Below is the most recently endorsed version of the measure specifications:
Measure Description:
This measure assesses patients with elective vaginal deliveries or elective cesarean births at >= 37 and < 39 weeks of gestation completed. This measure is part of a set of four nationally implemented measures that address perinatal care (PC-01: Elective Delivery, ePC-01: Elective Delivery; PC-02: Cesarean Birth, ePC-02: Cesarean Birth will be added as an eCQM 1/1/2020; PC-05: Exclusive Breast Milk Feeding, ePC-05: Exclusive Breast Milk Feeding; PC-06 Unexpected Complications in Term Newborns was added 1/1/2019).
PC-01: Elective Delivery is one of three measures in this set that have been re-engineered as eCQMs (ePC-01 Elective Delivery, ePC-02 Cesarean Birth and ePC-05 Exclusive Breast Milk Feeding).
A reduction in the number of non-medically indicated elective deliveries at >=37 to <39 weeks gestation results in a substantial decrease in neonatal morbidity and mortality, as well as a significant savings in health care costs. In addition, the rate of cesarean sections should decrease with fewer elective inductions resulting in decreased length of stay and health care costs (AAFP, 2000).
The measure will assist health care organizations (HCOs) to track non-medically indicated early term elective deliveries and reduce the occurrence.
American Academy of Family Physicians. (2000). Tips from Other Journals: Elective induction doubles cesarean delivery rate, 61, 4.Retrieved December 29, 2008 at: http://www.aafp.org/afp/20000215/tips/39.html.
Numerator Statement:
Patients with elective deliveries with ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for one or more of the following:
• Medical induction of labor as defined in Appendix A, Table 11.05 while not in Labor prior to the procedure
• Cesarean birth as defined in Appendix A, Table 11.06 and all of the following:
•not in Labor
•no history of a Prior Uterine Surgery
Numerator Details:
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Denominator Statement:
Patients delivering newborns with >= 37 and < 39 weeks of gestation completed with ICD-10-PCS Principal or Other Procedure Codes for delivery as defined in Appendix A, Table 11.01.1 and with ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for planned cesarean birth in labor as defined in Appendix A, Table 11.06.1.
Denominator Details:
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Exclusions:
ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix A, Table 11.07 include the following:
• History of prior stillbirth
• Less than 8 years of age
• Greater than or equal to 65 years of age
• Length of Stay >120 days
• Gestational Age < 37 or >= 39 weeks or UTD
Exclusion Details:
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Risk Adjustment:
No risk adjustment or risk stratification
Classification:
Measure Type:
Process
Measure Format:
measure
Condition:
Perinatal Health
Non-Condition Specific:
Safety: Complications, Safety: Overuse
Care Setting:
Inpatient/Hospital
National Quality Strategy Priorities:
Affordable Care
Current Use:
Public Reporting, Regulatory and Accreditation Programs
Planned Use:
Data Source:
Electronic Health Records: Electronic Health Records, Other, Paper Medical Records
Level of Analysis:
Facility, Other
Target Population:
Women
Measure Steward Contact Information:
For additional measure specification information, please contact the Measure Steward.
Measure Steward Organization:
The Joint Commission
Primary Measure Steward Contact:
Measure Steward Copyright:
No royalty or use fee is required for copying or reprinting this manual, but the following are required as a condition of usage: 1) disclosure that the Specifications Manual is periodically updated, and that the version being copied or reprinted may not be up-to-date when used unless the copier or printer has verified the version to be up-to-date and affirms that, and 2) users participating in Joint Commission accreditation, including vendors, are required to update their software and associated documentation based on the published manual production timelines.
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