2021 ECPR41: Rh Status Evaluation and Treatment of Pregnant Women at Risk of Fetal Blood Exposure

Measure Description

Percentage of Women Aged 14-50 Years at Risk of Fetal Blood Exposure Who Had Their Rh Status Evaluated in the Emergency Department (ED) and Received Rh-Immunoglobulin (Rhogam) if Rh-negative

Denominator

• Any Female Patient > 14 Years of Age and < 51 Years of Age Evaluated by the Eligible Professional in the ED (E/M Codes 99281-99285 & 99291-99292) PLUS
• ED Diagnosis of high risk pregnancy complication:
  • ICD-10: O00.80, O00.81, O00.90, O00.91, O02.1, O03.1, O03.6, O04.6, O07.1, O08.1, O20.0, O20.8, O20.9, O43.011, O43.019, O44.10, O44.11, O45.001, O45.009, O45.011, O45.019, O45.021, O45.029, O45.091, O45.099, O45.8X1, O45.8X9, O45.90, O45.91, O46.001, O46.011, O46.021, O46.8X1, O46.8X9, O46.90, O46.91
• Transferred, eloped or AMA patients are excluded (V0700)

Numerator

Women Aged 14-50 Years at Risk of Fetal Blood Exposure Who Had Their Rh Status Evaluated in the ED and Received Rh-Immunoglobulin (Rhogam) if Rh-negative

Numerator Options

• Performance Met (VE257): Patients who had their Rh status evaluated and were confirmed Rh-positive OR Patients who had Rh status evaluated AND received an order for Rh-Immunoglobulin (Rhogam) if Rh-negative
  • Definition of Rh status evaluated: Laboratory testing of Rh status or documented Rh status (e.g., “Patient known Rh+”)
• Medical Performance Exclusion (Denominator Exception) (VE258): Patients who did not have Rh status evaluated or did not receive an order of Rh-Immunoglobulin (Rhogam) if Rh-negative for documented medical reasons
• Patient Performance Exclusion (Denominator Exception) (VE259): Patients who did not have Rh status evaluated or did not receive an order of Rh-Immunoglobulin (Rhogam) if Rh-negative for documented patient reason(s) (e.g., patient refused Rh testing or Rhogam)
• Performance Not Met (VE260): Patients who did not have Rh status evaluated or did not receive Rh-Immunoglobulin (Rhogam) if Rh-negative, reason not given

Numerator Exclusions

None

NQF ID Number

N/A

NQS Domain

Effective Clinical Care

High Priority Measure

No

Includes Telehealth?

Yes

Inverse Measure

No

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be calculated and submitted

1

Risk-Adjusted Status?

No