth on the claim inf ormation. Suggested Data Sources: Emergency department record Face sheet Registration form Guidelines for Abstraction: Inclusion None Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 10 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) Data Element Name: Born in this Facility Collected For: NEWB-2 Definition: Documentation that the newborn was born in this f acility Suggested Data Collection Question: Was the newborn born in this f acility? Format: Allowable Values: Length: 1 Type: Alphanumeric Occurs: 1 Y (Yes) N (No) There is documentation that the newborn was born in this f acility There is documentation that the newborn was born outside this f acility or unable to determine f rom record documentation. Notes for Abstraction: The f ollowing are NOT considered born in this facility: • Delivered at home • Newborn is transf erred in from another facility Suggested Data Sources: Admission History and Physical Nursing notes Physician progress notes Discharge summary Guidelines for Abstraction: Inclusion None Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 11 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) Data Element Name: Comf ort Measures Only Collected For: NEWB-2 Definition: Comf ort Measures Only ref ers to medical treatment of a dying newborn where the natural dying process is permitted to occur while assuring maximum comf ort. It includes attention to the psychological and spiritual needs of the f amily and support f or the dying newborn and the newborn's f amily. Comf ort Measures Only is commonly ref erred to as “comf ort care” by the general public. It is not equivalent to a physician order to withhold emergency resuscitative measures such as Do Not Resuscitate (DNR). Suggested Data Collection Question: Is there documentation of Comfort Measures Only? Format: Length: Type: Occurs: 1 Alphanumeric 1 Allowable Values: Y (Yes) There is documentation of Comfort Measures Only during this hospitalization. N (No) There is no documentation of Comfort Measures Only during this hospitalization or unable to determine from medical record documentation. Notes for Abstraction: Physician/APN/PA documentation of comfort measures only (hospice, comf ort care, etc.) mentioned in the f ollowing contexts suffices: • Comf ort measures only recommendation • Order f or consultation or evaluation by a hospice care service • Family request f or comf ort measures only • Plan f or comf ort measures only • Ref erral to hospice care service • Discussion of comfort measures Suggested Data Sources: Guidelines for Abstraction: Inclusion • Brain dead • Brain death • Comf ort care • Comf ort measures • Comf ort measures only (CMO) • Comf ort only • DNR-CC • End of lif e care • Hospice • Hospice care • Organ harvest • Terminal care • Terminal extubation PHYSICIAN/APN/PA DOCUMENTATION ONLY • Consultation notes • Discharge summary • DNR f orms • History and physical • Physician orders Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 12 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) Data Element Name: Contact Inf ormation 24hrs/ 7 days Collected For: CCM-2 Definition: Contact inf ormation 24hrs/ 7 days ref ers to any phone number that is listed for the patient to call for questions, concerns, or emergencies that is answered 24 hours a day, 7 days a week. A transition record that included documentation on 24 hr/ 7 day Contact Inf ormation for questions, concerns, or emergencies related to the inpatient stay. Suggested Data Collection Question: Does the Transition Record include 24 hr/ 7 day Contact Information for questions, concerns, or emergencies related to the inpatient stay? Format: Length: 1 Type: Alphanumeric Occurs: 1 Allowable Values: Y (Yes) The transition record includes 24 hr/ 7 day Contact Information for questions, concerns, or emergencies related to the inpatient stay. N (No) Notes for Abstraction: The transition record does not include 24 hr/ 7 day Contact Inf ormation f or questions, concerns, or emergencies related to the inpatient stay. Any number listed that is answered 24 hours a day, 7 days a week . Must be clear to the patient that this is the number to call for questions, concerns, or emergencies. Examples: • For any questions, please call your PCP at … • 24/7 Contact Inf ormation: Emergency Department phone number is ____ • Call 911 if chest pain In the event the patient is transferred to another site of care, this data element may be documented as Y(Yes). Documentation of Y(Yes) also applies to patients discharged and admitted within the same site of care. Suggested Data Sources: Transition Record Discharge Instructions Guidelines for Abstraction: Inclusion • Call 911 • Emergency Room Phone Number • Primary Care Physician Phone Number • Specialist Phone Number • Discharging Unit Phone Number • Hospital phone number Exclusion RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 13 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) Data Element Name: Contact Inf ormation f or Studies Pending at Discharge Collected For: CCM-2 Definition: Contact inf ormation for studies pending refers to the name and/or phone number of a contact person that will provide information on tests when results are pending at discharge. A transition record that included Contact Inf ormation for obtaining results of studies pending at discharge. Suggested Data Collection Question: Does the Transition Record include Contact Information for obtaining results of studies pending at discharge? Format: Length: 1 Type: Alphanumeric Occurs: 1 Allowable Values: Y (Yes) The transition record includes Contact Information for Studies Pending at Discharge or documentation that there were no studies pending at discharge. N (No) The transition record does not include Contact Information for Studies Pending at Discharge or documentation that there were no studies pending at discharge. Notes for Abstraction: If it is documented on the Transition Record that there were no studies pending at discharge, contact information for studies pending is not required and the abstractor should select Y(Yes). The physician and/ or phone number to contact for Studies Pending must be clearly stated. Statements such as “Contact the Follow-up Physician listed above for any pending test results” will be accepted as long as the physician’s name and /or phone number are documented on the transition record. “Dr Jackson will discuss pending test results at your follow up appointment” will be accepted. “MD to discuss at next visit” will NOT be accepted. In the event of a transfer to another site of care, this element may be documented as Y(Yes). Documentation of Y(Yes) also applies to patients discharged and admitted within the same site. See also data element Studies Pending at Discharge Suggested Data Sources: Transition Record Discharge Instructions Guidelines for Abstraction: Inclusion • Primary Care Physician • Name of Next Provider or Site of Care • Specialist Of f ice • Hospital Lab or Radiology Department Exclusion RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 14 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) Data Element Name: Current Medication List Collected For: CCM-2 Definition: A Current Medication List is a list of all medications (continued and new) to be taken by the patient after discharge. A transition record that included a Current Medication List given to the patient at the time of inpatient discharge. Suggested Data Collection Question: Does the Transition Record include a Current Medication List? Format: Length: 1 Type: Alphanumeric Occurs: 1 Allowable Values: Y (Yes) The Transition Record includes a current medication list at the time of discharge or documentation of no medications. N (No) The Transition Record does not include a current medication list at the time of discharge or documentation of no medications. Notes for Abstraction: If there are no current medications at discharge, there must be documentation of “none” or “N/A”. the abstractor selects “Yes” A reconciled medication list given to the patient at discharge meets the requirement f or Current Medication List. In the event the patient is transferred to another site of care and a listing of current medications is provided to the next site of care, this data element may be documented as Y(Yes). Documentation of Y(Yes) also applies to patients discharged and admitted within the same site. Suggested Data Sources: Guidelines for Abstraction: Inclusion Transition Record Discharge Instructions Discharge Medication Reconciliation Form Exclusion RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 15 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) Data Element Name: Discharge Date Collected For: All MassHealth Records Definition: The month, day, and year the patient was discharged from acute care, left against medical advice (AMA), or expired during this stay. Suggested Data Collection Question: What is the date the patient was discharged from acute care, left against medical advice (AMA), or expired during this stay? Format: Length: Type: Occurs: 10 – MM-DD-YYYY (includes dashes) Date 1 Allowable Values: MM = DD = YYYY = Month (01-12) Day (01-31) Year (2000 – 9999) Notes for Abstraction: Because this data element is critical in determining the population for many measures, the abstractor should NOT assume that the claim information for the discharge date is correct. If the abstractor determines through chart review that the date is incorrect, for purposes of abstraction, she/he should correct and override the downloaded value. If the abstractor is unable to determine the correct discharge date through chart review, she/he should default to the discharge date on the claim information. Suggested Data Sources: Discharge summary Face sheet Nursing discharge notes Physician orders Progress notes Transf er note Guidelines for Abstraction: Inclusion None Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 16 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) Data Element Name: Discharge Diagnosis Collected For: CCM-2 Definition: The discharge diagnosis is defined as the diagnosis determined at discharge, af ter procedures and tests were administered, to be chiefly responsible for resulting in the patient being admitted for inpatient hospital care. A transition record that included the Discharge Diagnosis. Suggested Data Collection Question: Does the Transition Record include the Discharge Diagnosis? Format: Length: 1 Type: Alphanumeric Occurs: 1 Allowable Values: Y (Yes) The transition record includes the Discharge Diagnosis. N (No) Notes for Abstraction: The transition record does not include the Discharge Diagnosis. The discharge diagnosis must be specifically documented as the discharge diagnosis and differentiated from the Reason for Inpatient Admission. Discharge instructions with a title of the patient’s condition does not meet the requirement f or documentation of the patient’s discharge diagnosis. Examples: Postpartum discharge instructions, Knee Replacement discharge instructions. A discharge diagnosis of “Postpartum” does not meet the requirement. The delivery type must be specified. For example: vaginal delivery, spontaneous vaginal delivery (SVD), Cesarean section etc. If the admission and discharge diagnosis are the same, documentation of “Same” f or the discharge diagnosis will be accepted. The abstractor should select Y (Yes). For example, a patient’s admission diagnosis is pneumonia and the documented discharge diagnosis is pneumonia. In the event the patient is transferred to another site of care and the discharge diagnosis is provided to the next site of care, this data element may be documented as Y(Yes). Documentation of Y(Yes) also applies to patients discharged and admitted within the same site. Suggested Data Sources: Transition Record Discharge Instructions Guidelines for Abstraction: Inclusion • Discharge diagnosis • Final diagnosis • Primary diagnosis at discharge • Principal diagnosis • Working diagnosis Exclusion Post-op diagnosis Secondary diagnosis RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 17 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) Data Element Name: Discharge Disposition Collected For: All MassHealth Records Definition: The f inal place or setting to which the patient was discharged on the day of discharge. Suggested Data Collection Question: What was the patient’s discharge disposition on the day of discharge? Format: Length: Type: Occurs: 1 Alphanumeric 1 Allowable Values: 1 Home 2 Hospice- Home 3 Hospice- Health Care Facility. 4 Acute Care Facility 5 Other Health Care Facility 6 Expired 7 Lef t Against Medical Advice / AMA 8 Not Documented or Unable to Determine (UTD) Notes for Abstraction: • Only use documentation written on the day prior to discharge through 30 days af ter discharge when abstracting this data element. Example: Documentation in the discharge planning notes on 04-01-20xx state that the patient will be discharged back home. On 04-06-20xx the physician orders and nursing discharge notes on the day of discharge ref lect that the patient was being transf erred to skilled care. The documentation from 04-06-20xx would be used to select value “5”. • The medical record must be abstracted as documented (taken at “f ace value”). Inf erences should not be made based on internal knowledge. • If there is documentation that further clarifies the level of care, that documentation should be used to determine the correct value to abstract. If documentation is contradictory, use the latest documentation. Example: o Discharge summary dictated 2 days after discharge states patient went “home”. Physician note on day of discharge further clarifies that the patient will be going “home with hospice”. Select value “2”(HospiceHome) o Discharge planner note from day before discharge states “XYZ Nursing Home”. Discharge order from day of discharge states “Discharge home”. Contradictory documentation, use latest. Select value “1”(Home). o Physician order on discharge states “Discharge to ALF”. Discharge instruction sheet completed after physician order states patient discharged to “SNF”. Contradictory documentation, use latest. Select value “5” (Other Health Care Facility). RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 18 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) • If documentation is contradictory, and you are unable to determine the latest documentation, select the disposition ranked highest (top to bottom) in the f ollowing list. See inclusion lists for examples. o Acute Care Facility o Hospice-Health Care Facility o Hospice-Home o Other Health Care Facility o Home • Hospice (values “2” and “3”) includes discharges with hospice referrals and evaluations. • If the medical record states only that the patient is being discharged to another hospital and does not reflect the level of care that the patient will be receiving, select value “4”. • If the medical record identifies the facility the patient is being discharged to by name only (e.g., “Park Meadows”), and does not reflect the type of facility or level of care, select value “5” (Other Health Care Facility). • If the medical record states only that the patient is being “discharged” and does not address the place or setting to which the patient was discharged, select value “1” (Home). • When determining whether to select value “7” (Lef t Against Medical Advice/ AMA): o Explicit “left against medical advice” documentation is not required. E.g., “Patient is ref using to stay for continued care”- Select value “7”. o Documentation suggesting that the patient left before discharge instructions could be given does not count. o A signed AMA form is not required for the purposes of this data element. o Do not consider AMA documentation and other disposition documentation as “contradictory”. If any source states the patient left against medical advice, select value “7”, regardless of whether the AMA documentation was written last. E.g., AMA form signed and discharge instruction sheet states “Discharged home with belongings”- Select “7”. Suggested Data Sources: Discharge instruction sheet Discharge planning notes Discharge summary Nursing discharge notes Physician orders Progress notes Social service notes Transf er record Excluded Data Source: Any documentation prior to the last two days of hospitalization. Guidelines for Abstraction: Inclusion For Value 1: • Assisted Living Facilities (ALFs)- includes ALFs and assisted living care at nursing home, intermediate care, and skilled nursing f acilities • Court/Law Enf orcement- includes detention f acilities, jails, prison • Home- includes board and care, f oster or residential care, group or personal care homes, retirement communities, and homeless shelters • Home with Home Health Services • Outpatient Services including outpatient procedures at another hospital, Outpatient Chemical Dependency Programs and Partial Hospitalization Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 19 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) For Value 2: • Hospice in the home (or other “Home” setting as above in Value 1) For Value 3: • Hospice Care- General Inpatient and Respite • Hospice Care- Residential and Skilled Facilities • Hospice Care- Other Health Care Facilities (excludes home) For Value 4: • Acute Short Term General and Critical Access Hospitals • Cancer and Children’s Hospitals • Department of Def ense and Veteran’s Administration Hospitals For Value 5: • Extended or Immediate Care Facility (ECF/ICF) • Long Term Acute Care Hospital (LTACH) • Nursing Home or Facility including Veteran’s Administration Nursing Facility • Psychiatric Hospital or Psychiatric Unit of a Hospital • Rehabilitation Facility including Inpatient Rehabilitation Facility/ Hospital or Rehabilitation Unit of a Hospital • Skilled Nursing Facility (SNF), Sub -Acute Care or Swing Bed • Transitional Care Unit (TCU) • Veterans Home RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 20 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) Data Element Name: DVT Prophylaxis f or Cesarean Delivery Collected For: MAT-5 Definition: Deep vein thrombosis (DVT) prophylaxis is defined as medical prophylaxis including the administration of fractionated or unfractionated Heparin or heparinoid, or mechanical prophylaxis defined as the application of pneumatic compression devices to the patient prior to Cesarean delivery. Suggested Data Collection Question: Was DVT prophylaxis administered to the patient prior to Cesarean delivery? Format: Length: Type: Occurs: 1 Alphanumeric 1 Allowable Values: Y (Yes) There is documentation of the administration of fractionated or unf ractionated Heparin or heparinoid, or application of pneumatic compression devices prior to Cesarean delivery. N (No) There is no documentation of the administration of fractionated or unf ractionated Heparin or heparinoid, or application of pneumatic compression devices prior to Cesarean delivery OR unable to determine f rom medical record documentation. Notes for Abstraction: None Suggested Data Sources: Circulator notes Emergency Department record Graphic/f low sheet Medication Administration Record Nursing notes Operative notes Physician notes Preoperative nursing notes Progress notes Guidelines for Abstraction: Inclusion • Fractionated or unf ractionated heparin or heparinoid • Pneumatic compression devices Exclusion Any f orm of DVT prophylaxis not included in the Guidelines f or Abstraction INCLUSION list. RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 21 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) Data Element Name: Episode of Care Collected For: All MassHealth Records Definition: The measure code f or the data that is being submitted. Suggested Data Collection Question: What is the measure code for the data being submitted? Format: Length: Type: Occurs: 22 Alphanumeric 1 Allowable Values: CCM ED MAT-3 MAT-4 MAT-5 NEWB 1 NEWB 2 TOB Care Coordination (includes CCM-1, CCM-2, & CCM-3) Emergency Department Times for admitted patients Elective Delivery Cesarean Delivery DVT Prophylaxis f or Cesarean Delivery Exclusive Breast Milk Feeding Newborn Bilirubin Screening Tobacco Treatment Notes for Abstraction: None Suggested Data Sources: Not Applicable Guidelines for Abstraction: Inclusion None Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 22 Consolidated Data Dictionary (MAT-3, MAT-4, MAT-5, NEWB-1, NEWB-2, CCM 1, 2, 3, Crosswalk) Data Element Name: Ethnicity Collected For: All MassHealth Records Definition: The patient’s self-reported ethnicity as defined by Massachusetts regulation noted in Section 2 of this EOHHS manual. The def inition of the “Ethnicity” data element differs from the CMS National Hospital Inpatient Quality Measures reporting requirement. Suggested Data Collection Question: What is the patient’s self-reported ethnicity? Format: Length: Type: Occurs: Allowable Values: Select one: Below is a partial listing of ethnicity codes. See Section 2.C.3 of this manual f or new coding standards that will apply to ethnicity subgroup codes and allowable values (in asterisks) noted in Table below, as of Q1-2015 data. Code 6 Alphanumeric 1 Allowable Value Code Allowable Value 2060-2 Af rican* 2071-9 Haitian 2058-6 Af rican American 2158-4 Honduran American 2039-6 Japanese 2028-9 Asian* 2040-4 Korean 2029-7 Asian Indian 2041-2 Laotian Brazilian 2148-5 Mexican* Cambodian 2118-8 Middle Eastern* AMERCN BRAZIL 2033-9 CVERDN Cape Verdean PORTUG CARIBI Caribbean Island* 2034-7 Chinese 2169-1 Columbian 2161-8 Salvadoran 2182-4 Cuban 2047-9 Vietnamese 2184-0 Dominican 2155-0 Central American* Eastern European 2165-9 South American* 2108-9 European* OTHER Other Ethnicity 2036-2 Filipino 2157-6 Guatemalan EASTEU 2180-8 Portuguese RUSSIA UNKNOW RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) Puerto Rican Russian Unknown/not specif ied 23 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Notes for Abstraction: Hospitals must use the revised Massachusetts regulation Ethnicity codes and allowable values when preparing all MassHealth data files for submission. Only collect ethnicity data that is self-reported by the patient. Do not abstract a clinician’s assessment documented in the medical record. The terms “nationality” and “culture” are synonymous to ethnicity. If numeric code is used, include the hyphen after the fourth number. If the medical record contains conflicting documentation on patient self reported ethnicity, abstract the most recent dated documentation. If the medical record contains multiple patient self-reported ethnicities on one document, abstract the first self-reported ethnicity listed (e.g. – American/Irish/French, select American). If the medical record contains 1) self reported as Unknown or 2) no ethnicity can be f ound in the medical record, select “UNKNOW”. If the ethnicity documented in the medical record is not listed in any of the revised ethnicity values in Section 2.C.3, Table 2.3, select “OTHER”. If codes and allowable values, other than those listed above, are documented in the medical record, a crosswalk that links the hospitals’ codes/values to the Massachusetts regulation requirements must be provided for chart validation. Suggested Data Sources: Guidelines for Abstraction: Inclusion None Administrative record Face sheet (Emergency Department / Inpatient) Nursing admission assessment Prenatal initial assessment form Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 24 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Exclusive Breast Milk Feeding Collected For: NEWB -1 Definition: Documentation that the newborn was exclusively f ed breast milk during the entire hospitalization. Exclusive breast milk f eeding is def ined as a newborn receiving only breast milk and no other liquids or solids except f or drops or syrups consisting of vitamins, minerals, or medicines. Suggested Data Collection Question: Is there documentation that the newborn was exclusively f ed breast milk during the entire hospitalization? Format: Length: Type: Occurs: 1 Alphanumeric 1 Allowable Values: Y (Yes) There is documentation that the newborn was exclusively f ed breast milk during the entire hospitalization. N (No) There is no documentation that the newborn was exclusively f ed breast milk during the entire hospitalization OR unable to determine f rom medical record documentation. Notes for Abstraction: If the newborn receives any other liquids including water during the entire hospitalization, select allowable value "No". Exclusive breast milk f eeding includes the newborn receiving breast milk via a bottle or other means beside the breast. Sweet-Ease® or a similar 24% sucrose and water solution given to the newborn f or the purpose of reducing discomf ort during a painf ul procedure is classif ied as a medication and is not considered a supplemental f eeding. If the newborn receives donor breast milk, select allowable value "Yes". If breast milk f ortif ier is added to the breast milk, select allowable value "Yes". In cases where there is conf licting documentation and both exclusive breast milk f eeding and f ormula supplementation is documented, select allowable value "No". If the newborn received drops of water or f ormula dribbled onto the mother's breast to stimulate latching and not an actual f eeding, select yes. If the newborn received IV fluids this is the same as a medication and not a feeding. Actual feedings must be abstracted from the only acceptable data sources regardless of any documentation about feeding plans and changes to feeding plans which mention inclusion of formula. Suggested Data Sources: Guidelines for Abstraction: Inclusion None Diet Flow Sheets Feeding f low sheets Intake and output sheets Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 25 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: First Name Collected For: All MassHealth Records Definition: The patient’s first name. Suggested Data Collection Question: What is the patient’s first name? Format: Length: Type: Occurs: Allowable Values: Enter the patient’s first name. Notes for Abstraction: None Suggested Data Sources: Emergency department record Face sheet History and physical Guidelines for Abstraction: Inclusion None 30 Alphanumeric 1 Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 26 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Gestational Age Collected For: MAT-3, MAT-4, NEWB-2 Definition: The weeks of gestation completed at the time of delivery. Gestational age is def ined as the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s f inal estimate of gestation, irrespective of whether the gestation results in a live birth or a f etal death. This estimate of gestation should be determined by all perinatal f actors and assessments such as ultrasound, but not the newborn exam. Ultrasound taken early in pregnancy is pref erred (source: American College of Obstetricians and Gynecologists reVITALize Initiative). Suggested Data Collection Question: How many weeks of gestation were completed at the time of delivery? Format: Length: Type: Occurs: 3 or UTD Alphanumeric 1 Allowable Values: In completed weeks No leading zero UTD 1-50 Notes for Abstraction: Use completed weeks of gestation, do not “round up”. For example, an inf ant born at 35 weeks 6 days is at a gestational age of 35 weeks. The delivery or operating room record should be reviewed first for gestational age. If gestational age is not recorded in the delivery or op erating room record, then continue to review the data sources in the following order: history and physical; prenatal forms; clinician admission progress note and discharge summary until a positive finding for gestational age is found. In cases where there is conflicting data, the gestational age found in the first document according to the order listed above should be used. The phrase “estimated gestational age” is an acceptable descriptor for gestational age. If the patient has not received prenatal care and no gestational age was documented, select allowable value UTD. When the admission date is different from the delivery date, use documentation of the gestational age completed closest to the delivery date. Gestational age should be documented by the clinician as a numeric value between 1-50. Gestational age (written with both weeks and days, eg. 39 weeks and 0 days) is calculated using the best obstetrical Estimated Due Date (EDD) based on the f ollowing f ormula: Gestational Age = (280 - (EDD - Ref erence Date)) / 7 (source: American College of Obstetricians and Gynecologists reVITALize Initiative). The clinician, not the abstractor, should perf orm the calculation to determine gestational age. If the gestational age entered by the clinician in the f irst document listed above is obviously incorrect (in error) but it is a valid number or two different numbers are listed in the f irst document and the correct number can be supported with RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 27 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) documentation in the other acceptable data sources in the medical record, the correct number may be entered. Documentation in the acceptable data sources may be written by the following clinicians: physician, certified nurse midwife (CNM), advanced practice nurse/physician assistant (APN/PA) or registered nurse (RN). It is acceptable to use data derived from vital records reports received from state or local departments of public health if they are available and are directly derived f rom the medical record with a process in place to confirm their accuracy. If this is the case, these may be used in lieu of the acceptable data sources listed below. The EHR takes precedence over a hand written entry if dif ferent gestational ages are documented in equivalent data sources, e.g., delivery record and delivery summary. Suggested Data Sources: ONLY ACCEPTABLE SOURCES IN ORDER OF PREFERENCE • • • • • • Guidelines for Abstraction: Inclusion None Delivery room record, note or summary Operating room record, note or summary History and physical Prenatal f orms Admission clinician progress notes Discharge summary Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 28 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Hispanic Indicator Collected For: All MassHealth Records Definition: The patient self-reported as Hispanic, Latino, or Spanish as defined by Massachusetts regulation noted in Section 2 of this EOHHS manual. The def inition of the “Hispanic” data element in the Massachusetts regulation dif fers from the CMS National Hospital Inpatient Quality Measures reporting requirement. Suggested Data Collection Question: Is there documentation that the patient self-reported as Hispanic, Latino, or Spanish? Format: Length: Type: Occurs: 1 Alphanumeric 1 Allowable Values: Y (Yes) Patient self -reported as Hispanic / Latino / Spanish. N (No) Patient did not self-report as Hispanic / Latino / Spanish or unable to determine from medical record documentation. Notes for Abstraction: As noted in Section 2, Table 2.3 comparison chart, the Massachusetts regulation valid entry codes and allowable values for the “Hispanic” data element dif fers from CMS reporting requirement. Hospitals must use the Massachusetts regulation definition and allowable values when preparing all MassHealth data f iles for submission. Only collect data that is self-reported by the patient. Do not abstract a clinician’s assessment documented in the medical record. If the medical record contains conf licting documentation on patient self reported Hispanic Indicator, abstract the most recent dated documentation. If the patient’s self -reported Race is Hispanic, abstract “Yes” f or Hispanic Indicator. Suggested Data Sources: Administrative records Face sheet (Emergency Department / Inpatient) Nursing admission assessment Prenatal initial assessment form Guidelines for Abstraction: Inclusion The term “Hispanic” or “Latino” can be used in addition to “Spanish origin” to include a person of Spanish culture or origin regardless of race. Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 29 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Hospital Bill Number Collected For: All MassHealth Records Definition: The def inition of the hospital bill number (or account number) is the unique number assigned to each patient's bill that distinguishes the patient and their bill f rom all others in that institution as def ined by Massachusetts regulation noted in Section 2 of this EOHHS manual. Suggested Data Collection Question: What is the patient’s hospital bill number? Format: Length: Type: Occurs: Allowable Values: Up to 20 letters and/ or numbers Notes for Abstraction: None Suggested Data Sources: Face sheet Guidelines for Abstraction: Inclusion • Account Number • Bill Number 20 Alphanumeric 1 Exclusion RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 30 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: ICD-10-CM Other Diagnosis Codes Collected For: All MassHealth Records Definition: The other or secondary ICD-10-CM codes associated with the diagnosis for this hospitalization. Suggested Data Collection Question: What were the ICD-10-CM other diagnosis codes selected for this medical record? Format: Length: Type: Occurs: Allowable Values: Any valid diagnosis code as per the CMS ICD-10-CM master code table (2016 Code Descriptions in Tabular Order): https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-andGEMs.html Notes for Abstraction: None Suggested Data Sources: Discharge summary Face sheet Guidelines for Abstraction: Inclusion None 3-7 (without decimal point or dot) Character (upper or lower case) 24 Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 31 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: ICD-10-PCS Other Procedure Codes Collected For: All MassHealth Records Definition: The other or secondary ICD-10-PCS codes identifying all significant procedures other then the principal procedure. Suggested Data Collection Question: What were the ICD-10-PCS code(s) selected as other procedure(s) for this record? Format: Length: Type: Occurs: Allowable Values: Any valid procedure code as per the CMS ICD-10-PCS master code table (2016 PCS Long and Abbreviated Titles): https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-andGEMs.html Notes for Abstraction: None Suggested Data Sources: Discharge summary Face sheet Guidelines for Abstraction: Inclusion None 3-7 (without decimal point or dot) Character (upper or lower case) 24 Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 32 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: ICD-10-PCS Other Procedure Dates Collected For: All MassHealth Records Definition: The month, day, and year when the associated procedure(s) was (were) perf ormed. Suggested Data Collection Question: What were the date(s) the other procedure(s) were perf ormed? 10 – MM-DD-YYYY (included dashed) or UTD Date 24 Format: Length: Type: Occurs: Allowable Values: MM = Month (01-12) DD = Day (01-31) YYYY = Year (2001 – Current Year) UTD = Unable to Determine Notes for Abstraction: • If the procedure date for the associated procedure is unable to be determined f rom the medical record, select “UTD”. • The medical record must be abstracted as documented (taken at “f ace value”). When the date documented is obviously in error (not valid format/range or outside of the parameters of care [after Discharge Date]) and no other documentation is found that provides this information, the abstractor should select “UTD”. Examples: • Documentation indicates the ICD-10-PCS Other Procedure Dates was 02-42-20xx. No other documentation in the medical record provides a valid date. Since the ICD-10-PCS Other Procedure Dates is outside of the range listed in the Allowable Values for “Day”, It is not a valid date and the abstractor should select “UTD” • Patient expires on 02-12-20xx and documentation indicates the ICD10-PCS Other Procedure Dates was 03-12-20xx. Other documentation in the medical records supports the date of death as being accurate. Since the ICD-10-PCS Other Procedure Dates is after the Discharge Date (death), it is outside of the parameters of care and abstractor should select “UTD” Notes: Transmission of a case with an invalid date as described above will be rejected f rom the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” f or ICD-10-PCS Other Procedure Dates allows the case to be accepted in the warehouse Suggested Data Sources: Guidelines for Abstraction: Inclusion None Consultation notes Diagnostic test reports Discharge summary Face sheet Operative notes Procedure notes Progress notes Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 33 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: ICD-10-CM Principal Diagnosis Code Collected For: All MassHealth Records Definition: The ICD-10-CM diagnosis code that is primarily responsible for the admission of the patient to the hospital for care during this hospitalization. Suggested Data Collection Question: What was the ICD-10-CM code selected as the principal diagnosis for this record? Format: Length: Type: Occurs: Allowable Values: Any valid diagnosis code as per the CMS ICD-10-CM master code table (2016 Code Descriptions in Tabular Order): https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-andGEMs.html Notes for Abstraction: None Suggested Data Sources: Discharge summary Face sheet Guidelines for Abstraction: Inclusion None 3-7 (without decimal point or dot) Character (upper or lower case) 1 Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 34 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: ICD-10-PCS Principal Procedure Code Collected For: All MassHealth Records Definition: The principal procedure is the procedure performed for definitive treatment rather than diagnostic or exploratory purposes, or which is necessary to take care of a complication. Suggested Data Collection Question: What was the ICD-10-PCS code selected as the principal procedure f or this record? Format: Length: Type: Occurs: Allowable Values: Any valid procedure code as per the CMS ICD-10-PCS master code table (2016 PCS Long and Abbreviated Titles): https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-andGEMs.html Notes for Abstraction: None Suggested Data Sources: Discharge summary Face sheet Guidelines for Abstraction: Inclusion None 3-7 (without decimal point or dot) Character (upper or lower case) 1 Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 35 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: ICD-10-PCS Principal Procedure Date Collected For: All MassHealth Records Definition: The month, day, and year when the principal procedure was perf ormed. Suggested Data Collection Question: What was the date the principal procedure was perf ormed? Format: Length: Type: Occurs: 10-MM-DD-YYYY (includes dashes) or UTD Date 1 Allowable Values: MM = Month (01-12) DD = Day (01-31) YYYY = Year (2001-Current Year) UTD = Unable to Determine Notes for Abstraction: If the principal procedure date is unable to be determined from medical record documentation, select “UTD” The medical record must be abstracted as documented (taken at “f ace value”). When the date documented is obviously in error (not valid date/format or is outside of the parameters of care [after Discharge Date]) and no other documentation is found that provides this information, the abstractor should select “UTD” Examples: • Documentation indicates the ICD-10-PCS Principal Procedure Date was 02-42-20xx. No other documentation n the medical record provides a valid date. Since the ICD-10-PCS Principal Procedure Date is outside of the range listed in the Allowable Values for “Day”, it is not a valid date and the abstractor should select “UTD” • Patient expires on 02-12-20xx and documentation indicates the ICD-10PCS Principal Procedure Date was 03-12-20xx. Other documentation in the medical record supports the date of death as being accurate. Since the ICD-10-PCS Principal Procedure Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select “UTD”. Note: Transmission of a case with an invalid date as described above will be rejected f rom the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” f or ICD-10-PCS Principal Procedure Date allows the case to be accepted into the warehouse. Suggested Data Sources: Guidelines for Abstraction: Inclusion None Consultation notes Diagnostic test reports Discharge summary Face sheet Operative notes Procedure notes Progress notes Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 36 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Labor Collected For: MAT-3 Definition: Documentation by the clinician that the patient was in labor prior to induction and/or cesarean birth. Suggested Data Collection Question: Is there documentation that the patient was in labor prior to induction and/or cesarean birth? Format: Length: Type: Occurs: 1 Alphanumeric 1 Allowable Values: Y (Yes) There is documentation that the patient was in labor prior to induction and/or cesarean birth. N (No) There is no documentation that the patient was in labor prior to induction and/or cesarean birth OR unable to determine f rom medical record documentation. Notes for Abstraction: A clinician is defined as a physician, certified nurse midwife (CNM), advanced practice nurse/physician assistant (APN/PA) or registered nurse (RN). Documentation of labor by the clinician should be abstracted at face value. There is no requirement f or acceptable descriptors to be present in order to answer “yes” to labor. Documentation of regular contractions with or without cervical change; i.e., dilation, effacement without mention of labor may be used to answer “yes” to labor Documentation of regular contractions with or without cervical change, e.g.: o contractions every 4 to 5 minutes o regular contractions and dilation o effacement 50% with contractions every 3 minutes o steady contractions Induction of labor is def ined as the use of medications or other methods to bring on (induce) labor. Methods of induction of labor include, but are not limited to: o Administration of Oxytocin (Pitocin) o Artif icial rupture of membranes (AROM) or amniotomy o Insertion of a catheter with an inf latable balloon to dilate the cervix o Ripening of the cervix with prostaglandins, i.e. Cervidil, Prepidil, Cytotec, etc. o Stripping of the membranes when the clinician sweeps a gloved f inger over the thin membranes that connect the amniotic sac to the wall of the uterus. Suggested Data Sources: History and physical Nursing Notes Physician orders Medication administration record (MAR) Labor flow sheet Physician progress notes RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 37 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Guidelines for Abstraction: Inclusion The f ollowing are acceptable descriptors f or labor: • Active • Early • Latent • Spontaneous Exclusion The f ollowing is not an acceptable descriptor f or labor: • Prodromal RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 38 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Last Name Collected For: All MassHealth Records Definition: The patient’s last name. Suggested Data Collection Question: What is the patient’s last name? Format: Length: Type: Occurs: Allowable Values: Enter the patient’s last name. Notes for Abstraction: None Suggested Data Sources: Emergency department record Face sheet History and physical Guidelines for Abstraction: Inclusion None 60 Alphanumeric 1 Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 39 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: MassHealth Member ID Collected For: All MassHealth Records Definition: The patient’s MassHealth Member ID. Suggested Data Collection Question: What is the patient’s MassHealth Member ID? Format: Length: Type: Occurs: 20 Alphanumeric 1 Allowable Values: Any valid MassHealth Member ID number Alpha characters must be upper case No embedded dashes or spaces or special characters Notes for Abstraction: The Provider Regulations define a valid MassHealth Member ID as a twelve (12) digit number that contains numeric characters only. This 12 digit member ID number applies to members enrolled within various Medicaid managed care or f ee-f or-service insurance programs. However, some MassHealth managed care insurance plans may issue dif ferent MassHealth member ID numbers that use alphanumeric type and exceed the 12 digit numeric requirement. For the purposes of measures reporting the “f ormat length” was expanded to 20 f ields within the portal environment only. This portal edit allows data f iles that may exceed the 12 characters to not be rejected by the portal. The change in the portal environment does not constitute a change to existing MassHealth Provider Regulation def initions of member ID number. Once a member is assigned a MassHealth ID number it will not change through the duration of their enrollment or if they change managed care plans (e.g.: coverage changed from fee-for-service to an MCO plan).Member ID numbers can be verif ied using the on-line Eligibility Verification System (EVS) at: http://www.mass.gov/eohhs/provider/insurance/masshealth/claims/eligibilityverif ication/. EVS provides historical data on a member for any given point in time that can be reviewed by entering a particular date of service. The abstractor should NOT assume that their hospital’s claim information for the patient’s MassHealth Member ID number is correct. If the abstractor determines through chart review that the MassHealth Member ID number is incorrect, for purposes of abstraction, she/he should correct and override the downloaded value. Suggested Data Sources: Guidelines for Abstraction: Inclusion None Emergency department record Face sheet Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 40 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Medical Procedures and Tests & Summary of Results Collected For: CCM-2 Definition: Medical procedures and tests performed refer to procedures and tests perf ormed during the acute inpatient hospitalization to help establish the diagnosis at discharge and course of treatment. Summary of results refers to the results of the medical procedures and tests performed. A transition record includes the Medical Procedures and Tests that were signif icant and relevant to the care of the patient performed during inpatient stay and a Summary of Results. Suggested Data Collection Question: Does the Transition Record include the Medical Procedure(s) and Test(s) and a Summary of Results? Format: Length: 1 Type: Alphanumeric Occurs: 1 Allowable Values: Y (Yes) The transition record includes the Medical Procedure(s) and Test(s) and a Summary of Results or documentation of No Procedures and Tests. N (No) The transition record does not include the Medical Procedure(s) and Test(s) and a Summary of Results or documentation of No Procedures and Tests. Notes for Abstraction: Hospitals determine which procedures or tests are relevant to the care of the specific patient. Not all procedures and tests should be documented. Some examples of procedures and tests are: Procedures: -C-section -Vaginal delivery -Appendectomy -Heart cath with stent -Knee Replacement Tests -Urine Cultures -Blood Cultures -Imaging Studies (x-rays, CT scan) Surgical procedures documented do not require a summary of the results. Example: Appendectomy would not require a summary of the results. Examples of documentation for Summary of Results: “Results discussed with physician,” “Within normal limits,” “Contact your physician with any questions regarding your results,” should accompany the specific medical procedure or tests listed. Documentation of actual test results such as: “CT negative for pulmonary emboli” or “Echocardiogram shows your heart is enlarged” also meet the requirement. If there is documentation of “No procedures or tests/ None/ N/A”, the abstractor should select Y (Yes). In the event of a transfer to another site of care, if a summary or listing of medical procedures and tests performed during inpatient stay is provided with the patient to the receiving site, this element may be documented as Y (Yes). RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 41 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Documentation of Y(Yes) also applies to patients discharged and admitted within the same site. Suggested Data Sources: Transition Record Discharge Instructions Guidelines for Abstraction: Inclusion Normal/ Abnormal Within normal limits Results to be discussed with physician Exclusion RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 42 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: National Provider ID Collected For: All MassHealth Records Definition: The provider’s ten digit national provider identifier. Suggested Data Collection Question: What is the provider’s ten digit national provider identifier? Format: Length: Type: Occurs: Allowable Values: Any valid ten digit national provider ID. Notes for Abstraction: Hospitals must submit either their valid Medicare or Medicaid Provider ID or their National Provider ID for all MassHealth measure f iles . Suggested Data Sources: Administrative record Guidelines for Abstraction: Inclusion None 10 Alphanumeric 1 Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 43 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Newborn Bilirubin Screening Collected For: NEWB-2 Definition: Bilirubin screening involves measurement of the total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) level on newborns prior to discharge. Suggested Data Collection Question: Is there documentation the infant received a serum or transcutaneous bilirubin screen prior to discharge? Format: Length: Type: Occurs: 1 Alphanumeric 1 Allowable Values: 1 Yes, there is documentation the infant received a serum or transcutaneous bilirubin screen prior to discharge. 2 Documentation of parental refusal for bilirubin screening during the inpatient stay. 3 No, there is no documentation the infant received a serum or transcutaneous bilirubin screen prior to discharge or Unable to Determine (UTD). Notes for Abstraction: Suggested Data Sources: Guidelines for Abstraction: Inclusion None Lab reports Nursing documentation Physician Progress Notes Discharge Summary Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 44 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Number of Previous Live Births Collected For: MAT-4 Definition: The number of deliveries resulting in a live birth the patient experienced prior to current hospitalization. Suggested Data Collection Question: How many deliveries resulting in a live birth did the patient experience prior to current hospitalization? Format: Length: Type: Occurs: 2 or UTD Alphanumeric 1 Allowable Values: 0 – 50 UTD= Unable to Determine Notes for Abstraction: Parity may be used f or the number of previous deliveries resulting in a live birth if zero is documented. For any number greater than zero, parity may ONLY be used provided there is additional documentation indicating the same number of live births experienced prior to this hospitalization. If the number for parity documented in the EHR is "one" and includes the delivery for the current hospitalization, abstract zero for previous live births. The delivery or operating room record should be reviewed f irst f or the number of live births. If the number of previous live birth is not recorded in the delivery or operating room record, then continue to review the data sources in the f ollowing order: history and physical, prenatal f orms, clinician admission progress note and discharge summary until a positive f inding f or the number of previous live births is f ound. In cases where there is conf licting data, the number of live births f ound in the f irst document according to the order listed in the Only Acceptable Sources should be used. If gravidity is documented as one, the number of previous live births should be considered zero. The previous delivery of twins or any multiple gestation is considered one live birth event. Documentation in the acceptable data sources may be written by the f ollowing clinicians: physician, certif ied nurse midwif e (CNM), advanced practice nurse/physician assistant (APN/PA) or registered nurse (RN). It is acceptable to use data derived f rom vital records reports received f rom state or local departments of public health, delivery logs or clinical inf ormation systems if they are available and are directly derived f rom the medical record with a process in place to conf irm their accuracy. If this is the case, these may be used in lieu of the Only Acceptable Sources listed below. If primagravida or nulliparous is documented select zero f or the number of previous live births. GTPAL documentation alone does not indicate previous live births. Previous live births may be abstracted from an acceptable data source by adding the number of all previous Term plus Preterm deliveries minus the Stillbirths and the current delivery. RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 45 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) If the number of previous live births entered by the clinician in the first document listed is obviously incorrect (in error) but it is a valid number or two different numbers are listed in the first document and the correct number can be supported with documentation in the other acceptable data sources in the medical record, the correct number may be entered. Suggested Data Sources: Guidelines for Abstraction: Inclusion • None ONLY • • • • • • ACCEPTABLE SOURCES IN ORDER OF PREFERENCE Delivery room record, note or summary Operating room record, note or summary History and physical Prenatal f orms Admission clinician progress note Discharge summary Exclusion • None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 46 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Patient Identif ier Collected For: All MassHealth Records Definition: The identification number used by the Hospital to identify this patient. Suggested Data Collection Question: What is the patient’s hospital patient identification number? Format: Length: Type: Occurs: Allowable Values: Up to 40 letters and / or numbers Notes for Abstraction: When abstracting this data element for a clinical measure f ile, the data in this f ield must match the hospital patient ID number submitted in the corresponding crosswalk file. Suggested Data Sources: Administrative record Face sheet Guidelines for Abstraction: Inclusion None 40 Alphanumeric 1 Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 47 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Patient Instructions Collected For: CCM-2 Definition: Patient Instructions refers to information that is associated with the diagnosis, treatment, and plan of care specific to the patient’s inpatient stay that should be f ollowed by the patient after discharge from inpatient care. A transition record that included patient instructions (discharge instructions) related to the inpatient stay. Suggested Data Collection Question: Does the Transition Record include Patient Instructions? Format: Length: 1 Type: Alphanumeric Occurs: 1 Allowable Values: Y (Yes) The transition record includes Patient Instructions. N (No) The transition record does not include Patient Instructions. Notes for Abstraction: Patient instructions include post-discharge patient self-management instructions. If the patient instructions given to the patient are on a separate page from the transition record and not retained in the permanent medical record, there must be a ref erence listing the patient instructions given to the patient. Patient instructions should be transmitted to the next provider of care with the Transition Record. In the event the patient is transferred to another site where the patient instructions will be determined at the time of discharge from that site of care, this data element may be documented as Y(Yes). Documentation of Y(Yes) also applies to patients discharged and admitted within the same site of care. Suggested Data Sources: Guidelines for Abstraction: Inclusion None Transition Record Patient Instructions (may be pre-printed forms) Discharge Instructions Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 48 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Payer Source Collected For: All MassHealth Records Definition: The def inition of Medicaid payer source as defined by the Massachusetts regulations noted in Section 2 of this EOHHS manual. The def inition of the Medicaid payer source data element differs from the CMS National Hospital Inpatient Quality Measures reporting requirement. Suggested Data Collection Question: What is the patient’s primary source of Medicaid payment for care provided? Format: Length: Type: Occurs: 3 Alphanumeric 1 Allowable Values: Payment source code values assigned by Massachusetts regulations include: • • • • • • • • • • • • • • • 103 104 108 110 113 118 207, 208 282 283 284 285 286 287 119 • 178 Children’s Medical Security Plan (CMSP) Medicaid - includes MassHealth Fee-f or-Service and “MassHealth Limited” Medicaid Managed Care – Primary Care Clinician Plan (PCCP) MCD Managed Care - Fallon Community Health Plan MCD Managed Care - Health New England MCD Managed Care - Neighborhood Health Plan MCD Managed Care - Mass Behavioral Health Partnership Plan 274 MCD Managed Care- Network Health (Cambridge Health Alliance) MCD Managed Care - HealthNet (Boston Medical Center) BMC- MassHealth CarePlus Fallon- MassHealth CarePlus NHP- MassHealth CarePlus Network Health- MassHealth CarePlus Celticare- MassHealth CarePlus MassHealth CarePlus Medicaid Managed Care Other (not listed elsewhere).This code is a catchall f or other insurance products that existed or new products that may arise during a given time period. These products may be assigned dif ferent revenue codes by the hospital depending on how they use it. Notes for Abstraction: As noted in Section 2.C.1 (Table 2.2) a revised list of included and excluded Medicaid payer codes resulting from Affordable Care Act requirements apply. The Massachusetts regulations outline the payer data reporting definitions and codes for Medicaid payment sources required when preparing MassHealth data f iles for submission. Primary source of payment is a MassHealth insurance program : • If Medicaid is the only payer listed (see payer codes above); • If Medicaid is primary and another secondary insurance is listed. Primary source of payment is NOT a MassHealth insurance program: • If Medicare is the only payer listed; • If Medicare is primary and lists Medicaid as secondary(ex: dual eligible) • If HMO/Commercial Plan is primary and lists Medicaid as secondary (TPL) RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 49 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Suggested Data Sources: Guidelines for Abstraction: Inclusion None Face sheet (Emergency Department / Inpatient) UB-04, f iled location, 50A, B, C MassHealth Eligibility Verif ication System (EVS) http://www.mass.gov/eohhs/provider/insurance/masshealth/claims/eligibility -verif ication/ Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 50 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Plan f or Follow-up Care Collected For: CCM-2 Definition: Plan f or Follow-up Care ref ers to a document that describes further action to be taken af ter the patient is discharged that is shared with patient/family caregiver. The purpose of a plan for follow-up care is to track and monitor progress toward patient goals. A transition record that included a Plan for Follow-up Care related to the inpatient stay or documentation by a physician of no follow-up care required. Suggested Data Collection Question: Does the Transition Record include a Plan f or Follow-up Care related to the inpatient stay OR documentation by a physician of no follow-up care required OR patient is a transfer to another site of care? Format: Length: 1 Type: Alphanumeric Occurs: 1 Allowable Values: Y (Yes) The transition record includes a Plan for Follow-up Care OR documentation by a physician of no follow-up care required OR patient is a transf er to another site of care. N (No) The transition record does not include a Plan f or Follow-up Care. Notes for Abstraction: The Plan f or follow-up care may include: • Any post discharge therapy needed (ex. physical, occupational, home health visits, VNA) • Any durable medical equipment needed • Family psychosocial resources available for patient support (ie. counseling, Alcoholics Anonymous), or • Follow up appointments A scheduled appointment or specific instructions for the patient to call within a certain timef rame to make an appointment with a physician/ health care prof essional will be accepted. Example: Call Dr Jackson for appointment in 1 week Primary Care Physician to call patient with appointment date/time Follow up with Dr Jackson as needed Call OB f or appointment in 1 week Appointment scheduled with Cardiology in 2 days If the patient does not have a primary care physician, then the patient can be ref erred to a healthcare clinic f or f ollow up . If it is documented that the patient has declined any plan f or f ollow-up care OR a primary care provider or clinic cannot be identif ied, then the patient can be ref erred to the Emergency Department f or emergent care. In the event the patient is transferred to another site of care where the plan f or f ollow-up care will be determined at the time of discharge from that site, this data element may be documented as Y(Yes). Documentation of Y(Yes) also applies to patients discharged and admitted within the same site. RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 51 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) If it is determined and documented by the physician that the patient requires no f ollow-up care, documentation of this on the transition record will be acceptable and Y(Yes) should be selected. Suggested Data Sources: Transition Record Discharge Instructions Guidelines for Abstraction: Inclusion • Instruction f or patient to call physician / health care prof essional or site of care such as a clinic to schedule appointment within a specif ic time f rame • A scheduled appointment • Oxygen therapy • Physical therapy • Occupational therapy • DME • VNA Exclusion RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 52 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Postal Code Collected For: All MassHealth Records Definition: The postal code of the patient’s residence. For the United States zip codes, the hyphen is implied. If the patient is determined to not have a permanent residence, then the patient is considered homeless. Suggested Data Collection Question: What is the postal code of the patient’s residence? Format: Length: Type: Occurs: Allowable Values: Any valid f ive or nine digit postal code or “HOMELESS” if the patient is determined not to have a permanent residence. If the patient is not a resident of the United States, use “Non-US.” Notes for Abstraction: If the postal code of the patient is unable to be determined from medical record documentation, enter the provider’s postal code. Suggested Data Sources: Face sheet UB-04 Guidelines for Abstraction: Inclusion None 9 Alphanumeric 1 Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 53 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Primary Physician or Other Health Care Prof essional f or Follow-up Care Collected For: CCM-2 Definition: Primary Physician refers to the physician responsible for overseeing the continued care of the patient immediately after discharge/ post-discharge (ex: Internist, Pediatrician, or Psychiatrist). Other Health Care Prof essional refers to any other medical specialist that may be involved in the continued care process (ex: surgeon, cardiologist, nurse practitioner etc). A transition record that included the name of the Primary Physician or other Health Care Prof essional or site designated for follow-up care. Suggested Data Collection Question: Does the Transition Record include the name of the Primary Physician or other Health Care Prof essional or site designated for follow-up care? Format: Length: 1 Type: Alphanumeric Occurs: 1 Allowable Values: Y (Yes) The transition record includes the name of the Primary Physician or other Health Care Prof essional or site designated f or f ollow-up care. N (No) The transition record does not include the name of the Primary Physician or other Health Care Prof essional or site designated f or f ollow-up care. . Notes for Abstraction: The primary physician or other health care provider’s name must be specified . The exception is for a site of care such as a nursing home when the physician name may not be known. In this case the site name must be documented. The VNA or home health agency is not acceptable as a Primary Care Physician or other Health Care Prof essional designated for follow-up care. If the patient is transferred to the next site of care and the physician designated for follow-up is unknown, “site physician” or site of care name will be accepted and this element may be documented as Y (Yes). If a f ollow-up appointment is made with a clinic where the physician / other health care professional is not known at the time of the appointment, this element may be documented as Y (Yes). Ex. Follow up appointment made at GI Clinic in one week In the case of a patient declining assignment of a PCP or clinic, the patient may be ref erred to the Emergency Room for follow up care. If it is determined and documented by the physician that the patient requires no f ollow-up care, the name of the patient’s primary physician or other health care prof essional or site designated for care must be documented. Suggested Data Sources: Transition Record Discharge Instructions RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 54 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Guidelines for Abstraction: Inclusion • Specif ic physician name • Specif ic health care prof essional • Clinic or site name • Transf erred • Emergency Room Exclusion • “PCP” “Primary Care Physician” • VNA RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 55 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Prior Uterine Surgery Collected For: MAT-3 Definition: Documentation that the patient had undergone prior uterine surgery. Suggested Data Collection Question: Is there documentation that the patient had undergone prior uterine surgery? Format: Length: 1 Type: Alphanumeric Occurs: 1 Allowable Values: Y(Yes) The medical record contains documentation that the patient had undergone prior uterine surgery. N(No) The medical record does not contain documentation that the patient had undergone a prior uterine surgery OR unable to determine from medical record documentation. Notes for Abstraction: Suggested Data Sources: History and physical Nursing admission assessment Progress notes Physician’s notes Prenatal f orms Guidelines for Abstraction: Inclusion The only prior uterine surgeries considered f or the purposes of the measure are: • Prior classical Cesarean birth which is def ined as a vertical incision into the upper uterine segment • Prior myomectomy • Prior uterine surgery resulting in a perf oration of the uterus due to an accidental injury • History of a uterine window or thinning or defect of the uterine wall noted during prior uterine surgery or during a past or current ultrasound • History of uterine rupture requiring surgical repair • History of a cornual ectopic pregnancy • History of transabdominal cerclage Exclusion • Prior low transverse cesarean birth • Prior cesarean birth without specif ying prior classical cesarean birth • History of an ectopic pregnancy without specif ying cornual ectopic pregnancy • History of a cerclage without specif ying transabdominal cerclage RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 56 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Provider ID Collected For: All MassHealth Records Definition: The provider’s ten digit acute care Medicaid or six digit Medicare provider. Suggested Data Collection Question: What is the provider’s ten digit acute care Medicaid or six digit Medicare ID? Format: Length: Type: Occurs: Allowable Values: Any valid ten digit Medicaid or six digit Medicare provider ID. Notes for Abstraction: Hospitals must submit either their valid Medicare or Medicaid Provider ID f or all MassHealth measure f iles or crosswalk files. Suggested Data Sources: Administrative record Guidelines for Abstraction: Inclusion None 10 Alphanumeric 1 Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 57 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Provider Name Collected For: All MassHealth Records Definition: The name of the provider of acute care inpatient services. Suggested Data Collection Question: What is the name of the provider of acute care inpatient services? Format: Length: Type: Occurs: Allowable Values: Provider name Notes for Abstraction: The provider name is the name of the hospital. Suggested Data Sources: Face sheet Guidelines for Abstraction: Inclusion None 60 Alphanumeric 1 Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 58 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Data Element Name: Race Collected For: All MassHealth Records Definition: The patient’s self-reported race as defined by the Massachusetts regulation noted in Section 2 of this EOHHS manual. The def inition of “Race” data element categories in the Massachusetts regulation differ from the CMS National Hospital Inpatient Quality Measures reporting requirement. Suggested Data Collection Question: What is the patient’s self-reported race? Format: Length: Type: Occurs: 6 Alphanumeric 1 Allowable Values: Select one: Code Race R1 American Indian or Alaska Native: R2 Asian: R3 Black / Af rican American: R4 Native Hawaiian or other Pacific Islander: R5 White: R9 Other Race: UNKNOW Notes for Abstraction: Unknown / not specified: As noted in Section 2, Table 2.3 comparison chart, the Massachusetts regulation codes and allowable values for the “Race” data element differ f rom CMS reporting requirement. Hospitals must use the Massachusetts regulation race codes and allowable values when preparing all MassHealth data files for submission. Only collect race data that is self-reported by the patient. Do not abstract a clinician’s assessment documented in the medical record. If the medical record contains conflicting documentation on patient self reported race, abstract the most recent dated documentation. If the medical record contains multiple patient self-reported races on one document, abstract the f irst self-reported race listed (e.g. – Black/Asian, select Black). If the patient self reports as Hispanic, the Race selected is “Other Race”. If codes and allowable values, other than those listed above, are documented in the medical record, a crosswalk that links the hospitals’ codes/values to the Massachusetts regulation requirements must be provided for chart validation. Suggested Data Sources: Administrative records Face sheet (Emergency Department / Inpatient) Nursing admission assessment Prenatal initial assessment form RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 59 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Crosswalk) Guidelines for Abstraction: Inclusions (OMB definitions) • American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal af f iliations or community attachment, e.g. any recognized tribal entity in North and South America (including Central America), Native American. • Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, f or example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. • Black / African American: A person having origins in any of the black racial groups of Af rica. Terms such as “Haitian” or “Negro”, can be used in addition to “Black or Af rican American”. • Native Hawaiian or Other Pacific Islander: A person having origins in any of the other original peoples of Hawaii, Guam, Samoa, or other Pacif ic Islands. • White: A person having origins in any of the original peoples of Europe, the Middle East, or North Af rica, e.g., Caucasian, Iranian, White. • Other Race: A person having an origin other than what has been listed above. • Unknown: Unable to determine the patient’s race or not stated (e.g., not documented, conf licting documentation or patient unwilling to provide). Exclusion None RY2017 EOHHS Technical Specifications Manual for MassHealth Acute Hospital Quality Measures (10.0) Effective with Q3-2016 discharges (07/01/16) 60 Consolidated Data Dictionary (MAT-3, MAT- 4, MAT- 5, NEWB 1, NEWB 2, CCM 1, 2, 3, Cross...

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