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					      ArkAnsAs MedicAid
i n pAt i e n t Q u A l i t y i n c e n t i v e

 Specifications
Manual, SFY 2011
        July 1, 2010 (3Q2010) through deceMber 31, 2010 (4Q2010)




                                                                   revised 11/17/10
Introduction                                                                                 Intro-1

Section 1 Data Dictionary
      A. Alphabetical Data Dictionary Element List                                              1-1
      B. Alphabetical Data Dictionary                                                           1-3

Section 2 Measure Information
      C. 2.1    Care Coordination Documentation
                Care Coordination Documentation IQI Submission Measures                        2-64
                Initial Patient Population Algorithm                                           2-65
                Measure Information Form And Flow Chart
                        CCD – 1 Reconciled Medication List Received By Discharged Patients     2-67
                        CCD – 2 Transition Record                                              2-70
                        CCD – 3 Timely Transmission                                            2-76
                Transition Record Example                                                      2-79
      D. 2.2    OBS
                Obstetric IQI Submission Measures                                              2-81
                OBS Initial Patient Population Algorithm                                       2-82
                Measure Information Form and Flow Chart
                        OBS – 1 Prophylactic Antibiotics                                       2-84
                        OBS – 2 Appropriate DVT Prophylaxis                                    2-88
                        OBS – 4 Elective Delivery                                              2-90

Section 3 Sampling Guidelines                                                                   3-1

Appendices
      E. B. Appendix A: ICD-9-CM Code Table                                                     A-1
      F. B. Appendix B: Suggested Antibiotic List                                               B-1

References                                                                             Reference-1
Introduction


This manual is the AFMC Data Abstraction Specifications and Guidelines for the
Inpatient Quality Incentive project for SFY2011. The measures were carefully selected
to improve care for a large number of Arkansans inclusive of the Arkansas Medicaid
Beneficiaries.

AMART will be made available for hospitals to begin collecting the data for 3rd Quarter
2010 and 4th Quarter 2010 discharges.

The criteria were developed jointly by Arkansas Medicaid, the Arkansas Hospital
Association, the Arkansas Foundation for Medical Care and the advisory committee
made up of hospital quality professionals.

This manual describes the data elements required to collect and submit the data for the Care
Transition and Obstetric measures for the Medicaid Inpatient Quality Incentive program for
SFY 2011. It includes information necessary for defining and formatting the data elements,
as well as the allowable values for each data element.

General data elements must be collected by the hospital and submitted for every patient that
falls into any of the selected Initial Patient Populations. These data elements are considered
“general” to each patient’s episode of care.

These data elements include:

• Provider Name

• Provider Medicaid Identification Number

• Patient’s First Name
• Patient’s Last Name

• Birthdate

• Hospital Patient Identification Number
• Admission Date
• Discharge Date

• Payment Source

• Discharge Status

Medicaid Inpatient Quality Incentive Guidelines SFY2011                                Intro-1
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
General Abstraction Guidelines
The General Abstraction Guidelines are a resource designed to assist abstractors in
determining how a question should be answered. The abstractor should first refer to the
specific notes and guidelines under each data element. These instructions should take
precedence over the following General Abstraction Guidelines. All of the allowable values
for a given data element are outlined, and notes and guidelines are often included which
provide the necessary direction for abstracting a data element. It is important to utilize the
information found in the notes and guidelines when entering or selecting the most appropriate
answer.

Suggested Data Sources

• Suggested Data Sources are NOT listed in priority order, unless otherwise specified in the
data element.

• Suggested Data Sources are designed to provide guidance to the abstractor as to the
locations/sources where the information needed to abstract a data element will likely be
found. However, the abstractor is not limited to these sources for abstracting the information
and must review the entire medical record unless otherwise specified in the data element.

• In some instances, a data element may restrict the sources that may be used to gain the
information. If so, these sources will be identified and labeled as “Excluded Data Sources.”

• If, after due diligence, the abstractor determines that a value is not documented or is not
able to determine the answer value, the abstractor must select “Unable to Determine (UTD)”
as the answer if that option is available.

• Hospitals often label forms and reports with unique names or titles. Suggested Data Sources
are listed by commonly used titles; however, information may be abstracted from any source
that is equivalent to those listed.

Example:
If the “nursing admission assessment” is listed as a suggested source, an acceptable
alternative might be titled “nurses initial assessment” or “nursing data base.”
Note:
Element specific notes and guidelines should take precedence over the General
Abstraction Guidelines.

Inclusions/Exclusions

• Inclusions are “acceptable terms” that should be abstracted as positive findings (e.g.,
“Yes”).

• Inclusion lists are limited to those terms that are believed to be most commonly used in
medical record documentation. The list of inclusions should not be considered all-
inclusive, unless otherwise specified in the data element.
Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 Intro-2
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
• Exclusions are “unacceptable terms” that should be abstracted as negative findings (e.g.,
“No”).

• Exclusion lists are limited to those terms an abstractor may most frequently question
whether or not to abstract as a positive finding for a particular element (e.g.,
“cardiomyopathy” is an unacceptable term for heart failure and should be abstracted as
"No"). The list of exclusions should not be considered all-inclusive, unless otherwise
specified in the data element.

• When both an inclusion and exclusion are documented in a medical record, the inclusion
takes precedence over the exclusion and would be abstracted as a positive finding (e.g.,
answer “Yes”), unless otherwise specified in the data element.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                               Intro-3
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Medicaid Inpatient Quality Incentive
       Program Populations
                          STATE FISCAL YEAR 2011


        VENOUS THROMBOEMBOLISM (VTE) POPULATION
        In the event a hospital chooses to enter MEDICAID-ONLY cases for VTE, complete the following steps:
        1.	 Pull	all	Medicaid	primary	(no	other	payment	source)	patients	for	the	quarter.
        2.	 Eliminate	any	cases	with	an	age	of		<18	years.
        3.	 Eliminate	any	cases	with	a	length	of	stay	>	120	days.
        4.	 Eliminate	any	cases	with	a		Principal	&	Other	Diagnosis	Code	on	Table	7.02,	7.03	and	7.04.
        5.	 	Once	this	number	is	determined,	a	hospital	may	enter	100%	of	the	Medicaid	cases	or	refer	to	the	sampling table	for	the	
             sampling	requirement	number.
        6.	 If	the	hospital	plans	to	sample,	it	should	be	a	random	sample.

        In the event a hospital chooses to enter ALL PAYORS for VTE, complete the following steps:
        1.	 Pull	all	cases	(all	payors)	for	the	quarter.
        2.	 Eliminate	all	cases	with	an	age	of	<	18	years.
        3.	 Eliminate	any	cases	with	a	length	of	stay	>	120	days.
        4.	 Eliminate	any	cases	with	a	Principal	&	Other	Diagnosis	Code	on	Table	7.02,	7.03	and	7.04.
        5.	 	Determine	how	many	of	the	remaining	cases	are	Medicaid	Primary.		This	is	the	number	which	will	be	used	for	sampling	
             requirements.
        6.	 Refer	to	the	sampling	table	using	the	number	of	Medicaid	cases	from	Step	5	and	determine	how	many	cases	should	be	submitted.
        7.	 	If	a	hospital	plans	to	sample	all	payors,	the	hospital	should	randomly	select	from	the	patients	remaining	following	Step	4	using	the	
             NUMBER	determined	from	the	sampling table	in	Step	5.
        8.	 There	must	be	at	least	one	Medicaid	patient	included.

        NOTE:	A	hospital	could	follow	the	steps	for	Medicaid-only	listed	above	to	determine	the	NUMBER	(STEPS	1-4)	needed	for	abstraction	
        and	then	enter	all	payors	by	starting	with	Step	7	under	the	ALL	PAYORS	section	and	randomly	select	from	all	payors.

                                                                                                       See back for CCD & OBS populations

        SAMPLING TABLE

           SAMPLING REQUIREMENTS
           n	 Hospitals	must	abstract	and	submit	100%	of	their	Arkansas	Medicaid	cases	or	follow	these	sampling	
           guidelines:
           	 •	Quarterly	patient	population	>	1,250	..............................................abstract	250	medical	records
           	 •	Quarterly	patient	population	300	to	1,249........................................abstract	20%	of	medical	records
           	 •	Quarterly	patient	population	60	to	299	............................................abstract	60	medical	records
           	 •	Quarterly	patient	population	<	60	...................................................abstract	100%	of	medical	records
           n	 Quarterly	patient	populations	will	be	based	on	Arkansas	Medicaid	billed	cases
           Note: Hospitals	may	choose	to	submit	more	than	the	required	Medicaid	cases,	but	if	they	choose	to	submit	
           all	payors,	they	must	submit	the	minimum	cases	required	for	the	Medicaid	population.		Hospitals	must	use	
           random	sampling	and	include	at	least	1	Arkansas	Medicaid	case	per	topic.	
                CARE COORDINATION DOCUMENTATION (CCD) POPULATION
               In the event a hospital chooses to enter MEDICAID-ONLY cases for CCD, complete the following steps:
               1.	 Pull	all	Medicaid	primary	(no	other	payment	source)	patients	for	the	quarter.
               2.	 Eliminate	any	cases	with	Discharge	Status	codes	07	or	20.
               3.	 Eliminate	any	cases	with	a	patient	age	of	<	1	year.
               4.	 At	this	point,	a	facility	will	have	the	number	of	cases	that	must	be	used	to	determine	the	required	sample	size.
               5.	 	Once	this	number	of	patients	is	determined,	a	hospital	may	enter	100%	of	the	Medicaid	cases	or	refer	to	the	sampling table	
                    for	the	sampling	requirement	number.
               6.	 If	a	hospital	plans	to	sample,	it	should	be	a	random	sample.

               In the event a hospital chooses to enter ALL PAYORS for CCD, complete the following steps:
               1.	 Pull	all	cases	(all	payors)	for	the	quarter.
               2.	 Eliminate	all	cases	with	Discharge	Status	codes	07	or	20.
               3.	 Eliminate	any	cases	with	a	patient	age	of	<	1	year.
               4.	 	Determine	how	many	of	the	remaining	cases	are	Medicaid	primary.		This	is	the	number	which	will	be	used	for	sampling	
                    requirements.
               5.	 	Refer	to	the	sampling table	using	the	number	of	Medicaid	cases	from	Step	4	and	determine	how	many	cases	should	be	
                    submitted.
               6.	 	If	a	hospital	plans	to	sample	all	payors,	the	hospital	should	randomly	select	from	the	patients	remaining	following	Step	3	using	
                    the	number	determined	from	the	sampling table	in	Step	5.
               7.	 There	must	be	at	least	one	Medicaid	patient	included.



                OBSTETRICS (OBS) POPULATION
               In the event a hospital chooses to enter MEDICAID-ONLY cases for OBS, complete the following steps:
               1.		 	Pull	all	Medicaid	primary	(no	other	payment	source)	patients	for	the	quarter	that	has	a	Principle	or	other	Diagnosis	Code	on	Table	
                     11.01,	11.02,	11.03,	and	11.04.
               2.		 Eliminate	all	Medicaid	patients	that	are	aged	<	8	years	and	>=	65	years.
               3.		 Eliminate	all	Medicaid	patients	that	have	a	length	of	stay	>	120	days.
               4.		 At	this	point,	a	facility	will	have	the	NUMBER	of	cases	that	must	be	used	to	determine	sampling	size.
               5.		 	Once	this	number	of	patients	is	determined,	a	hospital	may	enter	100%	of	the	Medicaid	cases	or	refer	to	the	sampling table	for	
                     the	sampling	requirement	number.
               6.		 If	a	hospital	plans	to	sample,	it	should	be	a	random	sample.

               In the event a hospital chooses to enter All PAYORS for OBS, complete the following steps:
               1.	 Pull	all	cases	(all	payors)	for	the	quarter	which	has	a	Principle	or	other	Diagnosis	Code	on	Table	11.01,11.02,	11.03,	and	11.04.
               2.	 Eliminate	all	patients	that	are	<	8	years	and	>=	65	years.
               3.	 Eliminate	all	patients	that	have	a	length	of	stay	>	120	days.
               4.	 Determine	how	many	of	the	remaining	cases	are	Medicaid.		This	is	the	number	which	will	be	used	for	sampling	requirements.
               5.	 	Refer	to	the	sampling table	using	the	number	of	Medicaid	cases	from	Step	4	and	determine	how	many	cases	should	be	
                    submitted.
               6.	 	If	a	hospital	plans	to	sample	all	payors,	the	hospital	should	randomly	select	from	the	patients	remaining	following	Step	3	using	
                    the	number	determined	from	the	sampling table	in	Step	5.
               7.	 There	must	be	at	least	one	Medicaid	patient	included.




This	material	was	prepared	by	the	Arkansas	Foundation	for	Medical	Care	Inc.	(AFMC)	under	contract	with	the	Arkansas	Department	of	Human	Services,	Division	of	Medical	Services.
The	contents	presented	do	not	necessarily	reflect	Arkansas	DHS	policy.	The	Arkansas	Department	of	Human	Services	is	in	compliance	with	Titles	VI	and	VII	of	the	Civil	Rights	Act.		QP2-IQIPOP.FLY,3-9/10
1   Section 1 Data Dictionary


                   Alphabetical Data Dictionary Element List

    Element Name                                                               Page
    24hr/7day Contact Information                                               1-3
    Active Labor                                                                1-5
    Admission Date                                                              1-7
    Advance Care Plan                                                           1-8
    Antibiotic Received Within 24 Hours Prior to Arrival                       1-10
    Appropriate DVT Prophylaxis                                                1-12
    Birthdate                                                                  1-13
    Clinical Trial                                                             1-14
    Contact Information for Studies Pending at Discharge                       1-16
    Current Medication List (Reconciled)                                       1-18
    Discharge Date                                                             1-20
    Discharge Status                                                           1-21
    Documented Infection                                                       1-24
    First Name                                                                 1-26
    Gestational Age                                                            1-27
    Hospital Patient ID Number                                                 1-29
    ICD-9-CM Other Diagnosis Codes                                             1-30
    ICD-9-CM Other Procedure Codes                                             1-31
    ICD-9-CM Other Procedure Dates                                             1-32
    ICD-9-CM Principal Diagnosis Code                                          1-33
    ICD-9-CM Principal Procedure Code                                          1-34
    ICD-9-CM Principal Procedure Date                                          1-35
    Last Name                                                                  1-36
    Major Procedures and Tests Performed During Stay                           1-37
    Other Surgeries                                                            1-39
    Patient Instructions                                                       1-40
    Payment Source                                                             1-42
    Plan for Follow-Up Care                                                    1-44
    Planned/Elective C-section                                                 1-46
    Primary Physician/Health Care Professional Designated for Follow-up Care   1-47
    Principle Diagnosis at Discharge                                           1-49




    Medicaid Inpatient Quality Incentive Guidelines SFY2011                     1-1
    Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information



Element Name                                                                     Page
Prophylactic Antibiotic Received within One Hour of Cut Time or at the time of   1-50
delivery
Reason for Inpatient Admission                                                    1-52
Reconciled Medication List                                                        1-53
Sample                                                                            1-56
Spontaneous Rupture of Membranes                                                  1-57
Studies Pending at Discharge                                                      1-59
Timely Transmission of Transition Record                                          1-61
Written Transition Record                                                         1-63




Medicaid Inpatient Quality Incentive Guidelines SFY2011                          1-2
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


                          Alphabetical Data Dictionary

Data Element Name:              24hr/7day Contact Information

Collected For:                  CCD-2-9

Definition:                     A written transition record that included 24hr/7day Contact
                                Information Including Physician for Emergencies Related
                                to Inpatient Stay was received by the patient or their
                                caregiver(s) at the time of discharge.

Suggested Data
Collection Question:            Did the patient/caregiver(s) receive a Written Transition
                                Record at the time of discharge that included 24hr/7day
                                Contact Information Including Physician for Emergencies
                                Related to Inpatient Stay?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient/caregiver(s) received a Written Transition
                                Record at the time of discharge that included 24hr/7day
                                Contact Information Including Physician for Emergencies
                                Related to Inpatient Stay

                                N - The patient/caregiver(s) did not receive a Written
                                Transition Record at the time of discharge that included the
                                24hr/7day Contact Information Including Physician for
                                Emergencies Related to Inpatient Stay
.

Notes for Abstraction:          Sources for 24hr/7day Emergency Contact Information
                                include, but are not limited to:
                                            Face sheet
                                            Discharge instructions
                                            Emergency Department records
                                            Teaching sheets
                                            Transfer sheets

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
                                • Written Transition Record



Medicaid Inpatient Quality Incentive Guidelines SFY2011                               1-3
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Guidelines for Abstraction:
                Inclusion                                          Exclusion
• Emergency Room Phone Number                     • Patients who expired
• Primary Care Physician Phone Number             • Patients who left against medical advice
• Hospital Phone Number                           (AMA)




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-4
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Active labor

Collected For:                  OBS-4

Definition:                     Documentation that the patient was in active labor with
                                regular uterine contractions with cervical change before
                                medical induction and/or cesarean section.
Suggested Data
Collection Question:            Is there documentation that the patient was in active labor
                                with regular uterine contractions with cervical change
                                before medical induction and/or cesarean section?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1


Allowable Values:               Y (Yes) There is documentation that the patient was in
                                active labor with regular uterine contractions with cervical
                                change before medical induction and/or cesarean section.

                                N (No) There is no documentation that the patient was in
                                active labor with regular uterine contractions with cervical
                                change before medical induction and/or cesarean section
                                OR unable to determine from medical record
                                documentation.

Notes for Abstraction:          **This information is from the current Joint
                                Commission Specification and Guideline Manual for
                                3Q2010. The abstraction guidelines may change with
                                the 4Q2010, and if so, those changes will be distributed
                                as “Release Notes” in a separate correspondence.


                                If the patient presents without a previous cesarean section
                                scar with regular uterine contractions with demonstrated
                                cervical change, e.g., cervical dilation increased from 1cm
                                to 2cm before eventual augmentation and/or cesarean
                                section, select allowable value "Yes".

Medicaid Inpatient Quality Incentive Guidelines SFY2011                                1-5
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

                                If the patient presents with a previous cesarean section scar
                                with regular uterine contractions with demonstrated
                                cervical change, e.g., cervical dilation increases from 1cm
                                to 2cm or a cervix dilated 2cm or more before repeat
                                cesarean section, select allowable value "Yes".

Suggested Data Sources:         • History and physical
                                • Nursing note
                                • Physician progress note

Guidelines for Abstraction:
                Inclusion                                             Exclusion
None                                                  None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                1-6
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Admission Date

Collected For:                  All 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: 10 – MM/DD/YYYY (includes slashes)
                                Type:   Date
                                Occurs: 1

Allowable Values:               MM = Month (01-12)
                                DD =   Day (01-31)
                                YYYY = Year (1880-Current Year)

Notes for Abstraction:          A patient of a hospital is considered an inpatient upon
                                issuance of written doctor’s orders to that effect.

Suggested Data Sources:         PRIORITY ORDER FOR THESE SOURCES
                                • Physician’s orders
                                • Face Sheet


Guidelines for Abstraction:
                Inclusion                                         Exclusion
None                                              • Admit to observation
                                                  • Arrival date




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                   1-7
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Advance Care Plan

Collected For:                  CCD-2-5

Definition:                     A written transition record that included an Advance Care
                                Plan OR a Documented Reason for not providing same
                                was received by the patient or their caregiver(s) at the time
                                of discharge.

Suggested Data
Collection Question:            Did the patient/caregiver(s) receive a Written Transition
                                Record at the time of discharge that included an Advance
                                Care Plan OR a Documented Reason for not Providing
                                Same?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient/caregiver(s) received a Written Transition
                                Record at the time of discharge that included an Advance
                                Care Plan OR a Documented Reason for not providing
                                same

                                N - The patient/caregiver(s) did not receive a Written
                                Transition Record at the time of discharge that included the
                                an Advance Care Plan OR a Documented Reason for not
                                providing same


Notes for Abstraction:          Sources for Advance Care Plan OR a documented
                                Reason for not providing same include, but are not
                                limited to:
                                             Nursing Admission Assessment
                                             Physician Orders
                                             Face Sheet
                                             Emergency Department Records
                                             Progress Notes
                                             History & Physical

                                A copy of Advanced Directive is not required to be
                                attached to transition record.

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
                                • Written Transition Record
Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-8
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Guidelines for Abstraction:
                Inclusion                                          Exclusion
• Advance Care Directives                         • Patients who expired
• Power of Attorney                               • Patients who left against medical advice
• Do Not Resuscitate                              (AMA)
• Etc.                                            • Patients who are under 18 years of age




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-9
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Antibiotic Received within 24 hours prior to arrival

Collected For:                  OBS-1

Definition:                     The patient was treated with antibiotics within 24 hours
                                prior to arrival.

Suggested Data
Collection Question:            Did the patient receive antibiotics within 24 hours prior to
                                arrival?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient received prophylactic antibiotics within 24
                                hours prior to arrival.

                                N - The patient did not receive antibiotics within 24 hours
                                prior to arrival.

Notes for Abstraction:          • Excludes prophylaxis with Penicillin or Ampicillin for
                                Group B streptococcus(GBS)

Suggested Data Sources:         • Any source documenting antibiotic administration
                                • Emergency department record
                                • EMT/Ambulance records
                                • History and Physical
                                • Medication administration record
                                • Nursing admission assessment
                                • Nursing notes
                                • Progress notes




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-10
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Guidelines for Abstraction:
                 Inclusion                                          Exclusion
Include any antibiotics given:                           Penicillin or Ampicillin given for
Intravenous:                                              Group B Streptococcus(GBS)
     Bolus                                              Abdominal irrigation
     Infusion                                           Enema/rectally
     IV                                                 Inhalation
     I.V.                                               Mouthwash
     IVPB                                               Nasal sprays
     IV Piggyback                                       Topical antibiotics
     Parenteral                                         Vaginal administration
     Perfusion                                          Wound irrigation

PO/NG/PEG tube:
   Any kind of feeding tube (e.g.,
     percutaneous endoscopic
     gastrostomy, percutaneous
     endoscopic jejunostomy,
     gastrostomy tube)
   By mouth
   Gastric tube
   G-tube
   Jejunostomy
   J-tube
   Nasogastric tube
   PO
   P.O.

Refer to Appendix B for a list of
Antimicrobial Medications




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                  1-11
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Appropriate DVT Prophylaxis

Collected For:                  OBS-2

Definition:                     The appropriate type of DVT prophylaxis documented in
                                the medical record.

Suggested Data
Collection Question:            Did the patient receive the appropriate DVT prophylaxis
                                prior to surgery? (fractionated or unfractionated Heparin or
                                Pneumatic Compression Devices)

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient received appropriate DVT prophylaxis
                                prior to surgery.

                                N - The patient did not receive appropriate DVT
                                prophylaxis prior to surgery.
.
Notes for Abstraction:          None

Suggested Data Sources:         ONLY ACCEPTABLE SOURCE FOR
                                PHARMACOLOGICAL AND MECHANICAL
                                PROPHYLAXIS:
                                   Circulator notes
                                   Emergency department record
                                   Graphic/flow sheet
                                   Medication administration record
                                   Nursing notes
                                   Operative notes
                                   Physician notes
                                   Preoperative nursing notes
                                   Progress notes

Guidelines for Abstraction:
                 Inclusion                                         Exclusion
• Fractionated or Unfractionated Heparin          Any form of DVT Prophylaxis not
• Pneumatic compression Devices                   included in the INCLUSION List




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                1-12
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Birthdate

Collected For:                  All Records

Definition:                     The month, day, and year the patient was born.

Suggested Data
Collection Question:            What is the patient’s date of birth?

Format:                         Length: 10 – MM/DD/YYYY (includes slashes)
                                Type:   Date
                                Occurs: 1

Allowable Values:               MM = Month (01-12)
                                DD =   Day (01-31)
                                YYYY = Year (1880-Current Year)

Notes for Abstraction:          The Face Sheet should take priority if there is
                                conflicting information.

Suggested Data Sources:         • Face Sheet
                                • Registration Form
                                • Emergency Department Record
                                • UB-04, Field Location: 10

Guidelines for Abstraction:
                Inclusion                                             Exclusion
None                                              None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                           1-13
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Clinical Trial

Collected For:                  All Records

Definition:                     Documentation that during this hospital stay the patient was
                                enrolled in a clinical trial in which patients with the same
                                condition as the measure set were being studied.

Suggested Data
Collection Question:            During this hospital stay, was the patient enrolled in a
                                clinical trial in which patients with the same condition as
                                the measure set were being studied?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

        Allowable Values:         Y      There is documentation that during this hospital
                                         stay, the patient was enrolled in a clinical trial in
                                         which patients with the same condition as the
                                         measure set were being studied.

                                  N      There is no documentation that during this hospital
                                         stay, the patient was enrolled in a clinical trial in
                                         which patients with the same condition as the
                                         measure set were being studied, or unable to
                                         determine from medical record documentation.

Notes for Abstraction:          • To select “Yes” to this data element, BOTH of the
                                following must be true:
                                1. There must be a signed consent form for clinical
                                    trial. For the purposes of abstraction, a clinical trial is
                                    defined as an experimental study in which research
                                    subjects are recruited and assigned a
                                    treatment/intervention and their outcomes are measured
                                    based on the intervention received.
                                    Treatments/interventions most often include use of
                                    drugs, surgical procedures, and devices. Often a
                                    control group is used to compare with the
                                    treatment/intervention. Allocation of different
                                    interventions to participants is usually randomized.
                                2. There must be documentation on the signed consent
                                    form that during this hospital stay the patient was
                                    enrolled in a clinical trial in which patients with the
                                    same condition as the measure set were being
                                    studies. Patients may either be newly enrolled in a

Medicaid Inpatient Quality Incentive Guidelines SFY2011                                     1-14
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

                                    clinical trial during the hospital stay or enrolled in a
                                    clinical trial prior to arrival and continued active
                                    participation in that clinical trial during this hospital
                                    stay.

                                • In the following situations, select “No”:
                                1. There is a signed patient consent form for an
                                    observational study only. Observational studies are
                                    non-experimental and involve no intervention (e.g.,
                                    registries). Individuals are observed (perhaps with lab
                                    draws, interviews, etc.), data is collected, and outcomes
                                    are tracked by investigators. Although observational
                                    studies may include the assessment of the effects of an
                                    intervention, the study participants are not allocated
                                    into intervention or control groups.
                                2. It is not clear whether the study described in the
                                    signed patient consent form is experimental or
                                    observational.
                                3. It is not clear which study population the clinical
                                    trial is enrolling. Assumptions should not be made if
                                    it is not specified.

Suggested Data Sources:         ONLY ACCEPTABLE SOURCES:
                                • Signed consent form for clinical trial

                                PREGNANCY ONLY:
                                • UB-04, Field Locations: 67A-Q

Guidelines for Abstraction:
                Inclusion                                             Exclusion
None                                              None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                    1-15
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Contact Information for Studies Pending at Discharge

Collected For:                  CCD-2-8

Definition:                     A written transition record that included Contact
                                Information for Obtaining Results for Studies Pending at
                                Discharge was received by the patient or their caregiver(s)
                                at the time of discharge.

Suggested Data
Collection Question:            Did the patient/caregiver(s) receive a Written Transition
                                Record at the time of discharge that included Contact
                                Information for Obtaining Results for Studies Pending at
                                Discharge?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient/caregiver(s) received a Written Transition
                                Record at the time of discharge that included Contact
                                Information for Obtaining Results for Studies Pending at
                                Discharge

                                N - The patient/caregiver(s) did not receive a Written
                                Transition Record at the time of discharge that included the
                                Contact Information for Obtaining Results for Studies
                                Pending at Discharge
.
Notes for Abstraction:          Notes for abstracting CCD-2.8 Contact information for
                                obtaining results for studies pending at discharge:
                                For the 2011 project, if it is documented on the transition
                                record that there are NO studies pending and because of
                                this, there is no contact information documented on the
                                transition record, you will answer YES in AMART to
                                CCD-2.8, that this element was addressed.

                                Sources for Contact Information include, but are not
                                limited to:
                                             Face sheet
                                             Nursing assessment
                                             Discharge instructions
                                             Transfer sheets

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
Medicaid Inpatient Quality Incentive Guidelines SFY2011                                1-16
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

                                • Written Transition Record




Guidelines for Abstraction:
                 Inclusion                                         Exclusion
• Primary Care Physician                          • Patients who expired
• The Next Provider of Care                       • Patients who left against medical advice
• Surgeon’s Office                                (AMA)
• HIM/Medical Records Department if that
phone number is provided.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-17
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Current Medication List (Reconciled)

Collected For:                  CCD-2-6

Definition:                     A Written Transition Record that included a Current
                                Medication List (Reconciled) was received by the patient or
                                their caregiver(s) at the time of discharge.

Suggested Data
Collection Question:            Did the patient/caregiver(s) receive a Written Transition
                                Record at the time of discharge that included a Current
                                Medication List (Reconciled)?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient/caregiver(s) received a Written Transition
                                Record at the time of discharge that included a Current
                                Medication List (Reconciled)

                                N - The patient/caregiver(s) did not receive a Written
                                Transition Record at the time of discharge that included the
                                a Current Medication List (Reconciled)
.
Notes for Abstraction:          If the medication list is a separate page from the
                                Written Transition Record, there must be reference to
                                see the attached medication list documented on the
                                Written Transition Record.

                                Sources for Current Medication List include, but are
                                not limited to:
                                            Admission orders
                                            Emergency Department records
                                            Progress notes
                                            History and physical
                                            Medication reconciliation form
                                            Nursing admission assessment
                                            Discharge orders
                                            Discharge instructions
                                            Discharge summary
                                            Teaching sheets

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
                                • Written Transition Record
Medicaid Inpatient Quality Incentive Guidelines SFY2011                                1-18
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Guidelines for Abstraction:
                Inclusion                                          Exclusion
None                                              • Patients who expired
                                                  • Patients who left against medical advice
                                                  (AMA)




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-19
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Discharge Date

Collected For:                  All Records

Definition:                     The month, day, and year the patient was discharged from
                                acute care, left against medical advice, 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?

Format:                         Length: 10 – MM/DDYYYY (includes slashes)
                                Type:   Date
                                Occurs: 1

Allowable Values:               MM = Month (01-12)
                                DD =   Day (01-31)
                                YYYY = Year (1880-Current Year)

Notes for Abstraction:          If the abstractor determines through chart review that the
                                date is incorrect, 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:         • Physician’s orders
                                • Discharge summary
                                • Nursing discharge notes
                                • Face sheet

Guidelines for Abstraction:
                Inclusion                                             Exclusion
None                                              None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                               1-20
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Discharge Status

Collected For:                  All Records

Definition:                     The place or setting to which the patient was discharged.

Suggested Data
Collection Question:            What was the patient’s discharge disposition?

Format:                         Length: 2
                                Type: Alphanumeric
                                Occurs: 1

Allowable Values:               01 Discharged to home care or self care (routine discharge)
                                Usage Note: Includes discharge to home; home on oxygen
                                if DME only; any other DME only; group home, foster
                                care, independent living and other residential care
                                arrangements; outpatient programs, such as partial
                                hospitalization or outpatient chemical dependency
                                programs.

                                02 Discharged/transferred to a short term general
                                hospital for inpatient care

                                03 Discharged/transferred to skilled nursing facility
                                     (SNF) with Medicare certification in anticipation of
                                     skilled care.
                                Usage Note: Medicare-indicates that the patient is
                                discharged/transferred to a Medicare certified nursing
                                facility. For hospitals with an approved swing bed
                                arrangement, use Code 61-Swing Bed. For reporting other
                                discharges/transfers to nursing facilities see 04 and 64.

                                04 Discharged/transferred to a facility that provides
                                     custodial or supportive care.
                                Usage Note: Includes intermediate care facilities (ICFs) if
                                specifically designated at the state level. Also used to
                                designate patients that are discharged/transferred to a
                                nursing facility with neither Medicare nor Medicaid
                                certification and for discharges/transfers to Assisted Living
                                Facilities.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                1-21
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

                                05 Discharged/transferred to a designated cancer
                                     center or children’s hospital
                                Usage Note: Transfers to non-designated cancer hospitals
                                should use Code 02. A list of National Cancer Institute
                                Designated Cancer Centers can be found at
                                http://cancercenters.cancer.gov/cancer_centers/index.html

                                06 Discharged/transferred to home under care of
                                     organized home health service organization in
                                     anticipation of covered skilled care.
                                Usage Note: Report this code when the patient is
                                discharged/transferred to home with a written plan of care
                                (tailored to the patient’s medical needs) for home care
                                services.

                                07 Left against medical advice or discontinued care (If
                                   selected, then STOP)

                                20 Expired (If selected, then STOP)

                                21 Discharged/transferred to court/law enforcement
                                Usage Note: Includes transfers to incarceration facilities
                                such as jail, prison or other detention facilities.

                                43 Discharged/transferred to a federal health care
                                    facility
                                Usage Note: Discharges and transfers to a government
                                operated health care facility such as a Department of
                                Defense hospital, a Veteran’s Administration hospital or a
                                Veteran’s Administration nursing facility. To be used
                                whenever the destination at discharge is a federal health
                                care facility, whether the patient resides there or not.

                                50 Hospice – home

                                51 Hospice – medical facility (certified) providing
                                   hospice level of care.

                                61 Discharged/transferred to hospital-based Medicare
                                    approved swing bed.
                                Usage Note: Medicare-used for reporting patients
                                discharged/transferred to an SNF level of care within the
                                hospital’s approved swing bed arrangement.

                                   62 Discharged/transferred to an inpatient
                                        rehabilitation facility (IRF) including rehabilitation
                                        distinct part units of a hospital.
Medicaid Inpatient Quality Incentive Guidelines SFY2011                                  1-22
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

                                63 Discharged/transferred to a Medicare certified long
                                     term care hospital (LTCH)
                                Usage Note: For hospitals that meet the Medicare criteria
                                for LTCH certification.

                                64 Discharged/transferred to a nursing facility
                                   certified under Medicaid but not certified under
                                   Medicare

                                65 Discharged/transferred to a psychiatric hospital or
                                   psychiatric distinct part unit of a hospital

                                66 Discharged/transferred to a Critical Access
                                   Hospital (CAH)

                                70 Discharged/transferred to another type of health
                                   care institution not defined elsewhere in this code
                                   list (See Code 05)

Notes for Abstraction:          It would be appropriate to work with your billing office to
                                develop processes that can be incorporated to improve
                                medical record documentation to support the appropriate
                                discharge status and to ensure consistency between the
                                claim information discharge status and the medical record.

Suggested Data Sources:         • Discharge Instruction Sheet
                                • Discharge Summary
                                • Face Sheet
                                • Nursing Discharge Notes
                                • Physician Orders

Guidelines for Abstraction:
                Inclusion                                             Exclusion
None                                              None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                               1-23
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Documented Infection

Collected For:                  OBS-1

Definition:                     Documentation the patient had an infection during this
                                hospitalization.

Suggested Data
Collection Question:            Did the physician, advanced practice nurse, physician
                                assistant, or certified nurse midwife document infection
                                during this hospitalization?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The physician, advanced practice nurse, physician
                                assistant, or certified nurse midwife did document an
                                infection during this hospitalization

                                N - The physician, advanced practice nurse, physician
                                assistant, or certified nurse midwife did not document an
                                infection during this hospitalization.

Notes for Abstraction:          • Excludes prophylaxis with Penicillin or Ampicillin for
                                Group B streptococcus(GBS)

Suggested Data Sources:         PHYSICIAN/APN/PA/CERTIFIED NURSE
                                MIDWIFE DOCUMENTATION ONLY
                                   Anesthesia record
                                   History and Physical
                                   Progress Notes

                                Excluded Data Sources:
                                Any documentation of an infection found in the Operative
                                Report




Medicaid Inpatient Quality Incentive Guidelines SFY2011                               1-24
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Guidelines for Abstraction:
                Inclusion                                           Exclusion
    Abscess                                             Penicillin or Ampicillin given for
    Acute abdomen                                        Group B Streptococcus(GBS)
    Aspiration pneumonia                                Patients who had a principal ICD-9
    Bloodstream infection                                diagnosis code suggestive of
    Bone infection                                       preoperative infectious disease (as
    Cellulitis                                           defined in Appendix A, Table 5.09
    Endometritis                                         of this manual
    Fecal Contamination                                 Bacteria in urine (Bacteriuria)
    Free air in the abdomen                             “Carditis” (such as pericarditis)
    Gangrene                                             without mention of an infection
    H. pylori                                           Viral infections
    Necrosis                                            Fungal infections
    Necrotic/ischemic/infarcted bowel                   Colonization or positive screens for
                                                          MRSA, VRE, or for other bacteria
    Osteomyelitis
                                                         History of infection, recent
    Other documented infection
                                                          infection, or recurrent infection not
    Penetrating abdominal trauma
                                                          documented as a current or active
    Perforation of bowel                                 infection
    Purulence/pus
    Pneumonia or other lung infection
    Sepsis
    Surgical site or wound infection
    Urinary tract infection (UTI)
    Any other documented infection




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                  1-25
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              First Name

Collected For:                  All Records

Definition:                     The patient’s first name.

Suggested Data
Collection Question:            What is the patient’s first name?

Format:                         Length: 30
                                Type:   Character
                                Occurs: 1

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                                             Exclusion
None                                              None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                           1-26
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Gestational Age

Collected For:                  OBS-4

Definition:                     The weeks of gestation completed at the time of delivery.

                                Gestational age is defined as the number of weeks that have
                                elapsed between the first day of the last normal menstrual
                                period (not presumed time of conception) and the date of
                                delivery, irrespective of whether the gestation results in a
                                live birth or a fetal death.

Suggested Data
Collection Question:            How many weeks of gestation were completed at the time
                                of delivery?

Format:                         Length: 2 or UTD
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               1-50
                                UTD = Unable to Determine

Notes for Abstraction:          **This information is from the current Joint
                                Commission Specification and Guideline Manual for
                                3Q2010. The abstraction guidelines may change with
                                the 4Q2010, and if so, those changes will be distributed
                                as “Release Notes” in a separate correspondence.


                                Gestational age should be rounded off to the nearest
                                completed week, not the following week. For example, an
                                infant born on the 5th day of the 36th week (35 weeks and
                                5/7 days) is at a gestational age of 35 weeks, not 36 weeks.

                                The history and physical should be reviewed first for
                                gestational age. If gestational age is not recorded in the
                                history and physical, then continue to review the data
                                sources in the following order: prenatal forms, delivery or

Medicaid Inpatient Quality Incentive Guidelines SFY2011                                  1-27
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

                                operating room record and clinician admission progrss note
                                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.

                                The clinician admission progress note may be written by
                                the following clinicians: physician, certified nurse midwife
                                (CNM), advanced practice nurse/physician assistant
                                (APN/PA) or registered nurse (RN).

                                If the patient has not received prenatal care, and the
                                gestational age is unknown, select allowable value UTD.

Suggested Data Sources:         ONLY ACCEPTABLE SOURCES IN ORDER OF
                                PREFERENCE:
                                • History and physical
                                • Prenatal forms
                                • Delivery room record
                                • Operating room record
                                • Admission clinician progress notes

Guidelines for Abstraction:
                Inclusion                                             Exclusion
   None                                               None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                  1-28
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information



Data Element Name:              Hospital Patient ID Number

Collected For:                  All Records

Definition:                     The medical record number used by the hospital/facility to
                                identify the patient.

Suggested Data
Collection Question:            What was the number used by the hospital to identify this
                                patient’s stay?

Format:                         Length: 40
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Up to 40 letters and numbers

Notes for Abstraction:          None

Suggested Data Sources:         None

Guidelines for Abstraction:
                Inclusion                                             Exclusion
None                                              None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                              1-29
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              ICD-9-CM Other Diagnosis Codes

Collected For:                  All Records

Definition:                     The International Classification of Diseases, Ninth
                                Revision, Clinical Modification (ICD-9-CM) codes
                                associated with the diagnosis for this hospitalization.

Suggested Data
Collection Question:            What were the ICD-9-CM Other Diagnosis Codes selected
                                for this record?

Format:                         Length: 6 (with or without decimal point)
                                Type:   Alphanumeric
                                Occurs: 10

Allowable Values:               Any valid ICD-9-CM diagnosis code

Notes for Abstraction:          None

Suggested Data Sources:         • Discharge Summary
                                • Face Sheet
                                • UB-04, Field Location: 67A-Q

Guidelines for Abstraction:
                Inclusion                                             Exclusion
None                                              None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                   1-30
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              ICD-9-CM Other Procedure Codes

Collected For:                  All Records

Definition:                     The International Classification of Diseases, Ninth
                                Revision, Clinical Modification (ICD-9-CM) codes
                                identifying all significant procedures other than the
                                principal procedure.

Suggested Data
Collection Question:            What were the ICD-9-CM code(s) selected as the other
                                procedure(s) for this record?

Format:                         Length: 5 (with or without decimal point)
                                Type:   Alphanumeric
                                Occurs: 5

Allowable Values:               Any valid ICD-9-CM procedure code

Notes for Abstraction:          The principal procedure as described by the Uniform
                                Hospital Discharge Data Set (UHDDS) is one performed
                                for definitive treatment rather than diagnostic or
                                exploratory purposes, or which is necessary to take care of
                                a complication.

Suggested Data Sources:         • Discharge Summary
                                • Face Sheet
                                • UB-04, Field Location: 74

Guidelines for Abstraction:
                Inclusion                                             Exclusion
Refer to Appendix A for ICD-9-CM Code             None
Tables




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-31
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              ICD-9-CM Other Procedure Dates

Collected For:                  All Records

Definition:                     The month, day, and year when the associated procedure(s)
                                was (were) performed.

Suggested Data
Collection Question:            What were the date(s) the other procedure(s) were
                                performed?

Format:                         Length: 10 – MM/DD/YYYY (includes slashes) or UTD
                                Type:   Date
                                Occurs: 5

Allowable Values:               MM = Month (01-12)
                                DD = Day (01-31)
                                YYYY = Year (2001 – Current Year)
                                OR Leave Blank if Unable to Determine

Notes for Abstraction:          • If the procedure date for the associated procedure is
                                unable to be determined from medical record
                                documentation, leave blank.

                                • The medical record must be abstracted as documented
                                (taken at “face value”). When the date documented is
                                obviously in error (not a 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 leave this field blank.

Suggested Data Sources:         • Consultation notes
                                • Diagnostic test reports
                                • Discharge summary
                                • Face sheet
                                • Operative notes
                                • Procedure notes
                                • Progress notes
                                • UB-04, Field Location: 74

Guidelines for Abstraction:
                Inclusion                                             Exclusion
None                                              None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                   1-32
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              ICD-9-CM Principal Diagnosis Code

Collected For:                  All Records

Definition:                     The International Classification of Diseases, Ninth
                                Revision, Clinical Modification (ICD-9-CM) code
                                associated with the diagnosis established after study to be
                                chiefly responsible for occasioning the admission of the
                                patient for this hospitalization.

Suggested Data
Collection Question:            What was the ICD-9-CM code selected as the principal
                                diagnosis for this record?

Format:                         Length: 6 (with or without decimal point)
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Any valid ICD-9-CM diagnosis code

Notes for Abstraction:          The principal diagnosis is defined in the Uniform Hospital
                                Discharge Data Set (UHDDS) as “that condition
                                established after study to be chiefly responsible for
                                occasioning the admission of the patient to the hospital for
                                care.”

Suggested Data Sources:         • Discharge Summary
                                • Face Sheet
                                • UB-04, Field Location: 67

Guidelines for Abstraction:
                Inclusion                                             Exclusion
Refer to Appendix A for ICD-9-CM Code             None
Tables




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                1-33
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              ICD-9-CM Principal Procedure Code

Collected For:                  All Records

Definition:                     The International Classification of Diseases, Ninth
                                Revision, Clinical Modification (ICD-9-CM) code that
                                identifies the principal procedure performed during this
                                hospitalization. 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-9-CM code selected as the principle
                                procedure for this record?

Format:                         Length: 5 (with or without decimal point)
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Any valid ICD-9-CM procedure code

Notes for Abstraction:          The principal procedure as described by the Uniform
                                Hospital Discharge Data Set (UHDDS) is one performed
                                for definitive treatment rather than diagnostic or
                                exploratory purposes, or which is necessary to take care of
                                a complication.

Suggested Data Sources:         • Discharge Summary
                                • Face Sheet
                                • UB-04, Field Location: 74

Guidelines for Abstraction:
                Inclusion                                             Exclusion
Refer to Appendix A for ICD-9-CM Code             None
Tables




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                1-34
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information



Data Element Name:              ICD-9-CM Principal Procedure Date

Collected For:                  All Records

Definition:                     The month, day, and year when the principal procedure was
                                performed

Suggested Data
Collection Question:            What was the date the principal procedure was performed?

Format:                         Length: 10 – MM/DD/YYYY (includes slashes) or UTD
                                Type:   Date
                                Occurs: 1

Allowable Values:               MM = Month (01-12)
                                DD = Day (01-31)
                                YYYY = Year (2001 – Current Year)
                                OR Leave Blank if Unable to Determine

Notes for Abstraction:          • If the principal procedure date is unable to be determined
                                from medical record documentation leave blank.

                                • The medical record must be abstracted as documented
                                (taken at “face value”). When the date documented is
                                obviously in error (not a 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 leave this field blank.

Suggested Data Sources:         • Consultation Notes
                                • Diagnostic test reports
                                • Discharge summary
                                • Face Sheet
                                • Operative notes
                                • Procedure notes
                                • Progress notes
                                • UB-04, Field Location: 74

Guidelines for Abstraction:
                Inclusion                                             Exclusion
None                                              None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                1-35
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Last Name

Collected For:                  All Records

Definition:                     The patient’s last name.

Suggested Data
Collection Question:            What is the patient’s last name?

Format:                         Length: 60
                                Type:   Character
                                Occurs: 1

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                                             Exclusion
None                                              None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                           1-36
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Major Procedures and Tests Performed During Stay

Collected For:                  CCD-2-3

Definition:                     A written transition record that included the Major
                                Procedures and Tests Performed During Inpatient Stay and
                                Summary of Results was received by the patient or their
                                caregiver(s) at the time of discharge.

Suggested Data
Collection Question:            Did the patient/caregiver(s) receive a Written Transition
                                Record at the time of discharge that included the Major
                                Procedures and Tests Performed During Inpatient Stay and
                                Summary of Results?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient/caregiver(s) received a Written Transition
                                Record at the time of discharge that included the Major
                                Procedures and Tests Performed During Inpatient Stay and
                                Summary of Results.

                                N - The patient/caregiver(s) did not receive a Written
                                Transition Record at the time of discharge that included the
                                Major Procedures and Tests Performed During Inpatient
                                Stay and Summary of Results.
.
Notes for Abstraction:          • Any reference to actual study results or summary results
                                will answer “Y” (Yes)
                                        Example: “Echo results pending,” “Abnormal
                                results to be discussed with physician,” “Within normal
                                limits,” “Complicated,” “Abnormal,” or the actual test
                                results

                                • Documentation of No major procedures/None/NA are
                                acceptable

                                • If a procedure or test is documented, there must be a
                                summary of results.
                                • Reference to the words “Summary Results” or “Study
                                Results” without actually describing the results will answer
                                “N” (No)

Medicaid Inpatient Quality Incentive Guidelines SFY2011                               1-37
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


                                • Sources for Major Procedures and Tests Performed
                                During Inpatient Stay and Summary of Results include, but
                                are not limited to:
                                             Physician orders
                                             Emergency Department records
                                             Radiology reports/Laboratory reports
                                             Procedure note/Operative reports

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
                                • Written Transition Record

Guidelines for Abstraction:
                Inclusion                                          Exclusion
None                                              • Patients who expired
                                                  • Patients who left against medical advice
                                                  (AMA)




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-38
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Other Surgeries

Collected For:                  OBS-1

Definition:                     Other procedures that occurred within three days (72 hrs)
                                before or after the cesarean section.

Suggested Data
Collection Question:            Did the patient have other procedures that occurred within
                                three days (72 hrs) before or after the cesarean section?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient did have other procedures that occurred
                                within three days (72 hrs) before or after the cesarean
                                section.

                                N - The patient did not have other procedures that occurred
                                within three days (72 hrs) before or after the cesarean
                                section.

Notes for Abstraction:          • This data element is used to exclude cases that have
                                another major surgical procedure performed within three
                                days (72 hrs) prior to or after the cesarean section.

Suggested Data Sources:         • Admitting physician orders
                                • Admitting progress notes
                                • Consultation notes
                                • Discharge summary
                                • Emergency department record
                                • History and physical
                                • Nursing notes
                                • Operative notes/reports
                                • Physician admission notes
                                • Physician progress notes

Guidelines for Abstraction:
                Inclusion                                             Exclusion
None                                              None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                               1-39
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Patient Instructions

Collected For:                  CCD-2-10

Definition:                     A Written Transition Record that included the Patient
                                Instructions (Discharge Instructions) was received by the
                                patient or their caregiver(s) at the time of discharge.

Suggested Data
Collection Question:            Did the patient/caregiver(s) receive a Written Transition
                                Record at the time of discharge that included the Patient
                                Instructions (Discharge Instructions)?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient/caregiver(s) received a Written Transition
                                Record at the time of discharge that included the Patient
                                Instructions (Discharge Instructions)

                                N - The patient/caregiver(s) did not receive a Written
                                Transition Record at the time of discharge that included the
                                Patient Instructions (Discharge Instructions)
.
Notes for Abstraction:          If the discharge instructions are on a separate page
                                from the Written Transition Record, there must be
                                reference to see the attached discharge instructions
                                documented on the Written Transition Record.

                                Sources for Patient Instructions include, but are not
                                limited to:
                                             Nursing notes
                                             Teaching sheets
                                             Progress notes
                                             Discharge orders
                                             Discharge summary
                                             Transfer forms

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
                                • Written Transition Record




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                1-40
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Guidelines for Abstraction:
                Inclusion                                          Exclusion
None                                              • Patients who expired
                                                  • Patients who left against medical advice
                                                  (AMA)




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-41
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Payment Source

Collected For:                  All Records

Definition:                     The source of payment for this episode of care.

Suggested Data
Collection Question:            What is the source of payment for the patient’s services?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 5

Allowable Values:               Select ALL that apply:

                                Y/N – 1. Arkansas Medicaid (Title 19): Medicaid is listed as
                                a payment source.

                                Y/N – 2. Medicaid Other (Non-Arkansas): Medicaid which
                                is not included in 1. Arkansas Medicaid.

                                Y/N – 3. Medicare (Title 18): Medicare is listed as a
                                payment source and has a standard Patient HIC Number. This
                                would include Medicare Fee for Service (include DRG or
                                PPS), Black Lung, End Stage Renal Disease (ESRD),
                                Railroad Retirement Board (RRB) and Medicare coverage as
                                a secondary payer and may include Medicare HMO/Medicare
                                Advantage.

                                Y/N – 4. Medicare Other: Medicare is listed as a payment
                                source and does not have a standard Patient HIC Number.
                                This would include Undocumented Alien (Illegal immigrant)
                                status and may include Medicare HMO/Medicare Advantage.

                                Y/N – 5. Other: There is a payment source other than
                                Medicare or Medicaid (e.g., Veterans Administration [VA],
                                CHAMPUS [TRICARE], Workers' Compensation or private
                                insurance).

                                Y/N – 6. No Insurance/Not documented/Unable to
                                Determine: The patient has no insurance coverage, the
                                payment source is not documented, unable to determine the
                                payment source, or the payment source does not coincide with
                                one of the above options.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                               1-42
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


Notes for Abstraction:          None

Suggested Data Sources:         • Face Sheet

Guidelines for Abstraction:
                Inclusion                                             Exclusion
None                                              None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                           1-43
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Plan for Follow-up Care

Collected For:                  CCD-2-11

Definition:                     A Written Transition Record that included a Plan for
                                Follow-up Care was received by the patient or their
                                caregiver(s) at the time of discharge.

Suggested Data
Collection Question:            Did the patient/caregiver(s) receive a Written Transition
                                Record at the time of discharge that included a Plan for
                                Follow-up Care?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient/caregiver(s) received a Written Transition
                                Record at the time of discharge that included a Plan for
                                follow-up Care

                                N - The patient/caregiver(s) did not receive a Written
                                Transition Record at the time of discharge that included a
                                Plan for follow-up Care

Notes for Abstraction:          • May include any post-discharge therapy needed
                                       Ex: Oxygen therapy, physical therapy, occupational
                                therapy, any durable medical equipment,
                                family/psychosocial resources available for patient support,
                                etc.

                                • In the event the patient is transferred to another inpatient
                                facility where the plan for follow-up care will be
                                determined at the time of discharge from that facility, this
                                element may be documented as, “Transferred,” “NA,”
                                “None,” etc.

                                • Sources for Plan for Follow-Up Care include, but are not
                                limited to:
                                                 Discharge instructions
                                                 Discharge summary
                                                 Emergency Department records
                                                 Progress notes
                                                 Teaching sheets
                                                 Transfer records
Medicaid Inpatient Quality Incentive Guidelines SFY2011                                  1-44
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


                                                Nursing notes

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
                                • Written Transition Record


Guidelines for Abstraction:
                Inclusion                                          Exclusion
None                                              • Patients who expired
                                                  • Patients who left against medical advice
                                                  (AMA)




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-45
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Planned/Elective C-section

Collected For:                  OBS-2

Definition:                     C-sections that are planned or elective, and are non-
                                emergent.

Suggested Data
Collection Question:            Did the patient have a planned/elective C-section?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient did have a planned/elective C-section

                                N - The patient did not have a planned/elective C-section
.
Notes for Abstraction:          None

Suggested Data Sources:              •   Operating room record
                                        Anesthesia record
                                        Nursing notes
                                        Operative report
                                        Physician notes
                                        Progress notes
                                        History & Physical
                                        Discharge summary
                                        Emergency room record

Guidelines for Abstraction:
                Inclusion                                        Exclusion
    Planned or Elective C-section                       Emergent C-section




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-46
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Primary Physician/Health Care Professional Designated for
                                Follow-up Care

Collected For:                  CCD-2-12

Definition:                     A written transition record that included the Primary
                                Physician or other Health Care Professional Designated for
                                Follow-up Care was received by the patient or their
                                caregiver(s) at the time of discharge.

Suggested Data
Collection Question:            Did the patient/caregiver(s) receive a Written Transition
                                Record at the time of discharge that included the Primary
                                Physician or other Health Care Professional Designated for
                                Follow-up Care?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient/caregiver(s) received a Written Transition
                                Record at the time of discharge that included the Primary
                                Physician or other Health Care Professional Designated for
                                Follow-up Care

                                N - The patient/caregiver(s) did not receive a Written
                                Transition Record at the time of discharge that included the
                                Primary Physician or other Health Care Professional
                                Designated for Follow-up Care
.
Notes for Abstraction:          • In the event the patient is transferred to another inpatient
                                facility where the plan for follow-up care will be
                                determined at the time of discharge from that facility, this
                                element may be documented as, “Transferred,” “NA,”
                                “None,” etc.

                                Sources for Primary Physician or Other Healthcare
                                Professional Designated for Follow-Up Care include,
                                but are not limited to:
                                           Face sheet
                                           Emergency Department records
                                           Progress notes
                                           Discharge summary
                                           Discharge orders
                                           Transfer records

Medicaid Inpatient Quality Incentive Guidelines SFY2011                                  1-47
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
                                • Written Transition Record



Guidelines for Abstraction:
                Inclusion                                          Exclusion
None                                              • Patients who expired
                                                  • Patients who left against medical advice
                                                  (AMA)




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-48
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Principle Diagnosis at Discharge

Collected For:                  CCD-2-4

Definition:                     A written transition record that included the Principle
                                Diagnosis at Discharge was received by the patient or their
                                caregiver(s) at the time of discharge.

Suggested Data
Collection Question:            Did the patient/caregiver(s) receive a Written Transition
                                Record at the time of discharge that included the Principle
                                Diagnosis at Discharge?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient/caregiver(s) received a Written Transition
                                Record at the time of discharge that included the Principle
                                Diagnosis at Discharge

                                N - The patient/caregiver(s) did not receive a Written
                                Transition Record at the time of discharge that included the
                                Principle Diagnosis at Discharge
.
Notes for Abstraction:          Sources for Principle Diagnosis at Discharge include,
                                but are not limited to:
                                           Discharge orders
                                           Discharge instructions
                                           Progress notes
                                           Discharge summary

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
                                • Written Transition Record

Guidelines for Abstraction:
                Inclusion                                          Exclusion
None                                              • Patients who expired
                                                  • Patients who left against medical advice
                                                  (AMA)




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-49
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Prophylactic Antibiotic Received within One Hour of cut
                                time or at the time of delivery

Collected For:                  OBS-1

Definition:                     The patient was treated with prophylactic antibiotics within
                                1 hour of cut time or at the time of delivery
Suggested Data
Collection Question:            Was the patient treated with prophylactic antibiotics within
                                1 hour prior to surgical incision time or at the time of
                                delivery?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient was treated with prophylactic antibiotics
                                within 1 hour prior to surgical incision time or at the time
                                of delivery

                                N - The patient was not treated with prophylactic
                                antibiotics within 1 hour prior to surgical incision time or at
                                the time of delivery

Notes for Abstraction:          • Excludes prophylaxis with Penicillin or Ampicillin for
                                Group B streptococcus (GBS)

Suggested Data Sources:         • Any source documenting antibiotic administration
                                • Emergency department record
                                • EMT/Ambulance records
                                • History and physical
                                • Medication administration record
                                • Nursing admission assessment
                                • Nursing notes
                                • Progress notes




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                  1-50
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Guidelines for Abstraction:
                 Inclusion                                          Exclusion
Include any antibiotics given:                           Penicillin or Ampicillin given for
Intravenous:                                              Group B Streptococcus(GBS)
     Bolus                                              Abdominal irrigation
     Infusion                                           Enema/rectally
     IV                                                 Inhalation
     I.V.                                               Mouthwash
     IVPB                                               Nasal sprays
     IV Piggyback                                       Topical antibiotics
     Parenteral                                         Vaginal administration
     Perfusion                                          Wound irrigation

                                                  PO/NG/PEG tube:
                                                     Any kind of feeding tube (e.g.,
                                                       percutaneous endoscopic
                                                       gastrostomy, percutaneous
                                                       endoscopic jejunostomy,
                                                       gastrostomy tube)
                                                     By mouth
                                                     Gastric tube
                                                     G-tube
                                                     Jejunostomy
                                                     J-tube
                                                     Nasogastric tube
                                                     PO
Refer to Appendix B for a list of
Antimicrobial Medications                            P.O.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                  1-51
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Reason for Inpatient Admission

Collected For:                  CCD-2-2

Definition:                     A written transition record that included the Reason for
                                Inpatient Admission was received by the patient or their
                                caregiver(s) at the time of discharge.

Suggested Data
Collection Question:            Did the patient/caregiver(s) receive a Written Transition
                                Record at the time of discharge that included the Reason
                                for Inpatient Admission?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient/caregiver(s) received a Written Transition
                                Record at the time of discharge that included the Reason
                                for Inpatient Admission

                                N - The patient/caregiver(s) did not receive a Written
                                Transition Record at the time of discharge that included the
                                Reason for Inpatient Admission.

Notes for Abstraction:          • Documentation of a diagnosis or symptoms is acceptable

                                Sources for Reason for Inpatient Admission include,
                                but are not limited to:
                                           Admission orders
                                           Emergency Department records
                                           Progress notes
                                           History and physical

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
                                • Written Transition Record

Guidelines for Abstraction:
                Inclusion                                          Exclusion
None                                              • Patients who expired
                                                  • Patients who left against medical advice
                                                  (AMA)




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-52
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Reconciled Medication List

Collected For:                  CCD-1

Definition:                     A reconciled medication list was received by the
                                patient/caregiver(s) at the time of discharge including, at a
                                minimum, medications in the categories “Discontinued,”
                                “Continued,” and “New.”

Suggested Data
Collection Question:            Did the patient/caregiver(s) receive a copy of the reconciled
                                medication list at the time of discharge?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient/caregiver(s) received a reconciled
                                medication list at the time of discharge.

                                N - The patient/caregiver(s) did not receive a reconciled
                                medication list at the time of discharge.

Notes for Abstraction:          • Discontinued – Medications that should be discontinued
                                or held after discharge, AND
                                  Continued* – Medications (including any prescribed
                                before inpatient stay and any started during inpatient stay)
                                that patient should continue to take after discharge, AND
                                  New* – Newly prescribed medications that patient should
                                begin taking after discharge.

                                • At the time the patient enters the hospital or is admitted, a
                                complete list of the medications the patient is taking at
                                home (including dose, route, and frequency) is created and
                                documented.

                                • The medications ordered for the patient while under the
                                care of the hospital are compared to those on the list
                                created at the time of entry to the hospital or admission.

                                • Any discrepancies (that is, omissions, duplications,
                                adjustments, deletions, additions) are reconciled and
                                documented while the patient is under the care of the
                                hospital.

                                   • In the event the medication reconciliation form is present
                                   in the medical record and there is no documentation which
Medicaid Inpatient Quality Incentive Guidelines SFY2011                                    1-53
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

                                clearly suggests that a copy was given, the inference should
                                be made that it was given IF the patient’s name or the
                                medical record number appears on the material AND
                                hospital staff or the patient/caregiver has signed the
                                material.

                                • *Prescribed dosage, instructions, and intended duration if
                                applicable (ex. Rocephin x 10 days), must be included for
                                each continued and new medication listed.

                                • Abstraction is a two-step process:
                                1. Determine all of the medications being prescribed at
                                discharge, based on available medical record
                                documentation.
                                o Discharge medication information included in a discharge
                                summary dated after discharge should be used as long as it
                                was added within 30 days after discharge.
                                • If two discharge summaries are included in the medical
                                record, use the one with the latest date. If one or both are
                                not dated, and you cannot determine which was done last,
                                use both. This also applies to discharge medication
                                reconciliation forms.
                                Examples:
                                − Two discharge summaries, one dated 5/22 (day of
                                discharge) and one dated 5/27 - Use the 5/27 discharge
                                summary.
                                − Two discharge medication reconciliation forms, one not
                                dated and one dated 4/24 (day of discharge) - Use both.
                                • If discharge medications are noted using only references
                                such as “continue home meds,” “resume other meds,” or
                                “same medications,” rather than lists of the names of the
                                discharge medications, the abstractor should use all sources
                                to compile a list of medications the patient was on prior to
                                arrival (or in the case of acute care transfers, use the
                                medications the patient was on prior to arrival at the first
                                hospital).
                                o For the purpose of this measure, medications include
                                prescriptions, over-the-counter, and herbal products.
                                o Oxygen should not be considered a medication.
                                o Medications which the patient will not be taking at home
                                (and/or the caregiver will not be giving at home) are NOT
                                required in the medication list included in the written
                                discharge instructions (e.g., monthly B12 injections,
                                intermittent IV dobutamine, Natrecor infusions, dialysis
                                meds, chemotherapy).


Medicaid Inpatient Quality Incentive Guidelines SFY2011                                1-54
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

                                2. Check this list against the written discharge instructions
                                given to the patient to ensure that these instructions
                                addressed all medications, including name, dose, route,
                                frequency, and intended duration if applicable. If a list of
                                discharge medications is not documented elsewhere in the
                                record, and the completeness of the medication list in the
                                instructions cannot be confirmed as complete, or it can be
                                determined to be incomplete, select “No.”
                                o EXCEPTION: If a comparison list is not available, and
                                the discharge list in the written discharge instructions
                                cannot be determined to be complete or incomplete, but the
                                written discharge instructions have the name or initials of
                                the physician/advanced practice nurse/physician assistant
                                (physician/APN/PA) signed on the form, presume the list
                                of discharge medications in those instructions is complete.
                                o In making medication name comparisons, consider two
                                medications that are brand/trade name vs. generic name
                                in nature or that have the same generic equivalent as
                                matches.

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
                                • RECONCILED Medication Reconciliation Form

Guidelines for Abstraction:
                Inclusion                                          Exclusion
None                                              • Patients who expired
                                                  • Patients who left against medical advice
                                                  (AMA)




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-55
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Sample

Collected For:                  All Records

Definition:                     Indicates if the data being transmitted for a hospital has
                                been sampled, or represents an entire population for the
                                specified time period.

Suggested Data
Collection Question:            Does this case represent part of a sample?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – This data represents part of a sample.
                                N – The data is not part of a sample; this indicates the
                                hospital is performing 100% of the discharges eligible for
                                this measure set.

Notes for Abstraction:          None

Suggested Data Sources:         Not Applicable

Guidelines for Abstraction:
                Inclusion                                             Exclusion
None                                              None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-56
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Spontaneous Rupture of Membranes

Collected For:                  OBS-4

Definition:                     Documentation that the patient had spontaneous rupture of
                                membranes (SROM) before medical induction and/or
                                cesarean section.
Suggested Data
Collection Question:            Is there documentation that the patient had spontaneous
                                rupture of membranes before medical induction and/or
                                cesarean section?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y (Yes) There is documentation that the patient had
                                spontaneous rupture of membranes before medical
                                induction and/or cesarean section.

                                N (No) There is no documentation that the patient had
                                spontaneous rupture of membranes before medical
                                induction and/or cesarean section OR unable to determine
                                from medical record documentation.

Notes for Abstraction:          **This information is from the current Joint
                                Commission Specification and Guideline Manual for
                                3Q2010. The abstraction guidelines may change with
                                the 4Q2010, and if so, those changes will be distributed
                                as “Release Notes” in a separate correspondence.


                                If the patient's spontaneous rupture of membranes is
                                confirmed before medical induction and/or cesarean section
                                by one of the following methods, select allowable value
                                "Yes":

                                        Positive ferning test
                                        Positive nitrazine test
                                        Positive pooling (gross fluid in vagina)
Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-57
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


                                        Positive Amnisure test or equivalent
                                        Patient report of SROM prior to hospital arrival

Suggested Data Sources:         • History and physical
                                • Nursing note
                                • Physician progress note

Guidelines for Abstraction:
                Inclusion                                             Exclusion
None                                                  None




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-58
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Studies Pending at Discharge

Collected For:                  CCD-2-7

Definition:                     A written transition record that included the tissue
                                pathology and radiology studies Pending at Discharge
                                was received by the patient or their caregiver(s) at the time
                                of discharge.

Suggested Data
Collection Question:            Did the patient/caregiver(s) receive a Written Transition
                                Record at the time of discharge that included tissue
                                pathology and radiology studies pending at discharge?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient/caregiver(s) received a Written Transition
                                Record at the time of discharge that included the tissue
                                pathology and radiology studies pending at discharge

                                N - The patient/caregiver(s) did not receive a Written
                                Transition Record at the time of discharge that included the
                                tissue pathology and radiology studies pending at discharge
.
Notes for Abstraction:          Notes for abstracting CCD-2.7 Tissue pathology and
                                radiology studies pending at discharge:
                                If there are no studies pending, you will document “None,
                                NA, etc.” on the transition record. When answering that
                                question in AMART, IF there is “None, NA” marked on
                                the transition record, you will answer YES.

                                Sources for Studies Pending at Discharge include, but
                                are not limited to:
                                            Admission orders
                                            Emergency Department records
                                            Progress notes
                                            Biopsy reports
                                            Laboratory reports
                                            Radiology reports
                                            Procedure notes

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
                                • Written Transition Record
Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-59
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information



Guidelines for Abstraction:
                Inclusion                                          Exclusion
None                                              • Patients who expired
                                                  • Patients who left against medical advice
                                                  (AMA)




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-60
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Data Element Name:              Timely Transmission of Transition Record

Collected For:                  CCD-3

Definition:                     A written transition record was forwarded to the facility or
                                primary physician or other health care professional
                                designated for follow-up care.

Suggested Data
Collection Question:            Was the written transition record forwarded to the facility
                                or primary physician or other health care professional
                                designated for follow-up care within 24 hours of discharge?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The written transition record was forwarded to the
                                facility or primary physician or other health care
                                professional designated for follow-up care within 24 hours
                                of discharge

                                N – The written transition record was not forwarded to the
                                facility or primary physician or other health care
                                professional designated for follow-up care within 24 hours
                                of discharge

Notes for Abstraction:          • Must have documentation of Date, Time and
                                Location/Source the Transition Record was transmitted to
                                within 24 hours of discharge (e.g. 11/01/09, 1215, sent via
                                EMR to Dr. Smith, 12/12/09, 1325, faxed to ABC Home
                                Health, etc.)

                                • Records being given to patient to hand carry to the
                                next provider of care is NOT acceptable.

                                • Ensure that care information is transmitted and
                                appropriately documented in a timely manner and in a
                                clearly understandable form to patients and to all of the
                                patient’s healthcare providers/professionals, within and
                                between care settings, who need that information to provide
                                continued care.



Medicaid Inpatient Quality Incentive Guidelines SFY2011                                1-61
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


                                • Any documentation used to complete the Written
                                Transition Record must be transmitted with the Written
                                Transition Record (ex. Medication Reconciliation Form,
                                Discharge Instructions)

                                • Communication and information exchange between the
                                Medical Home and the receiving provider should occur in
                                an amount of time that will allow the receiving provider to
                                effectively treat the patient. This communication should
                                ideally occur whenever patients are at a transition of care;
                                e.g., at discharge from the inpatient setting.

                                • In the case of Electronic Health Records (EHR), there
                                must be an electronic signature by discharging staff
                                confirming that the information has been transmitted to the
                                next provider of care. The next provider of care having
                                access to the EHR is not enough to pass this measure.

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
                                • Written Transition Record

Guidelines for Abstraction:
                Inclusion                                          Exclusion
None                                              • Patients who expired
                                                  • Patients who left against medical advice
                                                  (AMA)




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 1-62
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information



Data Element Name:              Written Transition Record

Collected For:                  CCD-2-1

Definition:                     A Written Transition Record was received by the
                                patient/caregiver(s) at the time of discharge.

Suggested Data
Collection Question:            Did the patient/caregiver(s) receive a Written Transition
                                Record at the time of discharge?

Format:                         Length: 1
                                Type:   Alphanumeric
                                Occurs: 1

Allowable Values:               Y – The patient/caregiver(s) received a Written Transition
                                Record at the time of discharge.

                                N - The patient/caregiver(s) did not receive a Written
                                Transition Record at the time of discharge.

Notes for Abstraction:          • All patients, regardless of age, discharged from an
                                inpatient facility (e.g., hospital inpatient or observation,
                                skilled nursing facility, or rehabilitation facility) to
                                home/self care or any other site of care.

                                • When the material is present in the medical record and
                                there is no documentation which clearly suggests that a
                                copy was given, the inference should be made that it was
                                given IF the patient’s name or the medical record number
                                appears on the material AND hospital staff or the
                                patient/caregiver has signed the material.

Suggested Data Sources:         ONLY ACCEPTABLE DOCUMENTATION FOR
                                ABSTRACTION OF THIS DATA ELEMENT:
                                • Written Transition Record

Guidelines for Abstraction:
                Inclusion                                          Exclusion
None                                              • Patients who expired
                                                  • Patients who left against medical advice
                                                  (AMA)




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                   1-63
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
  Section 2       Measure Information


2 2.1 Care Coordination Documentation

   Care Coordination Documentation IQI Submission Measures

  Measure ID#                                    Measure Name
  CCD-1            Reconciled medication list received by discharged patients
  CCD-2            Transition record with specified elements received by discharged patients
  CCD-3            Timely transmission of transition record




  Medicaid Inpatient Quality Incentive Guidelines SFY2011                             2-64
  Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

CCD Initial Patient Population Algorithm

                      START                                 Note: Sampling size of initial
                                                            population is based on Payment
                                                            Source=1(Medicaid) only. But
                                                            providers may include all payment
                                                            sources in submission population.


                     Payment
                      Source



                            Select All That Apply
                            1,2,3,4,5,6

                     Discharge          = 07, 20
                       Status


                            = 01,02,03,04,05,06,21,43,50,
                              51,61,62,63,64,65,66,70

             Patient Age(in years) =
             Admission Date minus
                    Birthdate




                      Patient              <1 year
                       Age



                            >=1 year


                      CCD                                      Not In CCD
                    Population                                 Population




                                                                  STOP


Medicaid Inpatient Quality Incentive Guidelines SFY2011                                   2-65
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2              Measure Information


CARE COORDINATION DOCUMENTATION (CCD) POPULATION
In the event a hospital chooses to enter MEDICAID-ONLY cases for CCD, complete the following steps:
1. Pull all Medicaid primary (no other payment source) patients for the quarter.
2. Eliminate any cases with Discharge Status codes 07 or 20.
3. Eliminate any cases with a patient age of < 1 year.
4. At this point, a facility will have the number of cases that must be used to determine the required sample size.
5. Once this number of patients is determined, a hospital may enter 100% of the Medicaid cases or refer to the sampling table for the
sampling requirement number.
6. If a hospital plans to sample, it should be a random sample.
In the event a hospital chooses to enter ALL PAYORS for CCD, complete the following steps:
1. Pull all cases (all payors) for the quarter.
2. Eliminate all cases with Discharge Status codes 07 or 20.
3. Eliminate any cases with a patient age of < 1 year.
4. Determine how many of the remaining cases are Medicaid primary. This is the number which will be used for sampling requirements.
5. Refer to the sampling table using the number of Medicaid cases from Step 4 and determine how many cases should be submitted.
6. If a hospital plans to sample all payors, the hospital should randomly select from the patients remaining following Step 3 using the
number determined from the sampling table in Step 5.
7. There must be at least one Medicaid patient included.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                                                             2-66
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


                Measure Information Form and Flow Chart

Measure Set: Care Coordination Documentation

Measure ID#: CCD-1

Submission Measure Name: Reconciled Medication List Received by Discharged
Patients

Description: Percentage of patients discharged from an inpatient facility to home, home
with hospice, home with home health, or discharged to court/law enforcement, or their
caregiver(s), who received a reconciled medication list at the time of discharge including,
at a minimum, all of the specified elements.

Rationale: The Institute of Medicine estimated that medication errors harm 1.5 million
people each year in the United States, at an annual cost of at least $3.5 billion. Many of
these medication errors (approximately 60% in one study) occur during times of
transition, when patients receive medications from different prescribers who lack access
to patients’ comprehensive, reconciled medication list at each care transition (e.g.,
inpatient discharge). Providing a reconciled medication list at discharge may improve
patients’ ability to manage their medication regimen properly and reduce the number of
medication errors.

Type of measure: Performance

Numerator Statement: Patients or their caregiver(s) who received a reconciled
medication list at the time of discharge including, at a minimum, medications in the
following categories:

               Discontinued
                Medications that should be discontinued or held after discharge, AND
               Continued*
                Medications (including any prescribed before inpatient stay and any started during
                inpatient stay) that patient should continue to take after discharge, AND
               New*
                Newly prescribed medications that patient should begin taking after discharge

                *Prescribed dosage, instructions, route, frequency, and intended duration if applicable,
                must be included for each continued and new medication listed

                Included Populations: Not applicable

                Excluded Populations: None

Denominator Statement: Patients discharged from an inpatient facility (eg, hospital
inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self


Medicaid Inpatient Quality Incentive Guidelines SFY2011                                              2-67
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

care, home with hospice, home with home health, or discharged to court/law
enforcement.

Included Populations: Any patient discharged from an inpatient facility to home/self
care, home with hospice, home with home health, or discharged to court/law
enforcement.

Excluded Populations: Patients who expired
                      Patients who left against medical advice (AMA)
                      Patients less than 1 year of age

Sampling: Yes. For additional information see the Sampling Guidelines in Section 3 of this
manual.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                           2-68
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
     Section 2         Measure Information
CCD-1: Reconciled Medication List Received by Discharged Patients
Numerator:   Patients or their caregiver(s) who received a reconciled medication list at the time of discharge
Denominator: Patients discharged from an inpatient facility(eg, hospital inpatient or observation, skilled nursing facility, or
             rehabilitation facility) to home/self care, home with hospice, home with home health, or discharged to
             court/law enforcement.


                                                        START



                                             Cases that are included in the
                                                   CCD population

                                                               =Y
                                                                        Not =01,06,
                                                                        21,50


                                                                                                B
                                                       Discharge                           Not In Measure
                                                         Status                              Population



                                                               =01,06,21,50


                                                                        =N


                                                                                         D
                                                       Reconciled                      In Measure
                                                       Medication                      Population
                                                          List


                                                               =Y




                                                        E
                                                     In Numerator
                                                      Population




                                                         STOP




     Medicaid Inpatient Quality Incentive Guidelines SFY2011                                                  2-69
     Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


               Measure Information Form and Flow Chart

Measure Set: Care Coordination Documentation

Measure ID#: CCD-2

Submission Measure Name: Transition Record with Specified Elements Received by
Discharged Patients

Description: Percentage of patients discharged from an inpatient facility to home or any
other site of care, or their caregiver(s), who received a written transition record at the
time of discharge including, at a minimum, all of the specified elements.

Rationale: Providing detailed discharge information enhances patients’ preparation to
self-manage post-discharge care and comply with treatment plans. Additionally,
randomized trials have shown that many hospital readmissions can be prevented by
patient education, pre-discharge assessment, and domiciliary aftercare.

Type of measure: Performance

Numerator Statement: Patients or their caregiver(s) who received a written transition
record* at the time of discharge including, at a minimum, all of the following elements:

                             Reason for inpatient admission, AND
                             Major procedures and tests performed during inpatient stay and
                              summary of results, AND
                             Principal diagnosis at discharge, AND
                             Advance care plan (or documented reason for not providing
                              same)*, AND
                             Current medication list*, AND
                             Tissue pathology and radiology studies pending at discharge
                             Contact information for obtaining results for studies pending at
                              discharge, AND
                             24-hour/7-day contact information including physician for
                              emergencies related to inpatient stay, AND
                             Patient discharge instructions,AND
                             Plan for follow-up care, AND
                             Primary physician or other health care professional designated
                              for follow-up care*
        *Numerator element definitions:
            Transition record: a core, standardized set of data elements related to patient’s
               diagnosis, treatment, and care plan that is discussed with and provided to patient and
               transmitted to the facility/physician/other health care professional providing follow-up
               care.


Medicaid Inpatient Quality Incentive Guidelines SFY2011                                            2-70
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

               Advance care plan: advance directives (eg, written statement of patient wishes regarding
                future use of life-sustaining medical treatment) or surrogate decision maker documented
               Documented reason for not providing advance care plan: documentation that advance
                care plan was discussed but patient did not wish or was not able to name a surrogate
                decision maker or provide an advance care plan, OR documentation as appropriate that
                the patient’s cultural and/or spiritual beliefs preclude a discussion of advance care
                planning as it would be viewed as harmful to the patient’s beliefs and thus harmful to the
                physician-patient relationship
               Current medication list: all medications to be taken by patient after discharge, including
                all continued and new medications
               Primary physician or other health care professional designated for follow-up care: may
                be designated primary care physician (PCP), medical specialist, or other physician or
                health care professional

                Included Populations: Not applicable

                Excluded Populations: None

Denominator Statement: Patients discharged from an inpatient facility (eg, hospital
inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self
care or any other site of care.

Included Populations: Any patient discharged from an inpatient facility to home/self
care or any other site of care.

Excluded Populations: Patients who expired
                      Patients who left against medical advice (AMA)
                      Patients less than 1 year of age

Sampling: Yes. For additional information see the Sampling Guidelines in Section 3 of this
manual.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                            2-71
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
  Section 2     Measure Information
CCD-2: Transition Record with Specified Elements by Discharged Patients
Numerator:   Patients or their caregiver(s) who received a written transition record at the time of discharge.
Denominator: Patients discharged from an inpatient facility(eg, hospital inpatient or observation, skilled nursing facility, or
             rehabilitation facility) to home/self care or any other site of care.

                                                        START



                                             Cases that are included in the
                                                   CCD population




                                                        Written                         CCD-2
                                                       Transition             =N          D
                                                        Record


                                                               =Y

                                               Initialize Transition Record
                                                         Counter=0




                                                       Reason
                                                     for Inpatient
                                                      Admission

                                                                                                    =N
                                                               =Y

                                          Add 1 to Transition Record Counter



                                                        Major
                                                    Procedures &
                                                   Tests Performed
                                                     During Stay

                                                                                                    =N
                                                               =Y

                                          Add 1 to Transition Record Counter



                                                         CCD-2
                                                           H

     Medicaid Inpatient Quality Incentive Guidelines SFY2011                                                  2-72
     Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


                                              CCD-2
                                                H




                                            Principle
                                           Diagnosis
                                          at Discharge


                                                   =Y                 =N

                                Add 1 to Transition Record Counter




                      < 18
                                          Patient Age



                                                   >= 18



                                           Advance
                                           Care Plan


                                                   =Y                 =N

                                Add 1 to Transition Record Counter



                                            Current
                                           Medication
                                             List


                                                   =Y                 =N

                                Add 1 to Transition Record Counter



                                              CCD-2
                                                I


Medicaid Inpatient Quality Incentive Guidelines SFY2011                    2-73
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


                                              CCD-2
                                                I




                                            Studies
                                           Pending at
                                           Discharge


                                                                      =N

                                Add 1 to Transition Record Counter



                                             Contact
                                         Information for
                                             Studies
                                            Pending

                                                   =Y                 =N

                                Add 1 to Transition Record Counter



                                            24-Hour/
                                         7-Day Contact
                                          Information


                                                   =Y                 =N

                                Add 1 to Transition Record Counter




                                            Patient
                                          Instructions


                                                   =Y                 =N
                                Add 1 to Transition Record Counter


                                              CCD-2
                                                J
Medicaid Inpatient Quality Incentive Guidelines SFY2011                    2-74
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


                                                CCD-2
                                                  J




                                              Plan for
                                             Follow-Up
                                               Care

                                                      =Y                                   =N

                                 Add 1 to Transition Record Counter


                                                  Primary
                                                 Physician/
                                                Health Care
                                          Professional Designated
                                               for Follow-up
                                                   Care

                                                      =Y                                   =N

                                 Add 1 to Transition Record Counter



                            Age>=18                             Age<18
            Transition                           Age                               Transition
             Record                                                                 Record
             Counter                                                                Counter
                                                                    CCD-2
                                                                      D




                                              D
                      Not = 11              In Measure                 Not = 10
                                            Population




                                              E
                         = 11              In Numerator                     = 10
                                            Population



                                               STOP
Medicaid Inpatient Quality Incentive Guidelines SFY2011                                         2-75
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2        Measure Information


               Measure Information Form and Flow Chart

Measure Set: Care Coordination Documentation

Measure ID#: CCD-3

Submission Measure Name: Timely Transmission of Transition Record

Description: Percentage of patients discharged from an inpatient facility to home or any
other site of care for whom a written transition record was transmitted to the facility or
primary physician or other health care professional designated for follow-up care within
24 hours of discharge.

Rationale: The availability of the patient’s discharge information at the first post-
discharge physician visit improves the continuity of care and may be associated with a
decreased risk of re-hospitalization.

Type of measure: Performance

Numerator Statement: Patients for whom a written transition record* was transmitted*
to the facility or primary physician or other health care professional designated for
follow-up care* within 24 hours of discharge

*Numerator element definitions:
    Transition record: a core, standardized set of data elements related to patient’s diagnosis,
       treatment, and care plan that is discussed with and provided to patient and transmitted to the
       facility/physician/other health care professional providing follow-up care.
    Transmitted: transition record usty be transmitted to the facility or physician or other health care
       professional designated for follow-up. Primary physician or other health care professional
       designated for follow-up care: may be designated primary care physician (PCP), medical
       specialist, or other physician or health care professional


                 Included Populations: Not applicable

                 Excluded Populations: None

Denominator Statement: Patients discharged from an inpatient facility (eg, hospital
inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self
care or any other site of care.

Included Populations: Any patient discharged from an inpatient facility to home/self
care or any other site of care.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                            2-76
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

Excluded Populations: Patients who expired
                      Patients who left against medical advice (AMA)
                      Patients less than 1 year of age

Sampling: Yes. For additional information see the Sampling Guidelines in Section 3 of this
manual.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                           2-77
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2         Measure Information

CCD-3: Timely Transmission of Transition Record
Numerator:   Patients for whom a written transition record was transmitted to the facility or primary
             physician or other health care professional designated for follow-up care on the date of
             discharge.
Denominator: Patients discharged from an inpatient facility(eg, hospital inpatient or observation, skilled
             nursing facility, or rehabilitation facility) to home/self care or any other site of care.




                                                  START



                                        Cases that are included in the
                                              CCD population




                                                  Timely


                                                                                         D
                                              Transmission of            =N            In Measure
                                                 Transition                            Population
                                                  Record


                                                         =Y




                                                  E
                                               In Numerator
                                                Population




                                                   STOP




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                                2-78
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
       Section 2       Measure Information

                                         TRANSITION RECORD
                                       EXAMPLE ONLY
(Patient Label or Identification Information)  Care Coordination Form
                                                      Page 1 of 2
It is very important to communicate details about this hospital stay to your doctor and anyone
else that will be caring for your health. Please keep this sheet. Show it to your doctor and
any other healthcare provider at your next appointment.

Reason for inpatient admission: ________________________________________________

Major procedures and test performed during inpatient stay and summary results: __________

__________________________________________________________________________

Principle diagnosis at discharge: ________________________________________________

Advance care plan/directives   □ Living Will □ DNR □ POA □ Comfort Measures □ Other □ None
                               □ Info Given
Reason for None: ___________________________________________________________________

Medication List: □ See Medication Reconciliation Form
                                                                                  Continue
                                                                                 Medication
                                                                        Last         at
       Drug Name               Dose      Frequency        Route
                                                                       taken     discharge

                                                                                Yes      No




New Medication:
                                                                                 Expected
        Drug Name                Dose       Frequency          Route             Duration
                                                                             (If Applicable)




       Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 2-79
       Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
       Section 2        Measure Information




                                                        Care Coordination Form
                                                               Page 2 of 2

Tissue Pathology and Radiology Studies Pending at Discharge:

______________________________________________________

Contact Information for obtaining results for Studies Pending at Discharge:

Physician __________________________ Phone Number________________

24-hr/7-day contact information including physician for emergencies related to inpatient stay:

Emergency Room #___________________________


Patient instructions:
                Diet _______________________________________________________________

                Activity____________________________________________________________

                Other: _____________________________________________________________


Follow up care: □ PT □ OT □ DME □ Home Health □ Other

____________________________________________________




 Follow Up Appointment with:
 Dr._____________________________                 Location: ____________________________

 Date: _________________          Time: _______________           Phone#: ___________________




Discharge Status: □ Home □ Nursing Home □ Assisted Living □ Transferred to another Acute
Care Hospital □ Other

Care Coordination Form sent to: _________________ ______ ___ _____________________________

Sent via: FAX      Electronic Transmission   Phone    Mail          Date: _________ Time: _________

Form Received by Patient (Patient Care/Giver Signature): __________________________________

Discharge Nurse Signature: _________________________ Date: ______________ Time: _________
       Medicaid Inpatient Quality Incentive Guidelines SFY2011                                2-80
       Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information

2.2     OBS


                     Obstetric IQI Submission Measures

Measure ID#                                    Measure Name
OBS-1            Prophylactic antibiotics received within 1 hour of c-section cut time
OBS-2            Appropriate DVT prophylaxis in women undergoing c-sections
OBS-4            Elective delivery




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                  2-81
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


 OBS Initial Patient                   START                  Note: Sampling size of initial
 Population Algorithm                                         population is based on Payment
                                                              Source=1(Medicaid) only. But
                                                              providers may include all payment
                                                              sources in submission population.
                                       Payment
                                        Source

                                                    Select All That Apply
                                                    1,2,3,4,5,6
                                   Patient Age(in years)
                                    = Admission Date
                                     minus Birthdate



                                                              >=0 years and <8 years
                                        Patient               or >=65 years
                                         Age

                                                  >=8 years and
                                                  < 65 years
                                    Length of Stay =
                                  Discharge Date minus
                                     Admission Date




                                       Length of            > 120 days
                                         Stay

                                               <=120 days
                                                            None on Table
                                                            11.01, 11.02,
                                        ICD-9-CM            11.03 or 11.04
                                    Principal or Other
                                        DX Codes



                                                  At least one on
                                                  Table 11.01, 11.02,
                                                  11.03 or 11.04



                                       Mother
                                       Mother                                     Not in Mother
                                      Population
                                     Population                                    Population




                                                                                       STOP

Medicaid Inpatient Quality Incentive Guidelines SFY2011                                           2-82
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2              Measure Information


OBSTETRICS (OBS) POPULATION
In the event a hospital chooses to enter MEDICAID-ONLY cases for OBS, complete the following steps:
1. Pull all Medicaid primary (no other payment source) patients for the quarter that has a Principle or other Diagnosis Code on Table 11.01,
11.02, 11.03, and 11.04.
2. Eliminate all Medicaid patients that are aged < 8 years and >= 65 years.
3. Eliminate all Medicaid patients that have a length of stay > 120 days.
4. At this point, a facility will have the NUMBER of cases that must be used to determine sampling size.
5. Once this number of patients is determined, a hospital may enter 100% of the Medicaid cases or refer to the sampling table for the
sampling requirement number.
6. If a hospital plans to sample, it should be a random sample.
In the event a hospital chooses to enter All PAYORS for OBS, complete the following steps:
1. Pull all cases (all payors) for the quarter which has a Principle or other Diagnosis Code on Table 11.01,11.02, 11.03, and 11.04.
2. Eliminate all patients that are < 8 years and >= 65 years.
3. Eliminate all patients that have a length of stay > 120 days.
4. Determine how many of the remaining cases are Medicaid. This is the number which will be used for sampling requirements.
5. Refer to the sampling table using the number of Medicaid cases from Step 4 and determine how many cases should be submitted.
6. If a hospital plans to sample all payors, the hospital should randomly select from the patients remaining following Step 3 using the
number determined from the sampling table in Step 5.
7. There must be at least one Medicaid patient included.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                                                               2-83
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


Measure Information Form and Flow Chart

Measure Set: Obstetric Data Submission

Measure ID#: OBS-1

Submission Measure Name: Prophylactic Antibiotics Received Within 1 Hour of C-
Section Cut Time

Description: All women undergoing cesarean delivery without evidence of prior
infection or already receiving prophylactic antibiotics for other reasons who received
prophylactic antibiotics within one hour prior to surgical incision or at the time of
delivery

Rationale: The measure addresses an important and highly actionable perinatal health
issue for which there is considerable provider variation and substantial room for
improvement.

Type of measure: Performance

Numerator Statement: Patients who received prophylactic antibiotics within one hour
prior to surgical incision or at the time of delivery

                Included Populations: Not applicable

                Excluded Populations: None

Denominator Statement: All patients undergoing cesarean section without evidence of
prior infection or already receiving prophylactic antibiotics for other reasons

                Included Populations: Discharges with:
                     An ICD-9-CM Principal or Other Diagnosis Codes as defined in
                       Appendix A, Tables 11.01 through 11.04
                     An ICD-9-CM Principal or Other Procedure Codes as defined in
                       Appendix A, Table 11.06

                Excluded Populations:
                    An ICD-9-CM Principal or Other Diagnosis Codes as defined in
                       Appendix A, Table 11.08
                    Less than 8 years of age
                    Greater than or equal to 65 years old
                    Length of stay >120 days
                    Enrolled in a clinical trial



Medicaid Inpatient Quality Incentive Guidelines SFY2011                              2-84
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


                        Patients who were receiving antibiotics within 24 hours prior to
                         arrival, except that prophylaxis with penicillin or ampicillin for
                         Group B Streptococcus (GBS) is not a reason for exclusion
                        Patients with physician/advanced practice nurse/ physician
                         assistant/certified nurse midwife documented infection or
                         prophylaxis for infection, except that prophylaxis for GBS is not a
                         reason for exclusion
                        Patients who undergo other surgeries within 3 days before or after
                         the cesarean section

Sampling: Yes. For additional information see the Sampling Guidelines in Section 3 of this
manual.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                               2-85
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2  Measure Information
OBS-1: Prophylactic Antibiotics Received Within One Hour of C-Section Cut Time
Numerator:     Patients who received prophylactic antibiotics within one hour prior to surgical incision or at the time of
               delivery.
Denominator:   All patients undergoing cesarean section without evidence of prior infection or already receiving
               prophylactic antibiotics for other

                                                    START


                                           Case is included in the OBS
                                               mother population


                                                                           None on
                                                    ICD-9-CM              Table 11.06       OBS-1
                                                Principal or Other                            B
                                                   Proc. Codes

                                                              At least one on
                                                              Table 11.06

                                                    ICD-9-CM       On Table 11.08           OBS-1
                                                Principal or Other                            B
                                                    Diagnosis
                                                      Codes
                                                              None on
                                                              Table 11.08

                OBS-1                                                                       OBS-1
                  X          Missing                 Clinical                    =Y           B
                                                      Trial


                                                              =N


                OBS-1                              Antibiotic                               OBS-1
                  X          Missing            Received within                  =Y           B
                                                24 Hours Prior to
                                                    Arrival

                                                            =N


                OBS-1                                                                       OBS-1
                  X          Missing             Documented                      =Y           B
                                                  Infection


                                                            =N
                                                      OBS-1
                                                        H
Medicaid Inpatient Quality Incentive Guidelines SFY2011                                                  2-86
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2        Measure Information



                                                      OBS-1
                                                        H                                        OBS-1
                                                                                                   B




                                                                                        B
                              Missing               Other                      =Y    Not In Measure
                                                   Surgeries                           Population

         OBS-1
           X                                                =N


                                                    Prophylactic



                 X                                                                   D
              Case Will           Missing    Antibiotic Received Within   =N        In Measure
                                             One Hour of Cut Time or at
             Be Rejected                             the Time of                    Population
                                                       Delivery


                                                            =Y




                                                    E
                                                In Numerator
                                                 Population




                                                     STOP




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                      2-87
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


              Measure Information Form and Flow Chart

Measure Set: Obstetric Data Submission

Measure ID#: OBS-2

Submission Measure Name: Appropriate DVT Prophylaxis in Women Undergoing C-
Sections

Description: All women undergoing cesarean delivery who received either fractionated
or unfractionated heparin or pneumatic compression devices prior to surgery

Rationale: Surgery lasting greater than 30-45 minutes and pregnancy are listed as risk
factors that, if present together, require DVT prophylaxis – even if no other predisposing
factors (e.g. obesity) are present.

Type of measure: Performance

Numerator Statement: All women undergoing cesarean delivery who received either
fractionated or unfractionated heparin or pneumatic compression devices prior to surgery

                Included Populations: Not applicable

                Excluded Populations: None

Denominator Statement: All patients undergoing cesarean delivery

                Included Populations: Discharges with:
                     An ICD-9-CM Principal or Other Diagnosis Codes as defined in
                       Appendix A, Tables 11.01 through 11.04
                     An ICD-9-CM Principal or Other Procedure Codes as defined in
                       Appendix A, Table 11.06

                Excluded Populations:
                    Less than 8 years of age
                    Greater than or equal to 65 years old
                    Non-elective C-section
                    Length of stay >120 days
                    Enrolled in a clinical trial

Sampling: Yes. For additional information see the Sampling Guidelines in Section 3 of this
manual.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                              2-88
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2  Measure Information
 OBS-2: Appropriate DVT Prophylaxis in Women Undergoing C-Sections
 Numerator:   Patients who receive either fractionated or unfractionated heparin or pheumatic
              compression devices prior to surgery.
 Denominator: All women undergoing cesarean delivery.

                                                   START


                                          Case is included in the OBS
                                              mother population


                                                                         None on
                                                   ICD-9-CM             Table 11.06
                                               Principal or Other
                                                  Proc. Codes


                                                          At least one on
                                                          Table 11.06

                             Missing               Clinical             =Y
                                                    Trial


                                                            =N


                                                  Planned/


                                                                                          B
                             Missing               Elective              =N           Not In Measure
                                                  C-Section                             Population


                                                          =Y




              X
            Case Will
           Be Rejected
                                 Missing        Appropriate
                                              DVT Prophylaxis
                                                                    =N

                                                                                    D
                                                                                  In Measure
                                                                                  Population


                                                          =Y




                                                   E
                                                In Numerator
                                                 Population




                                                    STOP

Medicaid Inpatient Quality Incentive Guidelines SFY2011                                         2-89
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


        Measure Information Form and Flow Chart

Measure Set: Obstetric Data Submission

Measure ID#: OBS-4

Submission Measure Name: Elective Delivery

Description: Patients with elective vaginal deliveries or elective cesarean sections at >=
37 and < 39 weeks of gestation completed

Rationale: For almost 3 decades, the American College of Obstetricians and
Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have had in
place a standard requiring 39 completed weeks gestation prior to ELECTIVE delivery,
either vaginal or operative (ACOG, 1996). A survey conducted in 2007 of almost 20,000
births in HCA hospitals throughout the U.S. carried out in conjunction with the March of
Dimes at the request of ACOG revealed that almost 1/3 of all babies delivered in the
United States are electively delivered with 5% of all deliveries in the U.S. delivered in a
manner violating ACOG/AAP guidelines. Most of these are for convenience, and result
in significant short term neonatal morbidity (neonatal intensive care unit admission rates
of 13- 21%) (Clark et al., 2009).

According to Glantz (2005), compared to spontaneous labor, elective inductions result in
more cesarean deliveries and longer maternal length of stay. The American Academy of
Family Physicians (2000) also notes that elective induction doubles the cesarean delivery
rate. Repeat elective cesarean sections before 39 weeks gestation also result in higher
rates of adverse respiratory outcomes, mechanical ventilation, sepsis and hypoglycemia
for the newborns (Tita et al., 2009).

Type of measure: Performance

Numerator Statement: Patients with elective deliveries

Included Populations: ICD-9-CM Principal Procedure Code or ICD-9-CM Other
Procedure Codes for one or more of the following:

                       Medical induction of labor as defined in Appendix A, Table 11.05


Medicaid Inpatient Quality Incentive Guidelines SFY2011                                2-90
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


                       Cesarean section as defined in Appendix A, Table 11.06 while not
                        in Active Labor or experiencing Spontaneous Rupture of
                        Membranes

Excluded Populations: None

Denominator Statement: Patients delivering newborns with >= 37 and < 39 weeks of
gestation completed

Included Populations: Not Applicable

Excluded Populations:

                       ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other
                        Diagnosis Codes for conditions justifying elective delivery as
                        defined in Appendix A, Table 11.07
                       Less than 8 years of age
                       Greather than or equal to 65 years of age
                       Length of stay > 120 days
                       Enrolled in clinical trials


Sampling: Yes. For additional information see the Sampling Guidelines in Section 3 of this
manual.




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                  2-91
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2  Measure Information
 OBS-4: Elective Delivery
 Numerator:   Patients with elective deliveries completed
 Denominator: Patients delivering newborns with >=37 and <39 weeks of gestation completed.

                                             START



                                    Case is included in the OBS
                                        mother population



                                                                  At least one on
                                             ICD-9-CM             Table 11.07
                                         Principal or Other
                                             Diagnosis
                                               Codes

                                                   None on Table 11.07



                      Missing                Clinical                 =Y
                                              Trial


                                                   =N



                      Missing              Gestational                <37 or >=39
                                              Age


                                                      (>=37 and <39) or UTD


                                                                           OBS-4
                      Missing              Gestational        = UTD         E
                                              Age


                                                    >=37 and <39
                                                            At least one
                                             ICD-9-CM       on Table OBS-4
                                         Principal or Other 11.05        E
                                             Procedure
                                               Codes
                                                         All missing or
         OBS-4                                           None on Table               OBS-4
          X                                   OBS-4      11.05                        B
                                               H
Medicaid Inpatient Quality Incentive Guidelines SFY2011                                      2-92
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
Section 2       Measure Information


                                              OBS-4
                                               H

                                                               All missing or
                                                               None on Table
                                             ICD-9-CM          11.06
                                         Principal or Other
                                             Procedure
                                               Codes

                                                   At least one on
                                                   Table 11.06

                    = Missing                 Active             =Y
                                              Labor


                                                   =N



                    = Missing              Spontaneous           =Y
                                            Rupture of                              OBS-4
                                           Membranes                                 B
   OBS-4
     X                      OBS-4
                             E                     =N




        X
      Case Will
     Be Rejected
                                               E
                                          In Numerator
                                           Population                              B
                                                                                Not In Measure
                                                                                  Population




                                                                 D
                                                              In Measure
                                                              Population




                                                STOP




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                     2-93
Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
3 Section 3 Sampling Guidelines

     Sampling
     Sampling is a process of selecting a representative part of a population in order to
     estimate the hospital’s performance, without collecting data for its entire population.
     Using a statistically valid sample, a hospital can measure its performance in an
     effective and efficient manner. Sampling is a particularly useful technique for
     performance measures that require primary data collection from a source such as the
     medical record.

     Sampling Guidelines for new data submission measures
     Hospitals can submit 100% of their Arkansas Medicaid cases or they can follow the
     following sampling guidelines:

            Quarterly patient population* >1,250………….abstract 250 medical records
            Quarterly patient population* 300 to 1,249……abstract 20% of medical records
            Quarterly patient population* 60 to 299……….abstract 60 medical records
            Quarterly patient population* <60……………..abstract 100% of medical records

     Monthly:
        Monthly patient population* >417………….….abstract 83 medical records
        Monthly patient population* 100 to 416…….…abstract 20% of medical records
        Monthly patient population* 20 to 99………….abstract 20 medical records
        Monthly patient population* <20………………abstract 100% of medical
           records

 *Patient population will be based on Arkansas Medicaid ONLY billed cases.




 Medicaid Inpatient Quality Incentive Guidelines SFY2010                                  3-1
 Discharges 10/01/09 (4Q2009) through 03/31/10 (1Q2010)
   Appendices


                      B. Appendix A: ICD-9-CM Code Table

Table 11.01 Complication Mainly Related to Pregnancy
Code    ICD-9-CM Description                                     Shortened Description
640.81 Other specified hemorrhage in early pregnancy,            HEM EARLY PREG NEC-
       delivered w/ or w/o mention of antepartum condition       DELIV
640.91 Unspecified hemorrhage in early pregnancy, delivered      HEM EARLY PREG-
       w/ or w/o mention of antepartum condition                 DELIVERED
641.01 Placenta previa w/o hemorrhage, delivered w/ or w/out     PLACENTA PREVIA-
       mention of antepartum condition                           DELIVER
641.11 Hemorrhage from placenta previa, delivered w/ or          PLACENTA PREV HEM-
       w/out mention of antepartum condition                     DELIV
641.21 Premature separation of placenta, delivered, w/ or        PREM SEPAR PLACEN-
       w/out mention of antepartum condition                     DELIV
641.31 Antepartum hemorrhage associated w/coagulation            COAG DEF HEMORR-
       defects, delivered w/ or w/out mention of antepartum      DELIVER
       condition
641.81 Other antepartum hemorrhage, delivered w/ or w/out        ANTEPARTUM HEM NEC-
       mention of antepartum condition                           DELIV
641.91 Unspecified antepartum hemorrhage, delivered w/ or        ANTEPARTUM HEM NOS-
       w/out mention of antepartum condition                     DELIV
642.01 Benign essential hypertension complicating pregnancy,     ESSEN HYPERTEN-
       childbirth, & puerperium, delivered w/or w/out mention    DELIVERED
       of antepartum condition
642.02 Benign essential hypertension complicating pregnancy,     ESSEN HYPERTEN-DEL W
       childbirth, & puerperium, delivered w/mention of          P/P
       postpartum complication
642.11 Hypertension secondary to renal disease, complicating     RENAL HYPERTEN PG-
       pregnancy, childbirth, and the puerperium, delivered w/   DELIV
       or w/out mention of antepartum condition
642.12 Hypertension secondary to renal disease, complicating     RENAL HYPERTEN-DEL
       pregnancy, childbirth, and the puerperium, delivered      P/P
       w/mention of postpartum complication
642.21 Other pre-existing hypertension complicating              OLD HYPERTEN NEC-
       pregnancy, childbirth & puerperium, delivered w/ or       DELIVER
       w/out mention of antepartum condition
642.22 Other pre-existing hypertension complicating              OLD HYPERTEN-DELIV W
       pregnancy, childbirth & puerperium, delivered             P/P
       w/mention of postpartum complication
642.31 Transient hypertension of pregnancy, delivered w/ or      TRANS HYPERTEN-
       w/out mention of antepartum condition                     DELIVERED


   Medicaid Inpatient Quality Incentive Guidelines SFY2010                           A -1
   Discharges 10/01/09 (4Q2009) through 03/31/10 (1Q2010)
   Appendices


Table 11.01 Complication Mainly Related to Pregnancy
642.32 Transient hypertension of pregnancy, delivered            TRANS HYPERTEN-DEL W
       w/mention of postpartum complication                      P/P
642.41 Mild or unspecified pre-eclampsia, delivered w/ or        MILD/NOS PREECLAMP-
       w/out mention of antepartum condition                     DELIV
642.42 Mild or unspecified pre-eclampsia, delivered              MILD PREECLAMP-DEL W
       w/mention of postpartum complication                      P/P
642.51 Severe pre-eclampsia, delivered w/ or w/out mention of SEVERE PREECLAMP-
       antepartum condition                                      DELIVER
642.52 Severe pre-eclampsia, delivered w/mention of              SEV PREECLAMP-DEL W
       postpartum complication                                   P/P
642.61 Eclampsia, delivered w/ or w/out mention of              ECLAMPSIA-DELIVERED
       antepartum condition
642.62 Eclampsia, delivered w/mention of postpartum             ECLAMPSIA-DELIV W P/P
       complication
642.71 Pre-eclampsia or eclampsia superimposed on pre-          TOX W OLD HYPERTEN-
       existing hypertension, delivered w/ or w/out mention     DELIV
       of antepartum condition
642.72 Pre-eclampsia or eclampsia superimposed on pre-          TOX W OLD HYP-DEL W
       existing hypertension, delivered w/mention of          /P
       postpartum complication
642.91 Unspecified hypertension complicating pregnancy,         HYPERTENS NOS-
       childbirth, or the puerperium, delivered w/ or w/out     DELIVERED
       mention of antepartum condition
642.92 Unspecified hypertension complicating pregnancy,         HYPERTENS NOS-DEL W
       childbirth, or the puerperium, delivered w/mention of    P/P
       postpartum complication
643.01 Mild hyperemesis gravidarum, delivered w/ or w/out       MILD HYPEREM GRAV-
       mention of antepartum condition                          DELIV
643.11 Hyperemesis gravidarum w/metabolic disturbance,          HYPEREM W METAB DIS-
       delivered w/ or w/out mention of antepartum condition DEL
643.21 Late vomiting of pregnancy, delivered w/ or w/out        LATE VOMIT OF PREG-
       mention of antepartum condition                          DELIV
643.81 Other vomiting complicating pregnancy, delivered w/      VOMIT COMPL PREG-
       or w/out mention of antepartum condition                 DELIVER
643.91 Unspecified vomiting of pregnancy, delivered w/ or       VOMIT OF PREG NOS-
       w/out mention of antepartum condition                    DELIV
644.21 Early onset of delivery, delivered, w/ or w/out mention EARLY ONSET DELIVERY-
       of antepartum condition                                  DEL
645.11 Post term pregnancy, delivered, w/ or w/out mention of POST TERM PREG-DEL
       antepartum condition
645.21 Prolonged pregnancy, delivered w/ or w/out mention       PROLONGED PREG-DEL
       of antepartum condition
646.01 Papyraceous fetus, delivered w/ or w/out mention of      PAPYRACEOUS FETUS-
       antepartum condition                                     DELIV


   Medicaid Inpatient Quality Incentive Guidelines SFY2011                  A- 2
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices


Table 11.01 Complication Mainly Related to Pregnancy
646.11 Edema or excessive weight gain in pregnancy, w/out        EDEMA IN PREG-
       mention of hypertension, delivered w/ or w/out            DELIVERED
       mention of antepartum condition
646.12 Edema or excessive weight gain in pregnancy, w/out        EDEMA IN PREG-DEL W
       mention of hypertension, delivered w/mention of           P/P
       postpartum complication
646.21 Unspecified renal disease in pregnancy, w/out mention     RENAL DIS NOS-
       of hypertension, delivered w/ or w/out mention of         DELIVERED
       antepartum condition
646.22 Unspecified renal disease in pregnancy, w/out mention     RENAL DIS NOS-DEL W
       of hypertension, delivered w/mention of postpartum        P/P
       complication
646.31 Recurrent pregnancy loss, delivered, with or without      RECURNT PREG LOSS-
       mention of antepartum condition                           DELIV
646.41 Peripheral neuritis in pregnancy, delivered w/ or w/out   NEURITIS-DELIVERED
       mention of antepartum condition
646.42 Peripheral neuritis in pregnancy, delivered w/mention     NEURITIS-DELIVERED W
       of postpartum complication                                P/P
646.51 Asymptomatic bacteriuria in pregnancy, delivered w/       ASYM BACTERIURIA-
       or w/out mention of antepartum condition                  DELIVER
646.52 Asymptomatic bacteriuria in pregnancy, delivered          ASY BACTERURIA-DEL W
       w/mention of postpartum complication                      P/P
646.61 Infections of genitourinary tract in pregnancy,           GU INFECTION-
       delivered w/ or w/out mention of antepartum condition     DELIVERED
646.62 Infections of genitourinary tract in pregnancy,           GU INFECTION-DELIV W
       delivered w/mention of postpartum complication            P/P
646.71 Liver disorders in pregnancy, delivered w/ or w/out       LIVER DISORDER-
       mention of antepartum condition                           DELIVERED
646.81 Other specified complications of pregnancy, delivered     PREG COMPL NEC-
       w/ or w/out mention of antepartum condition               DELIVERED
646.82 Other specified complications of pregnancy, delivered     PREG COMPL NEC-DEL W
       w/mention of postpartum complication                      P/P
646.91 Unspecified complication of pregnancy, delivered w/       PREG COMPL NOS-
       or w/out mention of antepartum condition                  DELIVERED
647.01 Syphilis, delivered w/ or w/out mention of antepartum     SYPHILIS-DELIVERED
       condition
647.02 Syphilis, delivered w/mention of postpartum               SYPHILIS-DELIVERED W
       complication                                              P/P
647.11 Gonorrhea, delivered w/ or w/out mention of               GONORRHEA-DELIVERED
       antepartum condition
647.12 Gonorrhea, delivered w/mention of postpartum              GONORRHEA-DELIVER W
       complication                                              P/P
647.21 Other venereal diseases, delivered w/ or w/out mention    OTHER VD-DELIVERED
       of antepartum condition


   Medicaid Inpatient Quality Incentive Guidelines SFY2011                        A- 3
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices


Table 11.01 Complication Mainly Related to Pregnancy
647.22 Other venereal diseases, delivered w/mention of           OTHER VD-DELIVERED W
       postpartum complication                                   P/P
647.31 Tuberculosis, delivered w/ or w/out mention of            TUBERCULOSIS-
       antepartum condition                                      DELIVERED
647.32 Tuberculosis, delivered w/mention of postpartum           TUBERCULOSIS-DELIV W
       complication                                              P/P
647.41 Malaria, delivered w/ or w/out mention of antepartum      MALARIA-DELIVERED
       condition
647.42 Malaria, delivered w/mention of postpartum                MALARIA-DELIVERED W
       complication                                              P/P
647.51 Rubella, delivered w/ or w/out mention of antepartum      RUBELLA-DELIVERED
       condition
647.52 Rubella, delivered w/mention of postpartum                RUBELLA-DELIVERED W
       complication                                              P/P
647.61 Other viral diseases, delivered w/ or w/out mention of    OTH VIRAL DIS-
       antepartum condition                                      DELIVERED
647.62 Other viral diseases, delivered w/mention of              OTH VIRAL DIS-DEL W P/P
       postpartum complication
647.81 Other specified infections and parasitic diseases,        INFECT DIS NEC-
       delivered w/ or w/out mention of antepartum condition     DELIVERED
647.82 Other specified infections and parasitic diseases,        INFECT DIS NEC-DEL W
       delivered w/mention of postpartum complication            P/P
647.91 Unspecified infection or infestation, delivered w/ or     INFECT NOS-DELIVERED
       w/out mention of antepartum condition
647.92 Unspecified infection or infestation, delivered           INFECT NOS-DELIVER W
       w/mention of postpartum complication                      P/P
648.01 Diabetes mellitus, delivered with or without mention of   DIABETES-DELIVERED
       antepartum condition
648.02 Diabetes mellitus, delivered with mention of              DIABETES-DELIVERED W
       postpartum condition                                      P/P
648.11 Thyroid dysfunction, delivered with or without            THYROID DYSFUNC-
       mention of antepartum condition                           DELIVER
648.12 Thyroid dysfunction, delivered with mention of            THYROID DYSFUN-DEL W
       postpartum condition                                      P/P
648.21 Anemia, delivered w/ or w/out mention of antepartum       ANEMIA-DELIVERED
       condition
648.22 Anemia, delivered w/mention of postpartum                 ANEMIA-DELIVERED W
       complication                                              P/P
648.31 Drug dependence, delivered w/ or w/out mention of         DRUG DEPENDENCE-
       antepartum condition                                      DELIVER
648.32 Drug dependence delivered w/mention of postpartum         DRUG DEPENDEN-DEL W
       complication                                              P/P
648.41 Mental disorders delivered w/ or w/out mention of         MENTAL DISORDER-
       antepartum condition                                      DELIVER

   Medicaid Inpatient Quality Incentive Guidelines SFY2011                      A- 4
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices


Table 11.01 Complication Mainly Related to Pregnancy
648.42 Mental disorders, delivered w/mention of postpartum      MENTAL DIS-DELIV W P/P
       complication
648.51 Congenital cardiovascular disorders, delivered w/ or     CONGEN CV DIS-
       w/out mention of antepartum condition                    DELIVERED
648.52 Congenital cardiovascular disorders, delivered           CONGEN CV DIS-DEL W
       w/mention of postpartum complication                     P/P
648.61 Other cardiovascular diseases, delivered w/ or w/o       CV DIS NEC PREG-
       mention of antepartum condition                          DELIVER
648.62 Other cardiovascular diseases, delivered w/mention of    CV DIS NEC-DELIVER W
       postpartum complication                                  P/P
648.71 Bone and joint disorders of back, pelvis, and lower      BONE DISORDER-
       limbs, delivered w/ or w/out mention of antepartum       DELIVERED
       condition
648.72 Bone and joint disorders of back, pelvis, and lower      BONE DISORDER-DEL W
       limbs, delivered w/mention of postpartum                 P/P
       complication
648.81 Abnormal glucose tolerance, delivered w/ or w/o          ABN GLUCOSE TOLER-
       mention of antepartum condition                          DELIV
648.82 Abnormal glucose tolerance, delivered w/mention of       ABN GLUCOSE-DELIV W
       postpartum complication                                  P/P
648.91 Other current conditions classifiable elsewhere,         OTH CURR COND-
       delivered w/ or w/out mention of antepartum condition    DELIVERED
648.92 Other current conditions classifiable elsewhere,         OTH CURR COND-DEL W
       delivered w/mention of postpartum complication           P/P
649.01 Tobacco use disorder complicating pregnancy,             TOBACCO USE DISOR-
       childbirth, or the puerperium, delivered, with or        DELLIV
       without mention of antepartum condition
649.02 Tobacco use disorder complicating pregnancy,             TOBACCO USE DIS-DEL-
       childbirth, or the puerperium, delivered, with mention   P/P
       of postpartum complication
649.11 Obesity complicating pregnancy, childbirth, or the       OBESITY-DELIVERED
       puerperium, delivered, with or without mention of
       antepartum condition
649.12 Obesity complicating pregnancy, childbirth, or the       OBESITY-DELIVERED W
       puerperium, delivered, with mention of postpartum        P/P
       complication
649.21 Bariatric surgery status complicating pregnancy,         BARIATRIC SURG STAT-
       childbirth, or the puerperium, delivered, with or        DEL
       without mention of antepartum condition
649.22 Bariatric surgery status complicating pregnancy,         BARIATRIC SURG-DEL W
       childbirth, or the puerperium, delivered, with mention   P/P
       of postpartum complication
649.31 Coagulation defects complicating pregnancy,              COAGULATION DEF-
       childbirth, or the puerperium, delivered, with or        DELIV
       without mention of antepartum condition
   Medicaid Inpatient Quality Incentive Guidelines SFY2011                    A- 5
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices


Table 11.01 Complication Mainly Related to Pregnancy
649.32 Coagulation defects complicating pregnancy,              COAGULATN DEF-DEL W
       childbirth, or the puerperium, delivered, with mention   P/P
       of postpartum complication
649.41 Epilepsy complicating pregnancy, childbirth, or the      EPILEPSY-DELIVERED
       puerperium, delivered, with or without mention of
       antepartum condition
649.42 Epilepsy complicating pregnancy, childbirth, or the      EPILEPSY-DELIVERED W
       puerperium, delivered, with mention of postpartum        P/P
       complication
649.51 Spotting complicating pregnancy, delivered, with or      SPOTTING-DELIVERED
       without mention of antepartum condition
649.61 Uterine size date discrepancy, delivered, with or        UTERINE SIZE DESCREP-
       without mention of antepartum condition                  DEL
649.62 Uterine size date discrepancy, delivered, with mention   UTERINE SIZE-DEL W P/P
       of postpartum complication




   Medicaid Inpatient Quality Incentive Guidelines SFY2011                     A- 6
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices



Table 11.02 Normal Delivery and Other Indications for Care
Code     ICD-9-CM Description                                     Shortened Description
   650 Delivery in a completely normal case                       NORMAL DELIVERY
651.01 Multiple gestation, twin pregnancy, delivered with or      TWIN PREGNANCY-
       without mention of antepartum condition                    DELIVERED
651.11 Multiple gestation, triplet pregnancy, delivered with or   TRIPLET PREGNANCY-
       without mention of antepartum condition                    DELIV
651.21 Multiple gestation, quadruplet pregnancy, delivered        QUADRUPLET PREG-
       with or without mention of antepartum condition            DELIVER
651.31 Multiple gestation, twin pregnancy w/fetal loss and        TWINS W FETAL LOSS-
       retention of 1 fetus, delivered with or without mention    DEL
       of antepartum condition
651.41 Multiple gestation, triplet pregnancy, w/fetal loss and    TRIPLETS W FET LOSS-
       retention of one or more fetus (es), delivered with or     DEL
       without mention of antepartum condition
651.51 Multiple gestation, quadruplet pregnancy, w/fetal loss     QUADS W FETAL LOSS-
       and retention of 1 or more fetus(es), delivered with or    DEL
       without mention of antepartum condition
651.61 Multiple gestation, other multiple pregnancy, w/fetal      MULT GES W FET LOSS-
       loss and retention of 1 or more fetus(es), delivered       DEL
       with or without mention of antepartum condition
651.71 Multiple gestation following (elective) fetal reduction,   MULT GEST-FET REDUCT
       delivered without mention of antepartum condition          DEL
651.81 Multiple gestation, other specified multiple gestation,    MULTI GESTAT NEC-
       delivered with or without mention of antepartum            DELIVER
       condition
651.91 Multiple gestation, unspecified multiple gestation,        MULT GESTATION NOS-
       delivered with or without mention of antepartum            DELIV
       condition
652.01 Unstable lie, delivered, w/ or w/out mention of            UNSTABLE LIE-
       antepartum condition                                       DELIVERED
652.11 Breech or other malpresentation successfully               CEPHALIC VERS NOS-
       converted to cephalic presentation, delivered, w/ or       DELIV
       w/out mention of antepartum condition
652.21 Breech presentation w/o mention of version, delivered,     BREECH PRESENTAT-
       w/ or w/out mention of antepartum condition                DELIVER
652.31 Transverse or oblique presentation, delivered, w/ or       TRANSVER/OBLIQ LIE-
       w/out mention of antepartum condition                      DELIV
652.41 Face or brow presentation, delivered, w/ or w/o            FACE/BROW PRESENT-
       mention of antepartum condition                            DELIV
652.51 High head at term, delivered, w/ or w/out mention of       HIGH HEAD AT TERM-
       antepartum condition                                       DELIV
652.61 Multiple gestation w/malpresentation of 1 fetus or         MULT GEST MALPRES-
       more, delivered, w/ or w/out mention of antepartum         DELIV

   Medicaid Inpatient Quality Incentive Guidelines SFY2011                                A- 7
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices


Table 11.02 Normal Delivery and Other Indications for Care
         condition

652.71 Prolapsed arm, delivered, w/ or w/out mention of          PROLAPSED ARM-
       antepartum condition                                      DELIVERED
652.81 Other specified malposition or malpresentation,           MALPOSITION NEC-
       delivered, w/ or w/out mention of antepartum              DELIVER
       condition
652.91 Unspecified malposition or malpresentation, delivered,    MALPOSITION NOS-
       w/ or w/out mention of antepartum condition               DELIVER
653.01 Major abnormality of bony pelvis, not further             PELVIC DEFORM NOS-
       specified, delivered, w/ or w/o mention of antepartum     DELIV
       condition
653.11 Generally contracted pelvis, delivered, w/ or w/o         CONTRACT PELV NOS-
       mention of antepartum condition                           DELIV
653.21 Inlet contraction of pelvis, delivered, w/ or w/o         INLET CONTRACTION-
       mention of antepartum condition                           DELIV
653.31 Outlet contraction of pelvis, delivered, w/ or w/o        OUTLET CONTRACTION-
       mention of antepartum condition                           DELIV
653.41 Fetopelvic disproportion, delivered, w/ or w/o mention    FETOPELV DISPROPOR-
       of antepartum condition                                   DELIV
653.51 Unusually large fetus causing disproportion, delivered,   FETAL DISPROP NOS-
       w/ or w/o mention of antepartum condition                 DELIV
653.61 Hydrocephalic fetus causing disproportion, delivered,     HYDROCEPH FETUS-
       w/ or w/o mention of antepartum condition                 DELIVER
653.71 Other fetal abnormality causing disproportion,            OTH ABN FET DISPRO-
       delivered, w/ or w/o mention of antepartum condition      DELIV
653.81 Disproportion of other origin, delivered, w/ or w/o       DISPROPORTION NEC-
       mention of antepartum condition                           DELIV
653.91 Unspecified disproportion, delivered, w/ or w/o           DISPROPORTION NOS-
       mention of antepartum condition                           DELIV
654.01 Congenital abnormalities of uterus, delivered w/ or       CONGEN ABN UTERUS-
       w/o mention of antepartum condition                       DELIV
654.02 Congenital abnormalities of uterus, delivered             CONG ABN UTER-DEL W
       w/mention of postpartum complication                      P/P
654.11 Tumors of body of uterus, delivered w/ or w/o mention     UTERINE TUMOR-
       of antepartum condition                                   DELIVERED
654.12 Tumors of body of uterus, delivered w/mention of          UTERINE TUMOR-DEL W
       postpartum complication                                   P/P
654.21 Previous cesarean delivery, delivered w/ or w/o           PREV C-DELIVERY-
       mention of antepartum condition                           DELIVRD
654.31 Retroverted and incarcerated gravid uterus, delivered     RETROVERT UTERUS-
       w/ or w/o mention of antepartum condition                 DELIVER
654.32 Retroverted and incarcerated gravid uterus, delivered     RETROVERT UTER-DEL
       w/mention of postpartum complication                      W P/P

   Medicaid Inpatient Quality Incentive Guidelines SFY2011                     A- 8
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices


Table 11.02 Normal Delivery and Other Indications for Care
654.41 Other abnormalities in shape or position of gravid       ABN UTERUS NEC-
       uterus and of neighboring structures, delivered w/ or    DELIVERED
       w/o mention of antepartum condition
654.42 Other abnormalities in shape or position of gravid       ABN UTERUS NEC-DEL W
       uterus and of neighboring structures, delivered          P/P
       w/mention of postpartum complication
654.51 Cervical incompetence, delivered w/ or w/o mention of    CERVICAL INCOMPET-
       antepartum condition                                     DELIV
654.52 Cervical incompetence, delivered w/mention of            CERV INCOMPET-DEL W
       postpartum complication                                  P/P
654.61 Other congenital or acquired abnormality of cervix,      ABN CERVIX NEC-
       delivered w/ or w/o mention of antepartum condition      DELIVERED
654.62 Other congenital or acquired abnormality of cervix,      ABN CERVIX NEC-DEL W
       delivered w/mention of postpartum complication           P/P
654.71 Congenital or acquired abnormality of vagina,            ABNORM VAGINA-
       delivered w/ or w/o mention of antepartum condition      DELIVERED
654.72 Congenital or acquired abnormality of vagina,            ABNORM VAGINA-DEL
       delivered w/mention of postpartum complication           W P/P
654.81 Congenital or acquired abnormality of vulva, delivered   ABNORMAL VULVA-
       w/ or w/o mention of antepartum condition                DELIVERED
654.82 Congenital or acquired abnormality of vulva, delivered   ABNORMAL VULVA-DEL
       w/mention of postpartum complication                     W P/P
654.91 Other and unspecified abnormality of organs and soft     ABN PELV ORG NEC-
       tissues of pelvis, delivered w/ or w/o mention of        DELIVER
       antepartum condition
654.92 Other and unspecified abnormality of organs and soft     ABN PELV NEC-DELIV W
       tissues of pelvis, delivered w/mention of postpartum     P/P
       complication
655.01 Central nervous system malformation in fetus,            FETAL CNS MALFORM-
       delivered, w/ or w/o mention of antepartum condition     DELIV
655.11 Chromosomal abnormality in fetus, delivered w/ or        FETAL CHROMOSO ABN-
       w/o mention of antepartum condition                      DELIV
655.21 Hereditary disease in family possibly affecting fetus,   FAMIL HEREDIT DIS-
       delivered w/ or w/o mention of antepartum condition      DELIV
655.31 Suspected damage to fetus from viral disease in the      FET DAMG D/T VIRUS-
       mother, delivered w/ or w/o mention of antepartum        DELIV
       condition
655.41 Suspected damage to fetus from other disease in the      FET DAMG D/T DIS-
       mother, delivered w/ or w/o mention of antepartum        DELIVER
       condition
655.51 Suspected damage to fetus from drugs, delivered w/ or    FET DAMAG D/T DRUG-
       w/o mention of antepartum condition                      DELIV
655.61 Suspected damage to fetus from radiation, delivered w/   RADIAT FETAL DAMAG-
       or w/o mention of antepartum condition                   DELIV

   Medicaid Inpatient Quality Incentive Guidelines SFY2011                     A- 9
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices


Table 11.02 Normal Delivery and Other Indications for Care
655.71 Decreased fetal movements, delivered w/ or w/o             DECREASE FETAL
       mention of antepartum condition                            MOVMT DEL
655.81 Other known or suspected fetal abnormality, not            FETAL ABNORM NEC-
       elsewhere classified, delivered w/ or w/o mention of       DELIVER
       antepartum condition
655.91 Unspecified known or suspected fetal abnormality,          FETAL ABNORM NOS-
       delivered w/ or w/o mention of antepartum condition        DELIVER
656.01 Fetal-maternal hemorrhage, delivered, w/ or w/o            FETAL-MATERNAL HEM-
       mention of antepartum condition                            DELIV
656.11 Rhesus isoimmunization, delivered, w/ or w/o mention       RH ISOIMMUNIZAT-
       of antepartum condition                                    DELIVER
656.21 Isoimmunization from other and unspecified blood-          ABO ISOIMMUNIZAT-
       group incompatibility, delivered, w/ or w/o mention of     DELIVER
       antepartum condition
656.31 Fetal distress, delivered, w/ or w/o mention of            FETAL DISTRESS-
       antepartum condition                                       DELIVERED
656.41 Intrauterine death, delivered, w/ or w/o mention of        INTRAUTER DEATH-
       antepartum condition                                       DELIVER
656.51 Poor fetal growth, delivered, w/ or w/o mention of         POOR FETAL GROWTH-
       antepartum condition                                       DELIV
656.61 Excessive fetal growth, delivered, w/ or w/o mention       EXCESS FETAL GRTH-
       of antepartum condition                                    DELIV
656.71 Other placental conditions, delivered, w/ or w/o           OTH PLACENT COND-
       mention of antepartum condition                            DELIVER
656.81 Other specified fetal and placental problems, delivered,   FET/PLAC PROB NEC-
       w/ or w/o mention of antepartum condition                  DELIV
656.91 Unspecified fetal and placental problem, delivered, w/     FET/PLAC PROB NOS-
       or w/o mention of antepartum condition                     DELIV
657.01 Polyhydramnios, delivered w/ or w/o mention of             POLYHYDRAMNIOS-
       antepartum condition                                       DELIVERED
658.01 Oligohydramnios, delivered w/ or w/o mention of            OLIGOHYDRAMNIOS-
       antepartum condition                                       DELIVER
658.11 Premature rupture of membranes, delivered w/ or w/o        PREM RUPT MEMBRAN-
       mention of antepartum condition                            DELIV
658.21 Delayed delivery after spontaneous or unspecified          PROLONG RUPT MEMB-
       rupture of membranes, delivered w/ or w/o mention of       DELIV
       antepartum condition
658.31 Delayed delivery after artificial rupture of membranes,    ARTIFIC RUPT MEMBR-
       delivered w/ or w/o mention of antepartum condition        DELIV
658.41 Infection of amniotic cavity, delivered w/ or w/o          AMNIOTIC INFECTION-
       mention of antepartum condition                            DELIV
658.81 Other problems associated w/amniotic cavity and            AMNIOTIC PROB NEC-
       membranes, delivered w/ or w/o mention of                  DELIV
       antepartum condition

   Medicaid Inpatient Quality Incentive Guidelines SFY2011                      A- 10
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices


Table 11.02 Normal Delivery and Other Indications for Care
658.91 Unspecified problems associated w/amniotic cavity         AMNIOTIC PROB NOS-
       and membranes, delivered w/ or w/o mention of             DELIV
       antepartum condition
659.01 Failed mechanical induction, delivered w/ or w/o          FAIL MECH INDUCT-
       mention of antepartum condition                           DELIVER
659.11 Failed medical or unspecified induction, delivered w/     FAIL INDUCTION NOS-
       or w/o mention of antepartum condition                    DELIV
659.21 Maternal pyrexia during labor, unspecified, delivered     PYREXIA IN LABOR-
       w/ or w/o mention of antepartum condition                 DELIVER
659.31 Generalized infection during labor, delivered w/ or w/o   SEPTICEM IN LABOR-
       mention of antepartum condition                           DELIV
659.41 Grand multiparity, delivered w/ or w/o mention of         GRAND MULTIPARITY-
       antepartum condition                                      DELIV
659.51 Elderly primigravida, delivered w/ or w/o mention of      ELDERLY
       antepartum condition                                      PRIMIGRAVIDA-DEL
659.61 Elderly multigravida, delivered w/ or w/o mention of      ELDERLY
       antepartum condition                                      MULTIGRAVIDA-DEL
659.71 Abnormality in fetal heart rate or rhythm, delivered w/   ABN FTL HRT RATE/RHY-
       or w/o mention of antepartum condition                    DEL
659.81 Other specified indications for care or intervention      COMPLIC LABOR NEC-
       related to labor and delivery, delivered w/ or w/o        DELIV
       mention of antepartum condition
659.91 Unspecified indication for care or intervention related   COMPLIC LABOR NOS-
       to labor and delivery, delivered w/ or w/o mention of     DELIV
       antepartum condition




   Medicaid Inpatient Quality Incentive Guidelines SFY2011                     A- 11
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
    Appendices




Table 11.03 Complication Mainly in the Course of Labor and Delivery
Code    ICD-9-CM Description                                       Shortened Description
660.01 Obstructed labor, obstructions caused by malposition of     OBSTRUC/FET MALPOS-
       fetus at onset of labor, delivered with or without          DELIV
       mention of antepartum condition
660.11 Obstructed labor, obstruction by bony pelvis, delivered     BONY PELV OBSTRUCT-
       with or without mention of antepartum condition             DELIV
660.21 Obstructed labor, obstruction by abnormal pelvic soft       ABN PELV TIS OBSTR-
       tissues, delivered with or without mention of antepartum    DELIV
       condition
660.31 Obstructed labor, deep transverse arrest and persistent     PERSIST OCCIPTPOST-
       occipitoposterior position, delivered with or without       DELIV
       mention of antepartum condition
660.41 Shoulder (girdle) dystocia, delivered w/ or w/o mention     SHOULDER DYSTOCIA-
       of antepartum condition                                     DELIV
660.51 Locked twins, delivered w/ or w/o mention of                LOCKED TWINS-
       antepartum condition                                        DELIVERED
660.61 Failed trial of labor, unspecified, delivered w/ or w/o     FAIL TRIAL LAB NOS-
       mention of antepartum condition                             DELIV
660.71 Failed forceps or vacuum extractor, unspecified,            FAILED FORCEPS NOS-
       delivered w/ or w/o mention of antepartum condition         DELIV
660.81 Other causes of obstructed labor, delivered w/ or w/o       OBSTRUCT LABOR NEC-
       mention of antepartum condition                             DELIV
660.91 Unspecified obstructed labor, delivered w/ or w/o           OBSTRUCT LABOR NOS-
       mention of antepartum condition                             DELIV
661.01 Primary uterine inertia, delivered w/ or w/o mention of     PRIM UTERINE INERT-
       antepartum condition                                        DELIV
661.11 Secondary uterine inertia, delivered w/ or w/o mention      SEC UTERINE INERT-
       of antepartum condition                                     DELIV
661.21 Other and unspecified uterine inertia, delivered w/ or      UTERINE INERT NEC-
       w/o mention of antepartum condition                         DELIV
661.31 Precipitate labor, delivered w/ or w/o mention of           PRECIPITATE LABOR-
       antepartum condition                                        DELIV
661.41 Hypertonic, incoordinate, or prolonged uterine              UTER DYSTOCIA NOS-
       contractions, delivered w/ or w/o mention of antepartum     DELIV
       condition
661.91 Unspecified abnormality of labor, delivered w/ or w/o       ABNORMAL LABOR NOS-
       mention of antepartum condition                             DELIV
662.01 Prolonged first stage, delivered w/ or w/o mention of       PROLONG 1ST STAGE-
       antepartum condition                                        DELIV
662.11 Prolonged labor, unspecified, delivered w/ or w/o           PROLONG LABOR NOS-
       mention of antepartum condition                             DELIV
662.21 Prolonged second stage, delivered w/ or w/o mention of      PROLONG 2ND STAGE-
       antepartum condition                                        DELIV
    Medicaid Inpatient Quality Incentive Guidelines SFY2011                            A- 12
    Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
    Appendices



Table 11.03 Complication Mainly in the Course of Labor and Delivery
662.31 Delayed delivery of second twin, triplet, etc., delivered   DELAY DEL 2ND TWIN-
       w/ or w/o mention of antepartum condition                   DELIV
663.01 Prolapse of cord, delivered, w/ or w/o mention of           CORD PROLAPSE-
       antepartum condition                                        DELIVERED
663.11 Cord around neck, w/compression, delivered, w/ or w/o       CORD AROUND NECK-
       mention of antepartum condition                             DELIVER
663.21 Other and unspecified cord entanglement,                    CORD COMPRESS NEC-
       w/compression, delivered, w/ or w/o mention of              DELIV
       antepartum condition
663.31 Other and unspecified cord entanglement, w/o                CORD ENTANGLE NEC-
       compression, delivered, w/ or w/o mention of                DELIV
       antepartum condition
663.41 Short cord, delivered, w/ or w/o mention of antepartum      SHORT CORD-
       condition                                                   DELIVERED
663.51 Vasa previa, delivered, w/ or w/o mention of                VASA PREVIA-
       antepartum condition                                        DELIVERED
663.61 Vascular lesions of cord, delivered, w/ or w/o mention      VASC LESION CORD-
       of antepartum condition                                     DELIVER
663.81 Other umbilical cord complications, delivered, w/ or        CORD COMPLICAT NEC-
       w/o mention of antepartum condition                         DELIV
663.91 Unspecified umbilical cord complication, delivered, w/      CORD COMPLICAT NOS-
       or w/o mention of antepartum condition                      DELIV
664.01 First degree perineal laceration, delivered w/ or w/o       DEL W 1 DEG LACERAT-
       mention of antepartum condition                             DEL
664.11 Second degree perineal laceration, delivered w/ or w/o      DEL W 2 DEG LACERAT-
       mention of antepartum condition                             DEL
664.21 Third degree perineal laceration, delivered w/ or w/o       DEL W 3 DEG LACERAT-
       mention of antepartum condition                             DEL
664.31 Fourth degree perineal laceration, delivered w/ or w/o      DEL W 4 DEG LACERAT-
       mention of antepartum condition                             DEL
664.41 Unspecified perineal laceration, delivered w/ or w/o        OB PERINEAL LAC NOS-
       mention of antepartum condition                             DEL
664.51 Vulval and perineal hematoma, delivered w/ or w/o           OB PERINEAL
       mention of antepartum condition                             HEMATOMA-DEL
664.81 Other specified trauma to perineum and vulva,               OB PERINEAL TRAU
       delivered w/ or w/o mention of antepartum condition         NEC-DEL
664.91 Unspecified trauma to perineum and vulva, delivered         OB PERINEAL TRAU
       w/ or w/o mention of antepartum condition                   NOS-DEL
665.01 Rupture of uterus before onset of labor, delivered, w/ or   PRELABOR RUPT
       w/o mention of antepartum condition                         UTERUS-DEL
665.11 Rupture of uterus during labor, delivered, w/ or w/o        RUPTURE UTERUS NOS-
       mention of antepartum condition                             DELIV
665.22 Inversion of uterus, delivered, w/mention of                INVERS UTERUS-DEL W
       postpartum complication                                     P/P

    Medicaid Inpatient Quality Incentive Guidelines SFY2011                      A- 13
    Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
    Appendices



Table 11.03 Complication Mainly in the Course of Labor and Delivery
665.31 Laceration of cervix, delivered, w/ or w/o mention of      LACERAT OF CERVIX-
       antepartum condition                                       DELIV
665.41 High vaginal laceration, delivered, w/ or w/o mention      HIGH VAGINAL LACER-
       of antepartum condition                                    DELIV
665.51 Other injury to pelvic organs, delivered, w/ or w/o        OB INJ PELV ORG NEC-
       mention of antepartum condition                            DEL
665.61 Damage to pelvic joints and ligaments, delivered, w/ or    DAMAGE TO PELVIC JT-
       w/o mention of antepartum condition                        DEL
665.71 Pelvic hematoma, delivered, w/ or w/o mention of           OB PELVIC HEMATOMA-
       antepartum condition                                       DELIV
665.72 Pelvic hematoma, delivered, w/mention of postpartum        PELVIC HEMATOM-DEL
       complication                                               W PP
665.81 Other specified obstetrical trauma, delivered, w/ or w/o   OB TRAUMA NEC-
       mention of antepartum condition                            DELIVERED
665.82 Other specified obstetrical trauma, delivered,             OB TRAUMA NEC-DEL W
       w/mention of postpartum complication                       P/P
665.91 Unspecified obstetrical trauma, delivered, w/ or w/o       OB TRAUMA NOS-
       mention of antepartum condition                            DELIVERED
665.92 Unspecified obstetrical trauma, delivered, w/mention of    OB TRAUMA NOS-DEL W
       postpartum complication                                    P/P
666.02 Third stage hemorrhage, delivered w/mention of             THRD-STAGE HEM-DEL
       postpartum complication                                    W P/P
666.12 Other immediate postpartum hemorrhage, delivered           POSTPA HEM NEC-DEL W
       w/mention of postpartum complication                       P/P
666.22 Delayed and secondary postpartum hemorrhage,               DELAY P/P HEM-DEL W
       delivered w/mention of postpartum complication             P/P
666.32 Postpartum coagulation defects, delivered w/mention        P/P COAG DEF-DEL W P/P
       of postpartum complication
667.02 Retained placenta, w/o hemorrhage, delivered               RETND PLAC NOS-DEL W
       w/mention of postpartum complication                       P/P
667.12 Retained portions of placenta or membranes, w/o            RET PROD CONC-DEL W
       hemorrhage, delivered w/mention of postpartum              P/P
       complication
668.01 Pulmonary complications, delivered w/ or w/o mention       PULM COMPL IN DEL-
       of antepartum condition                                    DELIV
668.02 Pulmonary complications, delivered w/mention of            PULM COMPLIC-DEL W
       postpartum complication                                    P/P
668.11 Cardiac complications, delivered w/ or w/o mention of      HEART COMPL IN DEL-
       antepartum condition                                       DELIV
668.12 Cardiac complications, delivered w/mention of              HEART COMPL-DEL W
       postpartum complication                                    P/P
668.21 Central nervous system complications, delivered w/ or      CNS COMPL LAB/DEL-
       w/o mention of antepartum condition                        DELIV


    Medicaid Inpatient Quality Incentive Guidelines SFY2011                      A- 14
    Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices



Table 11.03 Complication Mainly in the Course of Labor and Delivery
668.22 Central nervous system complications, delivered           CNS COMPLIC-DEL W P/P
       w/mention of postpartum complication
668.81 Other complications of anesthesia or other sedation in    ANESTH COMPL NEC-
       labor and delivery, delivered w/ or w/o mention of        DELIVER
       antepartum condition
668.82 Other complications of anesthesia or other sedation in    ANESTH COMPL NEC-
       labor and delivery, delivered w/mention of postpartum     DEL P/P
       complication
668.91 Unspecified complications of anesthesia and other         ANESTH COMPL NOS-
       sedation, delivered w/ or w/o mention of antepartum       DELIVER
       condition
668.92 Unspecified complications of anesthesia and sedation,     ANESTH COMPL NOS-
       delivered w/mention of postpartum complication            DEL P/P
669.01 Maternal distress, delivered w/ or w/o mention of         MATERNAL DISTRESS-
       antepartum condition                                      DELIV
669.02 Maternal distress, delivered w/mention of postpartum      MATERN DISTRES-DEL W
       complication                                              P/P
669.11 Shock during or following labor and delivery, delivered   OBSTETRIC SHOCK-
       w/ or w/o mention of antepartum condition                 DELIVER
669.12 Shock during or following labor and delivery, delivered   OBSTET SHOCK-DELIV W
       w/mention of postpartum complication                      P/P
669.21 Maternal hypotension syndrome, delivered w/ or w/o        MATERN HYPOTEN SYN-
       mention of antepartum condition                           DELIV
669.22 Maternal hypotension syndrome, delivered w/mention        MATERN HYPOTEN-DEL
       of postpartum complication                                W P/P
669.32 Acute kidney failure following labor and delivery,        AC REN FAIL-DELIV W
       delivered w/mention of postpartum complication            P/P
669.41 Other complications of obstetrical surgery and            OTH OB COMPL-
       procedures, delivered w/ or w/o mention of antepartum     DELIVERED
       condition
669.42 Other complications of obstetrical surgery and            OTH OB COMPL-DELIV W
       procedures, delivered w/mention of postpartum             P/P
       complication
669.51 Forceps or vacuum extractor delivery w/o mention of       FORCEP DELIV NOS-
       indication, delivered w/ or w/o mention of antepartum     DELIVER
       condition
669.61 Breech extraction, w/o mention of indication, delivered   BREECH EXTR NOS-
       w/ or w/o mention of antepartum condition                 DELIVER
669.71 Cesarean delivery, w/o mention of indication, delivered   CESAREAN DELIVERY
       w/ or w/o mention of antepartum condition                 NOS
669.81 Other complications of labor and delivery, delivered w/   COMP LAB/DELIV NEC-
       or w/o mention of antepartum condition                    DELIV
669.82 Other complications of labor and delivery, delivered      COMPL DEL NEC-DEL W
       w/mention of postpartum complication                      P/P

   Medicaid Inpatient Quality Incentive Guidelines SFY2011                     A- 15
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices



Table 11.03 Complication Mainly in the Course of Labor and Delivery
669.91 Unspecified complication of labor and delivery,           COMP LAB/DELIV NOS-
       delivered w/ or w/o mention of antepartum condition       DELIV
669.92 Unspecified complication of labor and delivery,           COMPL DEL NOS-DEL W
       delivered w/mention of postpartum complication            P/P




   Medicaid Inpatient Quality Incentive Guidelines SFY2011                    A- 16
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices




Table 11.04 Complication of the Puerperium
Code     ICD-9-CM Description                                   Shortened Description
670.02 Major puerperal infection, unspecified, delivered with   MAJOR PUERP INF-DEL
       mention of postpartum condition                          P/P
670.12 Puerperal endometritis, delivered, with mention of       PUERP ENDOMET DEL W
       postpartum complication                                  P/P
670.22 Puerperal sepsis, delivered, with mention of             PUERPRL SEPSIS-DEL W
       postpartum complication                                  P/P
670.32 Puerperal septic thrombophlebitis, delivered, with       PRP SPTC THRMB-DEL W
       mention od postpartum complication                       P/P
670.82 Other major puerperal infection, delivered, with         MAJ PRP INF NEC-DL W
       mention of postpartum complication                       P/P
671.01 Varicose veins of legs, delivered with or without        VARICOSE VEIN LEG-
       mention of antepartum condition                          DELIV
671.02 Varicose veins of legs, delivered with mention of        VARIC VEIN LEG-DEL W
       postpartum                                               P/P
671.11 Varicose veins of vulva and perineum, delivered with     VARICOSE VULVA-
       or without mention of antepartum condition               DELIVERED
671.12 Varicose veins of vulva and perineum, delivered          VARICOSE VULVA-DEL W
       w/mention of postpartum complication                     P/P
671.21 Superficial thrombophlebitis, delivered w/ or w/o        THROMBOPHLEBITIS-
       mention of antepartum condition                          DELIVER
671.22 Superficial thrombophlebitis, delivered w/mention of     THROMBOPHLEB-DELIV
       postpartum condition                                     W P/P
671.31 Deep phlebothrombosis, antepartum, delivered w/ or       DEEP THROM ANTEPAR-
       w/o mention of antepartum condition                      DELIV
671.42 Deep phlebothrombosis, postpartum, delivered             THROMB POSTPAR-DEL
       w/mention of postpartum complication                     W P/P
671.51 Other phlebitis and thrombosis, delivered w/ or w/o      THROMBOSIS NEC-
       mention of antepartum condition                          DELIVERED
671.52 Other phlebitis and thrombosis, delivered w/mention      THROMB NEC-DELIV W
       of postpartum complication                               P/P
671.81 Other venous complication, delivered w/ or w/o           VENOUS COMPL NEC-
       mention of antepartum condition                          DELIVER
671.82 Other venous complication, delivered w/mention of        VEN COMP NEC-DELIV W
       postpartum complication                                  P/P
671.91 Unspecified venous complication, delivered w/ or w/o     VENOUS COMPL NOS-
       mention of antepartum condition                          DELIVER
671.92 Unspecified venous complication, delivered               VEN COMP NOS-DELIV W
       w/mention of postpartum complication                     P/P
672.02 Pyrexia of unknown origin during the puerperium,         PUERP PYREXIA-DEL W
       delivered w/mention of postpartum complication           P/P
673.01 Obstetrical air embolism, delivered w/ or w/o mention    OB AIR EMBOLISM-
       of antepartum condition                                  DELIVER

   Medicaid Inpatient Quality Incentive Guidelines SFY2011                              A- 17
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices


Table 11.04 Complication of the Puerperium
673.02 Obstetrical air embolism, delivered w/mention of       OB AIR EMBOL-DELIV W
       postpartum complication                                P/P
673.11 Amniotic fluid embolism, delivered w/ or w/o mention   AMNIOTIC EMBOLISM-
       of antepartum condition                                DELIV
673.12 Amniotic fluid embolism, delivered w/mention of        AMNIOT EMBOL-DELIV
       postpartum complication                                W P/P
673.21 Obstetrical blood-clot embolism, delivered w/ or w/o   PULM EMBOL NOS-
       mention of antepartum condition                        DELIVERED
673.22 Obstetrical blood-clot embolism, delivered w/mention   PULM EMBOL NOS-DEL W
       of postpartum complication                             P/P
673.31 Obstetrical pyemic and septic embolism, delivered w/   OB PYEMIC EMBOL-
       or w/o mention of antepartum condition                 DELIVER
673.32 Obstetrical pyemic and septic embolism, delivered      OB PYEM EMBOL-DEL W
       w/mention of postpartum complication                   P/P
673.81 Other pulmonary embolism, delivered w/ or w/o          PULMON EMBOL NEC-
       mention of antepartum condition                        DELIVER
673.82 Other pulmonary embolism, delivered w/mention of       PULM EMBOL NEC-DEL W
       postpartum complication                                P/P
674.01 Cerebrovascular disorders in the puerperium,           PUERP CEREBVAS DIS-
       delivered w/ or w/o mention of antepartum condition    DELIV
674.02 Cerebrovascular disorders in the puerperium,           CEREBVAS DIS-DELIV W
       delivered w/mention of postpartum complication         P/P
674.12 Disruption of cesarean wound, delivered w/mention of   DISRUPT C-SECT-DEL W
       postpartum complication                                P/P
674.22 Disruption of perineal wound, delivered w/mention of   DISRUPT PERIN-DEL W
       postpartum complication                                P/P
674.32 Other complications of obstetrical surgical wounds,    OB SURG COMPL-DEL W
       delivered w/mention of postpartum complication         P/P
674.42 Placental polyp, delivered w/mention of postpartum     PLACENT POLYP-DEL W
       complication                                           P/P
674.82 Other complications of the puerperium, delivered       PUERP COMP NEC-DEL W
       w/mention of postpartum complication                   P/P
674.92 Unspecified complications of the puerperium,           PUERP COMP NOS-DEL W
       delivered w/mention of postpartum complication         P/P
675.01 Infections of nipple, delivered w/ or w/o mention of   INFECT NIPPLE-
       antepartum condition                                   DELIVERED
675.02 Infections of nipple, delivered w/mention of           INFECT NIPPLE-DEL W P/P
       postpartum complication
675.11 Abscess of breast, delivered w/ or w/o mention of      BREAST ABSCESS-
       antepartum condition                                   DELIVERED
675.12 Abscess of breast, delivered w/mention of postpartum   BREAST ABSCESS-DEL W
       complication                                           P/P
675.21 Nonpurulent mastitis, delivered w/ or w/o mention of   MASTITIS-DELIVERED
       antepartum condition

   Medicaid Inpatient Quality Incentive Guidelines SFY2011                   A- 18
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices


Table 11.04 Complication of the Puerperium
675.22 Nonpurulent mastitis, delivered w/mention of             MASTITIS-DELIV W P/P
       postpartum complication
675.81 Other specified infections of the breast and nipple,     BREAST INFECT NEC-
       delivered w/ or w/o mention of antepartum condition      DELIV
675.82 Other specified infections of the breast and nipple,     BREAST INF NEC-DEL W
       delivered w/mention of postpartum complication           P/P
675.91 Unspecified infection of the breast and nipple,          BREAST INFECT NOS-
       delivered w/ or w/o mention of antepartum condition      DELIV
675.92 Unspecified infection of the breast and nipple,          BREAST INF NOS-DEL W
       delivered w/mention of postpartum complication           P/P
676.01 Retracted nipple, delivered w/ or w/o mention of         RETRACTED NIPPLE-
       antepartum condition                                     DELIVER
676.02 Retracted nipple, delivered w/mention of postpartum      RETRACT NIPPLE-DEL W
       complication                                             P/P
676.11 Cracked nipple, delivered w/ or w/o mention of           CRACKED NIPPLE-
       antepartum condition                                     DELIVERED
676.12 Cracked nipple, delivered w/mention of postpartum        CRACKED NIPPLE-DEL W
       complication                                             P/P
676.21 Engorgement of breasts, delivered w/ or w/o mention      BREAST ENGORGE-
       of antepartum condition                                  DELIVERED
676.22 Engorgement of breasts, delivered w/mention of           BREAST ENGORGE-DEL
       postpartum complication                                  W P/P
676.31 Other and unspecified disorder of breast, delivered w/   BREAST DIS NEC-
       or w/o mention of antepartum condition                   DELIVERED
676.32 Other and unspecified disorder of breast, delivered      BREAST DIS NEC-DEL W
       w/mention of postpartum complication                     P/P
676.41 Failure of lactation, delivered w/ or w/o mention of     LACTATION FAIL-
       antepartum condition                                     DELIVERED
676.42 Failure of lactation, delivered w/mention of             LACTATION FAIL-DEL W
       postpartum complication                                  P/P
676.51 Suppressed lactation, delivered w/ or w/o mention of     SUPPR LACTATION-
       antepartum condition                                     DELIVER
676.52 Suppressed lactation, delivered w/mention of             SUPPR LACTAT-DEL W
       postpartum complication                                  P/P
676.61 Galactorrhea, delivered w/ or w/o mention of             GALACTORRHEA-
       antepartum condition                                     DELIVERED
676.62 Galactorrhea, delivered w/mention of postpartum          GALACTORRHEA-DEL W
       complication                                             P/P
676.81 Other disorders of lactation, delivered w/ or w/o        LACTATION DIS NEC-
       mention of antepartum condition                          DELIV
676.82 Other disorders of lactation, delivered w/mention of     LACTAT DIS NEC-DEL W
       postpartum complication                                  P/P
676.91 Unspecified disorder of lactation, delivered w/ or w/o   LACTATION DIS NOS-
       mention of antepartum condition                          DELIV

   Medicaid Inpatient Quality Incentive Guidelines SFY2011                     A- 19
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
   Appendices


Table 11.04 Complication of the Puerperium
676.92 Unspecified disorder of lactation, delivered w/mention   LACTAT DIS NOS-DEL W
       of postpartum complication                               P/P




   Medicaid Inpatient Quality Incentive Guidelines SFY2011                    A- 20
   Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
Appendices




   Table 11.05 Medical Induction of Labor
   Code ICD-9-CM Description                           Shortened Description
   73.01 Induction of labor by artificial rupture of   INDUCT LABOR-RUPT
         membranes                                     MEMB
    73.1 Other surgical induction of labor             SURG INDUCT LABOR
                                                       NEC
    73.4 Medical induction of labor                    MEDICAL INDUCTION
                                                       LABOR




   Table 11.06 Cesarean Section
   Code ICD-9-CM Description                           Shortened Description
    74.0 Classical cesarean section                    CLASSCIAL C-
                                                       SECTION
    74.1 Low cervical cesarean section                 LOW CERVICAL C-
                                                       SECTION
    74.2 Extraperitoneal cesarean section              EXTRAPERITONEAL
                                                       C-SECTION
    74.4 Cesarean section of other specified type      CESAREAN SECTION
                                                       NEC
   74.99 Other cesarean section of unspecified type    CESAREAN SECTION
                                                       NOS




Medicaid Inpatient Quality Incentive Guidelines SFY2011                        A- 21
Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
Appendices



                  Table 11.07 Conditions Possibly Justifying
               Elective Delivery Prior to 39 Weeks Gestation
   Code      ICD-9-CM Description                                      Shortened Description
   042       Human immunodeficiency virus [HIV] disease                HUMAN IMMUNO VIRUS DIS
             Placenta previa w/o hemorrhage, delivered w/ or           PLACENTA PREVIA-
   641.01
             w/out mention of antepartum condition                     DELIVER
             Hemorrhage from placenta previa, delivered w/ or          PLACENTA PREV HEM-
   641.11
             w/out mention of antepartum condition                     DELIV
             Premature separation of placenta, delivered, w/ or        PREM SEPAR PLACEN-
   641.21
             w/out mention of antepartum condition                     DELIV
             Antepartum hemorrhage associated w/coagulation defects,   COAG DEF HEMORR-
   641.31
             delivered w/ or w/out mention of antepartum condition     DELIVER
             Other antepartum hemorrhage, delivered w/ or w/out        ANTEPARTUM HEM NEC-
   641.81
             mention of antepartum condition                           DELIV
             Unspecified antepartum hemorrhage, delivered w/ or        ANTEPARTUM HEM NOS-
   641.91
             w/out mention of antepartum condition                     DELIV
             Benign essential hypertension complicating
                                                                       ESSEN HYPERTEN-
   642.01    pregnancy, childbirth, & puerperium, delivered w/or
                                                                       DELIVERED
             w/out mention of antepartum condition
             Benign essential hypertension complicating
                                                                       ESSEN HYPERTEN-DEL W
   642.02    pregnancy, childbirth, & puerperium, delivered
                                                                       P/P
             w/mention of postpartum complication
             Hypertension secondary to renal disease, complicating
                                                                       RENAL HYPERTEN PG-
   642.11    pregnancy, childbirth, and the puerperium, delivered w/
                                                                       DELIV
             or w/out mention of antepartum condition
             Hypertension secondary to renal disease, complicating
   642.12    pregnancy, childbirth, and the puerperium, delivered      RENAL HYPERTEN-DEL P/P
             w/mention of postpartum complication
             Other pre-existing hypertension complicating
                                                                       OLD HYPERTEN NEC-
   642.21    pregnancy, childbirth & puerperium, delivered w/ or
                                                                       DELIVER
             w/out mention of antepartum condition
             Other pre-existing hypertension complicating
                                                                       OLD HYPERTEN-DELIV W
   642.22    pregnancy, childbirth & puerperium, delivered
                                                                       P/P
             w/mention of postpartum complication
             Transient hypertension of pregnancy, delivered w/ or      TRANS HYPERTEN-
   642.31
             w/out mention of antepartum condition                     DELIVERED
             Transient hypertension of pregnancy, delivered            TRANS HYPERTEN-DEL W
   642.32
             w/mention of postpartum complication                      P/P
             Mild or unspecified pre-eclampsia, delivered w/ or        MILD/NOS PREECLAMP-
   642.41
             w/out mention of antepartum condition                     DELIV
             Mild or unspecified pre-eclampsia, delivered              MILD PREECLAMP-DEL W
   642.42
             w/mention of postpartum complication                      P/P
             Severe pre-eclampsia, delivered w/ or w/out mention       SEVERE PREECLAMP-
   642.51
             of antepartum condition                                   DELIVER
             Severe pre-eclampsia, delivered w/mention of              SEV PREECLAMP-DEL W
   642.52
             postpartum complication                                   P/P
             Eclampsia, delivered w/ or w/out mention of
   642.61                                                              ECLAMPSIA-DELIVERED
             antepartum condition
             Eclampsia, delivered w/mention of postpartum
   642.62                                                              ECLAMPSIA-DELIV W P/P
             complication

Medicaid Inpatient Quality Incentive Guidelines SFY2011                               A- 22
Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
Appendices

             Pre-eclampsia or eclampsia superimposed on pre-
                                                                         TOX W OLD HYPERTEN-
   642.71    existing hypertension, delivered w/ or w/out mention of
                                                                         DELIV
             antepartum condition
             Pre-eclampsia or eclampsia superimposed on pre-
   642.72    existing hypertension, delivered w/mention of               TOX W OLD HYP-DEL W P/P
             postpartum complication
             Unspecified hypertension complicating pregnancy,
                                                                         HYPERTENS NOS-
   642.91    childbirth, or the puerperium, delivered w/ or w/out
                                                                         DELIVERED
             mention of antepartum condition
             Unspecified hypertension complicating pregnancy,
                                                                         HYPERTENS NOS-DEL W
   642.92    childbirth, or the puerperium, delivered w/mention of
                                                                         P/P
             postpartum complication
             Post term pregnancy, delivered, w/ or w/out mention
   645.11                                                                POST TERM PREG-DEL
             of antepartum condition
             Unspecified renal disease in pregnancy, w/out
                                                                         RENAL DIS NOS-
   646.21    mention of hypertension, delivered w/ or w/out
                                                                         DELIVERED
             mention of antepartum condition
             Unspecified renal disease in pregnancy, w/out
   646.22    mention of hypertension, delivered w/mention of             RENAL DIS NOS-DEL W P/P
             postpartum complication
             Liver disorders in pregnancy, delivered w/ or w/out         LIVER DISORDER-
   646.71
             mention of antepartum condition                             DELIVERED
             Diabetes mellitus, delivered, with or without mention
   648.01                                                                DIABETES-DELIVERED
             of antepartum condition
             Congenital cardiovascular disorders, delivered w/ or        CONGEN CV DIS-
   648.51
             w/out mention of antepartum condition                       DELIVERED
             Congenital cardiovascular disorders, delivered
   648.52                                                                CONGEN CV DIS-DEL W P/P
             w/mention of postpartum complication
             Other cardiovascular diseases, delivered w/ or w/o
   648.61                                                                CV DIS NEC PREG-DELIVER
             mention of antepartum condition
             Other cardiovascular diseases, delivered w/mention of
   648.62                                                                CV DIS NEC-DELIVER W P/P
             postpartum complication
             Abnormal glucose tolerance, delivered w/ or w/o             ABN GLUCOSE TOLER-
   648.81
             mention of antepartum condition                             DELIV
             Abnormal glucose tolerance, delivered w/mention of          ABN GLUCOSE-DELIV W
   648.82
             postpartum complication                                     P/P
             Coagulation defects complicating pregnancy,
   649.31    childbirth, or the puerperium, delivered, with or without   COAGULATION DEF-DELIV
             mention of antepartum condition
             Coagulation defects complicating pregnancy,
                                                                         COAGULATN DEF-DEL W
   649.32    childbirth, or the puerperium, delivered, with mention
                                                                         P/P
             of postpartum complication
             Multiple gestation, twin pregnancy, delivered with or       TWIN PREGNANCY-
   651.01
             without mention of antepartum condition                     DELIVERED
             Multiple gestation, triplet pregnancy, delivered with or    TRIPLET PREGNANCY-
   651.11
             without mention of antepartum condition                     DELIV
             Multiple gestation, quadruplet pregnancy, delivered         QUADRUPLET PREG-
   651.21
             with or without mention of antepartum condition             DELIVER
             Multiple gestation, twin pregnancy w/fetal loss and
   651.31    retention of 1 fetus, delivered with or without mention     TWINS W FETAL LOSS-DEL
             of antepartum condition



Medicaid Inpatient Quality Incentive Guidelines SFY2011                                    A- 23
Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
Appendices


             Multiple gestation, triplet pregnancy, w/fetal loss and
   651.41    retention of one or more fetus (es), delivered with or     TRIPLETS W FET LOSS-DEL
             without mention of antepartum condition
             Multiple gestation, quadruplet pregnancy, w/fetal loss
   651.51    and retention of 1 or more fetus(es), delivered with or    QUADS W FETAL LOSS-DEL
             without mention of antepartum condition
             Multiple gestation, other multiple pregnancy, w/fetal
                                                                        MULT GES W FET LOSS-
   651.61    loss and retention of 1 or more fetus(es), delivered
                                                                        DEL
             with or without mention of antepartum condition
             Multiple gestation following (elective) fetal reduction,   MULT GEST-FET REDUCT
   651.71
             delivered without mention of antepartum condition          DEL
             Multiple gestation, other specified multiple gestation,
                                                                        MULTI GESTAT NEC-
   651.81    delivered with or without mention of antepartum
                                                                        DELIVER
             condition
             Multiple gestation, unspecified multiple gestation,
                                                                        MULT GESTATION NOS-
   651.91    delivered with or without mention of antepartum
                                                                        DELIV
             condition
             Unstable lie, delivered, w/ or w/out mention of
   652.01                                                               UNSTABLE LIE-DELIVERED
             antepartum condition
             Multiple gestation w/malpresentation of 1 fetus or
                                                                        MULT GEST MALPRES-
   652.61    more, delivered, w/ or w/out mention of antepartum
                                                                        DELIV
             condition
             Central nervous system malformation in fetus,              FETAL CNS MALFORM-
   655.01
             delivered, w/ or w/o mention of antepartum condition       DELIV
             Chromosomal abnormality in fetus, delivered w/ or w/o      FETAL CHROMOSO ABN-
   655.11
             mention of antepartum condition                            DELIV
             Suspected damage to fetus from viral disease in the
                                                                        FET DAMG D/T VIRUS-
   655.31    mother, delivered w/ or w/o mention of antepartum
                                                                        DELIV
             condition
             Suspected damage to fetus from other disease in the
                                                                        FET DAMG D/T DIS-
   655.41    mother, delivered w/ or w/o mention of antepartum
                                                                        DELIVER
             condition
             Suspected damage to fetus from drugs, delivered w/         FET DAMAG D/T DRUG-
   655.51
             or w/o mention of antepartum condition                     DELIV
             Suspected damage to fetus from radiation, delivered        RADIAT FETAL DAMAG-
   655.61
             w/ or w/o mention of antepartum condition                  DELIV
             Other known or suspected fetal abnormality, not            FETAL ABNORM NEC-
   655.8
             elsewhere specified                                        UNSPEC
             Fetal-maternal hemorrhage, delivered, w/ or w/o            FETAL-MATERNAL HEM-
   656.01
             mention of antepartum condition                            DELIV
             Rhesus isoimmunization, delivered, w/ or w/o mention       RH ISOIMMUNIZAT-
   656.11
             of antepartum condition                                    DELIVER
             Isoimmunization from other and unspecified blood-
                                                                        ABO ISOIMMUNIZAT-
   656.21    group incompatibility, delivered, w/ or w/o mention of
                                                                        DELIVER
             antepartum condition
             Fetal distress, delivered, w/ or w/o mention of            FETAL DISTRESS-
   656.31
             antepartum condition                                       DELIVERED
             Intrauterine death, delivered, w/ or w/o mention of        INTRAUTER DEATH-
   656.41
             antepartum condition                                       DELIVER
             Poor fetal growth, delivered, w/ or w/o mention of         POOR FETAL GROWTH-
   656.51
             antepartum condition                                       DELIV


Medicaid Inpatient Quality Incentive Guidelines SFY2011                                 A- 24
Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
Appendices

             Polyhydramnios, delivered w/ or w/o mention of             POLYHYDRAMNIOS-
   657.01
             antepartum condition                                       DELIVERED
             Oligohydramnios, delivered w/ or w/o mention of            OLIGOHYDRAMNIOS-
   658.01
             antepartum condition                                       DELIVER
             Premature rupture of membranes, delivered w/ or w/o        PREM RUPT MEMBRAN-
   658.11
             mention of antepartum condition                            DELIV
             Delayed delivery after spontaneous or unspecified
                                                                        PROLONG RUPT MEMB-
   658.21    rupture of membranes, delivered w/ or w/o mention of
                                                                        DELIV
             antepartum condition
             Delayed delivery after spontaneous or unspecified
                                                                        PROLONG RUPT MEMB-
   658.21    rupture of membranes, delivered w/ or w/o mention of
                                                                        DELIV
             antepartum condition
             Abnormality in fetal heart rate or rhythm, delivered, w/   ABN FTL HRT RATE/RHY-
   659.71
             or w/o mention of antepartum condition                     DEL
             Vasa previa complicating labor and delivery,               VASA PREVIA-
   663.5
             unspecified as to episode of care or not applicable        UNSPECIFIED
             Vasa previa complicating labor and delivery,
   663.51    delivered, with or without mention of antepartum           VASA PREVIA-DELIVERED
             condition
             Vasa previa complicating labor and delivery,
   663.53                                                               VASA PREVIA-ANTEPATUM
             antepartum condition or complication
             Asymptomatic human immunodeficiency virus [HIV]            ASYMP HIV INFECTN
    V08
             infection virus                                            STATUS
             Pregnancy with other poor obstetric history;               PREG W POOR
   V23.5
             Pregnancy with history of stillbirth or neonatal death     REPRODUCT HX
                                                                        DELIVER-SINGLE
   V27.1     Single stillborn
                                                                        STILLBORN




Medicaid Inpatient Quality Incentive Guidelines SFY2011                                A- 25
Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices



Table 11.08      Infection
Code                             ICD-9-CM Description                Shortened Description
                                                                     CHOLERA D/T VIB
 001.0   Cholera due to Vibrio cholerae                              CHOLERAE
                                                                     CHOLERA D/T VIB EL
 001.1   Cholera due to Vibrio cholerae el tor                       TOR
 001.9   Cholera, unspecified                                        CHOLERA NOS
 002.0   Typhoid fever                                               TYPHOID FEVER
 002.1   Paratyphoid fever A                                         PARATYPHOID FEVER A

 002.2   Paratyphoid fever B                                         PARATYPHOID FEVER B
 002.3   Paratyphoid fever C                                         PARATYPHOID FEVER C
                                                                     PARATYPHOID FEVER
 002.9   Paratyphoid fever, unspecified                              NOS
                                                                     SALMONELLA
 003.0   Salmonella gastroenteritis                                  ENTERITIS
                                                                     SALMONELLA
 003.1   Salmonella septicemia                                       SEPTICEMIA
                                                                     LOCAL SALMONELLA
003.20   Localized salmonella infection, unspecified                 INF NOS
                                                                     SALMONELLA
003.21   Salmonella meningitis                                       MENINGITIS
                                                                     SALMONELLA
003.22   Salmonella pneumonia                                        PNEUMONIA
                                                                     SALMONELLA
003.23   Salmonella arthritis                                        ARTHRITIS
                                                                     SALMONELLA
003.24   Salmonella osteomyelitis                                    OSTEOMYELITIS
                                                                     LOCAL SALMONELLA
003.29   Other salmonella                                            INF NEC
                                                                     SALMONELLA
 003.8   Other specified salmonella infections                       INFECTION NEC
                                                                     SALMONELLA
 003.9   Salmonella infection, unspecified                           INFECTION NOS
                                                                     SHIGELLA
 004.0   Shigella dysenteriae                                        DYSENTERIAE
 004.1   Shigella flexneri                                           SHIGELLA FLEXNERI
 004.2   Shigella boydii                                             SHIGELLA BOYDII
 004.3   Shigella sonnei                                             SHIGELLA SONNEI
                                                                     SHIGELLA INFECTION
 004.8   Other Shigella infections                                   NEC
 004.9   Shigellosis NOS                                             SHIGELLOSIS NOS
                                                                     AC AMEBIASIS W/O
 006.0   Acute amebic dysentery without mention of abscess           ABSCESS
                                                                     CHR AMEBIASIS W/O
 006.1   Chronic intestinal amebiasis without mention of abscess     ABSCES
                                                                     AMEBIC NONDYSENT
 006.2   Amebic nondysenteric colitis                                COLITIS
 006.3   Amebic liver abscess                                        AMEBIC LIVER ABSCESS
 006.4   Amebic lung abscess                                       AMEBIC LUNG ABSCESS
 006.5   Amebic brain abscess                                      AMEBIC BRAIN ABSCESS

  Medicaid Inpatient Quality Incentive Guidelines SFY2011                           A- 26
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices


 006.6   Amebic skin ulceration                                                  AMEBIC SKIN ULCERATION
 006.8   Amebic infection of other sites                                         AMEBIC INFECTION NEC
 006.9   Amebiasis, unspecified                                                  AMEBIASIS NOS
 007.1   Giardiasis                                                              GIARDIASIS
008.00   Escherichia coli, unspecified                                           INTEST INFEC E COLI NOS
008.01   Enteropathogenic E. coli                                                INT INF E COLI ENTRPATH
008.02   Enterotoxigenic E. coli                                                 INT INF E COLI ENTRTOXGN
008.03   Enteroinvasive E. coli                                                  INT INF E COLI ENTRNVSV
008.04   Enterohemorrhagic E. coli                                               INT INF E COLI ENTRHMRG
008.09   Other intestinal E. coli infections                                     INT INF E COLI SPCF NEC
 008.1   Arizona group of paracolon bacilli                                      ARIZONA ENTERITIS
 008.2   Aerobacter aerogenes                                                    AEROBACTER ENTERITIS
 008.3   Proteus (mirabilis) (morganii)                                          PROTEUS ENTERITIS
008.41   Staphylococcus                                                          STAPHYLOCOCC ENTERITIS
008.42   Pseudomonas                                                             PSEUDOMONAS ENTERITIS
                                                                                 INT INFEC
008.43   Campylobacter                                                           CAMPYLOBACTER
                                                                                 INT INF YRSNIA
008.44   Yersinia enterocolitica                                                 ENTRCLTCA
008.45   Clostridium difficile                                                   INT INF CLSTRDIUM DFCILE
                                                                                 INTES INFEC OTH
008.46   Other anaerobes                                                         ANEROBES
008.47   Other gram-negative bacteria                                            INT INF OTH GRM NEG BCTR
008.49   Other intestinal infections due to other organisms                      BACTERIAL ENTERITIS NEC
 008.5   Bacterial enteritis, unspecified                                        BACTERIAL ENTERITIS NOS
 008.8   Other organism, not elsewhere classified                                VIRAL ENTERITIS NOS
 009.0   Infectious colitis, enteritis and gastroenteritis                       INFECTIOUS ENTERITIS NOS
 009.1   Colitis, enteritis, and gastroenteritis of presumed infectious origin   ENTERITIS OF INFECT ORIG
 009.2   Infectious diarrhea                                                     INFECTIOUS DIARRHEA NOS
 009.3   Diarrhea of presumed infectious origin                                  DIARRHEA OF INFECT ORIG
 020.0   Bubonic plague                                                          BUBONIC PLAGUE
                                                                                 CELLULOCUTANEOUS
 020.1   Cellulocutaneous plague                                                 PLAGUE
 020.2   Septicemic plague                                                       SEPTICEMIC PLAGUE
                                                                                 PRIMARY PNEUMONIC
 020.3   Primary pneumonic plague                                                PLAGUE
                                                                                 SECONDARY PNEUMON
 020.4   Secondary pneumonic plague                                              PLAGUE
 020.5   Pneumonic plague, unspecified                                           PNEUMONIC PLAGUE NOS
 020.8   Other specified types of plague                                         OTHER TYPES OF PLAGUE
 020.9   Plague, unspecified                                                     PLAGUE NOS
                                                                                 ULCEROGLANDUL
 021.0   Ulceroglandular tularemia                                               TULAREMIA
 021.1   Enteric tularemia                                                       ENTERIC TULAREMIA
 021.2   Pulmonary tularemia                                                     PULMONARY TULAREMIA
                                                                                 OCULOGLANDULAR
 021.3   Oculoglandular tularemia                                                TULAREMIA
 021.8   Other specified tularemia                                               TULAREMIA NEC
 021.9   Unspecified tularemia                                                   TULAREMIA NOS
 022.0   Cutaneous anthrax                                                       CUTANEOUS ANTHRAX


  Medicaid Inpatient Quality Incentive Guidelines SFY2011                                        A- 27
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

 022.1   Pulmonary anthrax                                   PULMONARY ANTHRAX
                                                             GASTROINTESTINAL
 022.2   Gastrointestinal anthrax                            ANTHRAX
 022.3   Anthrax septicemia                                  ANTHRAX SEPTICEMIA
                                                             OTHER ANTHRAX
 022.8   Other specified manifestations of anthrax           MANIFEST
 022.9   Anthrax, unspecified                                ANTHRAX NOS
 023.0   Brucella melitensis                                 BRUCELLA MELITENSIS
 023.1   Brucella abortus                                    BRUCELLA ABORTUS
 023.2   Brucella suis                                       BRUCELLA SUIS
 023.3   Brucella canis                                      BRUCELLA CANIS
 023.8   Other brucellosis                                   BRUCELLOSIS NEC
 023.9   Brucellosis, unspecified                            BRUCELLOSIS NOS
  024    Glanders                                            GLANDERS
  025    Melioidosis                                         MELIOIDOSIS
 026.0   Spirillary fever                                    SPIRILLARY FEVER
 026.1   Streptobacillary fever                              STREPTOBACILLARY FEVER
 026.9   Unspecified rat-bite fever                          RAT-BITE FEVER NOS
 027.0   Listeriosis                                         LISTERIOSIS
                                                             ERYSIPELOTHRIX
 027.1   Erysipelothrix infection                            INFECTION
 027.2   Pasteurellosis                                      PASTEURELLOSIS
 027.8   Other specified zoonotic bacterial diseases         ZOONOTIC BACT DIS NEC
 027.9   Unspecified zoonotic bacterial disease              ZOONOTIC BACT DIS NOS
 030.0   Lepromatous leprosy (type L)                        LEPROMATOUS LEPROSY
 030.1   Tuberculoid leprosy (type T)                        TUBERCULOID LEPROSY
 030.2   Indeterminate leprosy (group I)                     INDETERMINATE LEPROSY
 030.3   Borderline leprosy (group B)                        BORDERLINE LEPROSY
 030.8   Other specified leprosy                             LEPROSY NEC
 030.9   Leprosy, unspecified                                LEPROSY NOS
                                                             PULMONARY
 031.0   Pulmonary disease due to other mycobacteria         MYCOBACTERIA
                                                             CUTANEOUS
 031.1   Cutaneous disease due to other mycobacteria         MYCOBACTERIA
 031.2   Disseminated disease due to other mycobacteria      DMAC BACTEREMIA
 031.8   Other specified mycobacterial diseases              MYCOBACTERIAL DIS NEC
 031.9   Unspecified diseases due to mycobacteria            MYCOBACTERIAL DIS NOS
 032.0   Faucial diphtheria                                  FAUCIAL DIPHTHERIA
                                                             NASOPHARYNX
 032.1   Nasopharyngeal diphtheria                           DIPHTHERIA
 032.2   Anterior nasal diphtheria                           ANT NASAL DIPHTHERIA
 032.3   Laryngeal diphtheria                                LARYNGEAL DIPHTHERIA
                                                             CONJUNCTIVAL
032.81   Conjunctival diphtheria                             DIPHTHERIA
                                                             DIPHTHERITIC
032.82   Diphtheritic myocarditis                            MYOCARDITIS
032.83   Diphtheritic peritonitis                            DIPHTHERITIC PERITONITIS
032.84   Diphtheritic cystitis                               DIPHTHERITIC CYSTITIS
032.85   Cutaneous diphtheria                                CUTANEOUS DIPHTHERIA
032.89   Other specified diphtheria                          DIPHTHERIA NEC
 032.9   Diphtheria, unspecified                             DIPHTHERIA NOS
 033.0   Bordetella pertussis                                BORDETELLA PERTUSSIS
 033.1   Bordetella parapertussis                            BORDETELLA


  Medicaid Inpatient Quality Incentive Guidelines SFY2011                    A- 28
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

                                                                    PARAPERTUSSIS
 033.8   Whooping cough due to other specified organism             WHOOPING COUGH NEC
 033.9   Whooping cough, unspecified organism                       WHOOPING COUGH NOS
 034.0   Streptococcal sore throat                                  STREP SORE THROAT
 034.1   Scarlet fever                                              SCARLET FEVER
  035    Erysipelas                                                 ERYSIPELAS
                                                                    MENINGOCOCCAL
 036.0   Meningococcal meningitis                                   MENINGITIS
                                                                    MENINGOCOCC
 036.1   Meningococcal encephalitis                                 ENCEPHALITIS
 036.2   Meningococcemia                                            MENINGOCOCCEMIA
                                                                    MENINGOCOCC ADRENAL
 036.3   Waterhouse-Friderichsen syndrome, meningococcal            SYND
                                                                    MENINGOCOCC CARDITIS
036.40   Meningococcal carditis, unspecified                        NOS
                                                                    MENINGOCOCC
036.41   Meningococcal pericarditis                                 PERICARDITIS
                                                                    MENINGOCOCC
036.42   Meningococcal endocarditis                                 ENDOCARDITIS
                                                                    MENINGOCOCC
036.43   Meningococcal myocarditis                                  MYOCARDITIS
                                                                    MENINGOCOCC OPTIC
036.81   Meningococcal optic neuritis                               NEURIT
                                                                    MENINGOCOCC
036.82   Meningococcal arthropathy                                  ARTHROPATHY
                                                                    MENINGOCOCCAL INFECT
036.89   Other specified meningococcal infections                   NEC
                                                                    MENINGOCOCCAL INFECT
 036.9   Meningococcal infection, unspecified                       NOS
  037    Tetanus                                                    TETANUS
                                                                    STREPTOCOCCAL
 038.0   Streptococcal septicemia                                   SEPTICEMIA
                                                                    STAPHYLCOCC SEPTICEM
038.10   Staphylococcal septicemia, unspecified                     NOS
                                                                    METH SUSC STAPH AUR
038.11   Methicillin susceptible Staphylococcus aureus septicemia   SEPT
038.12   Methicillin resistant Staphylococcus aureus septicemia     MRSA SEPTICEMIA
                                                                    STAPHYLCOCC SEPTICEM
038.19   Other staphylococcal septicemia                            NEC
                                                                    PNEUMOCOCCAL
 038.2   Pneumococcal septicemia                                    SEPTICEMIA
 038.3   Septicemia due to anaerobes                                ANAEROBIC SEPTICEMIA
                                                                    GRAM-NEG SEPTICEMIA
038.40   Septicemia due to gram-negative organism unspecified       NOS
038.41   Septicemia due to hemophilus influenzae                    H. INFLUENAE SEPTICEMIA
038.42   Septicemia due to escherichia coli                         E COLI SEPTICEMIA
                                                                    PSEUDOMONAS
038.43   Septicemia due to pseudomonas                              SEPTICEMIA
038.44   Septicemia due to serratia                                 SERRATIA SEPTICEMIA
                                                                    GRAM-NEG SEPTICEMIA
038.49   Septicemia due to other gram-negative organism             NEC
 038.8   Other specified septicemias                                SEPTICEMIA NEC
 038.9   Unspecified septicemia                                     SEPTICEMIA NOS
 039.0   Cutaneous actinomycotic infection                          CUTANEOUS

  Medicaid Inpatient Quality Incentive Guidelines SFY2011                           A- 29
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

                                                                                ACTINOMYCOSIS
                                                                                PULMONARY
 039.1   Pulmonary actinomycotic infection                                      ACTINOMYCOSIS
                                                                                ABDOMINAL
 039.2   Abdominal actinomycotic infection                                      ACTINOMYCOSIS
                                                                                CERVICOFAC
 039.3   Cervicofacial actinomycotic infection                                  ACTINOMYCOSIS
 039.4   Madura foot actinomycotic infection                                    MADURA FOOT
 039.8   Actinomycotic infection of other specified sites                       ACTINOMYCOSIS NEC
 039.9   Actinomycotic infection of other unspecified sites                     ACTINOMYCOSIS NOS
 040.0   Gas gangrene                                                           GAS GANGRENE
 040.1   Rhinoscleroma                                                          RHINOSCLEROMA
 040.2   Whipple’s disease                                                      WHIPPLE'S DISEASE
 040.3   Necrobacillosis                                                        NECROBACILLOSIS
040.81   Tropical pyomyositis                                                   TROPICAL PYOMYOSITIS
040.82   Toxic shock syndrome                                                   TOXIC SHOCK SYNDROME
040.89   Other pyomyositis                                                      BACTERIAL DISEASES NEC
041.00   Streptococcus, unspecified                                             STREPTOCOCCUS UNSPECF
041.01   Streptococcus Group A                                                  STREPTOCOCCUS GROUP A
041.02   Streptococcus Group B                                                  STREPTOCOCCUS GROUP B
041.03   Streptococcus Group C                                                  STREPTOCOCCUS GROUP C
041.04   Streptococcus Group D                                                  ENTEROCOCCUS GROUP D
041.05   Streptococcus Group G                                                  STREPTOCOCCUS GROUP G
041.09   Other Streptococcus                                                    OTHER STREPTOCOCCUS
                                                                                STAPHYLOCOCCUS
041.10   Staphylococcus, unspecified                                            UNSPCFIED
         Methicillin susceptible Staphylococcus aureus in conditions            MTH SUS STPH AUR
041.11   classified elsewhere and of unspecified site                           ELS/NOS
         Methicillin resistant Staphylococcus aureus in conditions classified
041.12   elsewhere and of unspecified site                                      MRSA ELSEWHERE/NOS
041.19   Other staphylococcus                                                   OTHER STAPHYLOCOCCUS
                                                                                PNEUMOCOCCUS INFECT
 041.2   Pneumococcus                                                           NOS
 041.3   Klebsiella pneumoniae                                                  KLEBSIELLA PNEUMONIAE
 041.4   Escherichia coli (E. coli)                                             E. COLI INFECT NOS
 041.5   Hemophilus influenzae                                                  H. INFLUENZAE INFECT NOS
 041.6   Proteus (mirabilis) (morganii)                                         PROTEUS INFECTION NOS
 041.7   Pseudomonas                                                            PSEUDOMONAS INFECT NOS
041.81   Mycoplasma                                                             MYCOPLASMA
041.82   Bacteroides fragilis                                                   BACTEROIDES FRAGILIS
                                                                                CLOSTRIDIUM
041.83   Clostridium perfringens                                                PERFRINGENS
041.84   Other anaerobes                                                        OTHER ANAEROBES
                                                                                OTH GRAM NEGATV
041.85   Other gram-negative organisms                                          BACTERIA
041.86   Helicobacter pylori [H. pylori]                                        HELICOBACTER PYLORI
041.89   Other specified bacteria                                               OTH SPECF BACTERIA
 041.9   Bacterial infection, unspecified                                       BACTERIAL INFECTION NOS
                                                                                CONTAGIOUS PUSTULAR
 051.2   Contagious pustular dermatitis                                         DERM
 073.0   Ornithosis with pneumonia                                              ORNITHOSIS PNEUMONIA
                                                                                ORNITHOSIS COMPLICAT
 073.7   Ornithosis with other specified complications                          NEC
 073.8   Ornithosis with unspecified complication                               ORNITHOSIS COMPLICAT

  Medicaid Inpatient Quality Incentive Guidelines SFY2011                                       A- 30
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

                                                             NOS
 073.9   Ornithosis, unspecified                             ORNITHOSIS NOS
 076.0   Trachoma initial stage                              TRACHOMA, INITIAL STAGE
 076.1   Trachoma active stage                               TRACHOMA, ACTIVE STAGE
 076.9   Trachoma, unspecified                               TRACHOMA NOS
 078.2   Sweating fever                                      SWEATING FEVER
 078.3   Cat-scratch disease                                 CAT-SCRATCH DISEASE
 078.4   Foot and mouth disease                              FOOT & MOUTH DISEASE
 078.6   Hemorrhagic nephrosonephritis                       HEM NEPHROSONEPHRITIS
078.88   Other specified diseases due to Chlamydiae          OTH SPEC DIS CHLAMYDIAE
                                                             OTH SPCF CHLAMYDIAL
079.88   Other specified chlamydial infection                INFC
                                                             CHLAMYDIAL INFECTION
079.98   Unspecified chlamydial infection                    NOS
082.40   Ehrlichiosis unspecified                            EHRLICHIOSIS NOS
082.41   Ehrlichiosis chaffeensis                            EHRLICHIOSIS CHAFEENSIS
082.49   Other ehrlichiosis                                  EHRLICHIOSIS NEC
 082.8   Other specified tick-borne rickettsioses            TICK-BORNE RICKETTS NEC
 082.9   Tick-borne rickettsiosis, unspecified               TICK-BORNE RICKETTS NOS
 083.2   Rickettsialpox                                      RICKETTSIALPOX
 083.8   Other specified rickettsioses                       RICKETTSIOSES NEC
 083.9   Rickettsiosis, unspecified                          RICKETTSIOSIS NOS
 088.0   Bartonellosis                                       BARTONELLOSIS
088.81   Lyme disease                                        LYME DISEASE
                                                             EARLY CONG SYPH
 090.0   Early congenital syphilis, symptomatic              SYMPTOM
                                                             EARLY CONGEN SYPH
 090.1   Early congenital syphilis, latent                   LATENT
 090.2   Early congenital syphilis, unspecified              EARLY CONGEN SYPH NOS
 090.3   Syphilitic interstitial keratitis                   SYPHILITIC KERATITIS
090.40   Juvenile neurosyphilis, unspecified                 JUVENILE NEUROSYPH NOS
                                                             CONGEN SYPH
090.41   Congenital syphilitic encephalitis                  ENCEPHALITIS
090.42   Congenital syphilitic meningitis                    CONGEN SYPH MENINGITIS
090.49   Other juvenile neurosyphilis                        JUVENILE NEUROSYPH NEC
                                                             LATE CONGEN SYPH
 090.5   Other late congenital syphilis, symptomatic         SYMPTOM
                                                             LATE CONGEN SYPH
 090.6   Late congenital syphilis, latent                    LATENT
 090.7   Late congenital syphilis, unspecified               LATE CONGEN SYPH NOS
 090.9   Congenital syphilis, unspecified                    CONGENITAL SYPHILIS NOS
                                                             PRIMARY GENITAL
 091.0   Genital syphilis (primary)                          SYPHILIS
 091.1   Primary anal syphilis                               PRIMARY ANAL SYPHILIS
 091.2   Other primary syphilis                              PRIMARY SYPHILIS NEC
 091.3   Secondary syphilis of skin or mucous membranes      SECONDARY SYPH SKIN
 091.4   Adenopathy due to secondary syphilis                SYPHILITIC ADENOPATHY
091.50   Syphilitic uveitis, unspecified                     SYPHILITIC UVEITIS NOS
091.51   Syphilitic chorioretinitis (secondary)              SYPHILIT CHORIORETINITIS
091.52   Syphilitic iridocyclitis (secondary)                SYPHILITIC IRIDOCYCLITIS
091.61   Secondary syphilitic periostitis                    SYPHILITIC PERIOSTITIS
091.62   Secondary syphilitic hepatitis                      SYPHILITIC HEPATITIS
091.69   Other viscera                                       SECOND SYPH VISCERA NEC


  Medicaid Inpatient Quality Incentive Guidelines SFY2011                   A- 31
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

 091.7   Secondary syphilis, relapse                                   SECOND SYPHILIS RELAPSE
091.81   Acute syphilitic meningitis (secondary)                       ACUTE SYPHIL MENINGITIS
091.82   Syphilitic alopecia                                           SYPHILITIC ALOPECIA
091.89   Other secondary syphilis                                      SECONDARY SYPHILIS NEC
 091.9   Unspecified secondary syphilis                                SECONDARY SYPHILIS NOS
                                                                       EARLY SYPH LATENT
 092.0   Early syphilis, latent, serological relapse after treatment   RELAPS
 092.9   Early syphilis, latent, unspecified                           EARLY SYPHIL LATENT NOS
 093.0   Aneurysm of aorta, specified as syphilitic                    AORTIC ANEURYSM, SYPHIL
 093.1   Syphilitic aortitis                                           SYPHILITIC AORTITIS
093.20   Syphilitic endocarditis valve, unspecified                    SYPHIL ENDOCARDITIS NOS
093.21   Syphilitic endocarditis mitral valve                          SYPHILITIC MITRAL VALVE
093.22   Syphilitic endocarditis aortic valve                          SYPHILITIC AORTIC VALVE
093.23   Syphilitic endocarditis tricuspid valve                       SYPHIL TRICUSPID VALVE
                                                                       SYPHIL PULMONARY
093.24   Syphilitic endocarditis pulmonary valve                       VALVE
093.81   Syphilitic pericarditis                                       SYPHILITIC PERICARDITIS
093.82   Syphilitic myocarditis                                        SYPHILITIC MYOCARDITIS
                                                                       CARDIOVASCULAR SYPH
093.89   Other specified cardiovascular syphilis                       NEC
                                                                       CARDIOVASCULAR SYPH
 093.9   Cardiovascular syphilis, unspecified                          NOS
 094.0   Tabes dorsalis                                                TABES DORSALIS
 094.1   General paresis                                               GENERAL PARESIS
 094.2   Syphilitic meningitis                                         SYPHILITIC MENINGITIS
                                                                       ASYMPTOMAT
 094.3   Asymptomatic neurosyphilis                                    NEUROSYPHILIS
094.81   Syphilitic encephalitis                                       SYPHILITIC ENCEPHALITIS
094.82   Syphilitic Parkinsonism                                       SYPHILITIC PARKINSONISM
094.83   Syphilitic disseminated retinochoroiditis                     SYPH DISSEM RETINITIS
094.84   Syphilitic optic atrophy                                      SYPHILITIC OPTIC ATROPHY
094.85   Syphilitic retrobulbar neuritis                               SYPH RETROBULB NEURITIS
094.86   Syphilitic acoustic neuritis                                  SYPHIL ACOUSTIC NEURITIS
                                                                       SYPH RUPT CEREB
094.87   Syphilitic ruptured cerebral aneurysm                         ANEURYSM
094.89   Other specified neurosyphilis                                 NEUROSYPHILIS NEC
 094.9   Neurosyphilis, unspecified                                    NEUROSYPHILIS NOS
 095.0   Syphilitic episcleritis                                       SYPHILITIC EPISCLERITIS
 095.1   Syphilis of lung                                              SYPHILIS OF LUNG
 093.0   Aneurysm of aorta, specified as syphilitic                    AORTIC ANEURYSM, SYPHIL
 093.1   Syphilitic aortitis                                           SYPHILITIC AORTITIS
 095.2   Syphilitic peritonitis                                        SYPHILITIC PERITONITIS
 095.3   Syphilis of liver                                             SYPHILIS OF LIVER
 095.4   Syphilis of kidney                                            SYPHILIS OF KIDNEY
 095.5   Syphilis of bone                                              SYPHILIS OF BONE
 095.6   Syphilis of muscle                                            SYPHILIS OF MUSCLE
                                                                       SYPHILIS OF
 095.7   Syphilis of synovium, tendon, and bursa                       TENDON/BURSA
 095.8   Other specified forms of late symptomatic syphilis            LATE SYMPT SYPHILIS NEC
 095.9   Late symptomatic syphilis, unspecified                        LATE SYMPT SYPHILIS NOS
  096    Late syphilis, latent                                         LATE SYPHILIS LATENT
 097.0   Late syphilis, unspecified                                    LATE SYPHILIS NOS
 097.1   Latent syphilis, unspecified                                  LATENT SYPHILIS NOS


  Medicaid Inpatient Quality Incentive Guidelines SFY2011                             A- 32
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

 097.9   Syphilis, unspecified                                              SYPHILIS NOS
                                                                            ACUTE GC INFECT LOWER
 098.0   Acute gonococcal infections of lower genitourinary tract           GU
         Gonococcal infection (acute) of upper genitourinary tract, site
098.10   unspecified                                                        GC (ACUTE) UPPER GU NOS
098.11   Gonococcal cystitis (acute)                                        GC CYSTITIS (ACUTE)
098.12   Gonococcal prostatitis, (acute)                                    GC PROSTATITIS (ACUTE)
098.13   Gonococcal epididymo-orchitis (acute)                              GC ORCHITIS (ACUTE)
098.14   Gonococcal seminal vesiculitis (acute)                             GC SEM VESICULIT (ACUTE)
098.15   Gonococcal cervicitis (acute)                                      GC CERVICITIS (ACUTE)
098.16   Gonococcal endometritis (acute)                                    GC ENDOMETRITIS (ACUTE)
098.17   Gonococcal salpingitis, specified as acute                         ACUTE GC SALPINGITIS
098.19   Other acute gonococcal infections of upper genitourinary tract     GC (ACUTE) UPPER GU NEC
 098.2   Chronic gonococcal infections of lower genitourinary tract         CHR GC INFECT LOWER GU
         Chronic gonococcal infection of upper genitourinary tract, site
098.30   unspecified                                                        CHR GC UPPER GU NOS
098.31   Gonococcal cystitis, chronic                                       GC CYSTITIS, CHRONIC
098.32   Gonococcal prostatitis, chronic                                    GC PROSTATITIS, CHRONIC
098.33   Gonococcal epididymo-orchitis, chronic                             GC ORCHITIS, CHRONIC
098.34   Gonococcal seminal vesiculitis, chronic                            GC SEM VESICULITIS, CHR
098.35   Gonococcal cervicitis, chronic                                     GC CERVICITIS, CHRONIC
                                                                            GC ENDOMETRITIS,
098.36   Gonococcal endometritis, chronic                                   CHRONIC
098.37   Gonococcal salpingitis (chronic)                                   GC SALPINGITIS (CHRONIC)
098.39   Other chronic gonococcal infections of upper genitourinary tract   CHR GC UPPER GU NEC
                                                                            GONOCOCCAL
098.40   Gonococcal conjunctivitis (neonatorum)                             CONJUNCTIVIT
                                                                            GONOCOCCAL
098.41   Gonococcal iridocyclitis                                           IRIDOCYCLITIS
                                                                            GONOCOCCAL
098.42   Gonococcal endophthalmia                                           ENDOPHTHALMIA
098.43   Gonococcal keratitis                                               GONOCOCCAL KERATITIS
098.49   Other gonococcal infection of eye                                  GONOCOCCAL EYE NEC
098.50   Gonococcal arthritis                                               GONOCOCCAL ARTHRITIS
098.51   Gonococcal synovitis and tenosynovitis                             GONOCOCCAL SYNOVITIS
098.52   Gonococcal bursitis                                                GONOCOCCAL BURSITIS
                                                                            GONOCOCCAL
098.53   Gonococcal spondylitis                                             SPONDYLITIS
098.59   Other gonococcal infection of joint                                GC INFECT JOINT NEC
                                                                            GONOCOCCAL INFEC
 098.6   Gonococcal infection of pharynx                                    PHARYNX
 098.7   Gonococcal infection of anus and rectum                            GC INFECT ANUS & RECTUM
098.81   Gonococcal keratosis (blennorrhagica)                              GONOCOCCAL KERATOSIS
098.82   Gonococcal meningitis                                              GONOCOCCAL MENINGITIS
                                                                            GONOCOCCAL
098.83   Gonococcal pericarditis                                            PERICARDITIS
                                                                            GONOCOCCAL
098.84   Gonococcal endocarditis                                            ENDOCARDITIS
                                                                            GONOCOCCAL HEART DIS
098.85   Other gonococcal heart disease                                     NEC
098.86   Gonococcal peritonitis                                             GONOCOCCAL PERITONITIS
098.89   Other gonococcal infection of other specified sites                GONOCOCCAL INF SITE NEC
 099.0   Chancroid                                                          CHANCROID
 099.1   Lymphogranuloma venereum                                           LYMPHOGRANULOMA

  Medicaid Inpatient Quality Incentive Guidelines SFY2011                                   A- 33
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

                                                                               VENEREUM
 099.2   Granuloma inguinale                                                   GRANULOMA INGUINALE
 099.3   Reiter’s disease                                                      REITER'S DISEASE
                                                                               UNSPCF NONGNCCL
099.40   Unspecified nongonococcal urethritis                                  URETHRTS
                                                                               CHLMYD TRACHOMATIS
099.41   Chlamydia trachomatis                                                 URETH
                                                                               NONGC URTH OTH SPF
099.49   Other specified nongonococcal urethritis organism                     ORGSM
                                                                               OTH VD CHLM TRCH UNSP
099.50   Other venereal diseases due to Chlamydia, unspecified site            ST
                                                                               OTH VD CHLM TRCH
099.51   Other venereal diseases due to Chlamydia, pharynx                     PHARYNX
                                                                               OTH VD CHLM TRCH ANS
099.52   Other venereal diseases due to Chlamydia, anus and rectum             RCT
                                                                               OTH VD CHLM TRCH LOWR
099.53   Other venereal diseases due to Chlamydia, lower genitourinary sites   GU
                                                                               OTH VD CHLM TRCH OTH
099.54   Other venereal diseases due to Chlamydia, other genitourinary sites   GU
         Other venereal diseases due to Chlamydia, unspecified                 OT VD CHLM TRCH UNSPF
099.55   genitourinary sites                                                   GU
                                                                               OT VD CHLM TRCH
099.56   Other venereal diseases due to Chlamydia, peritoneum                  PRTONEUM
                                                                               OTH VD CHLM TRCH SPCF
099.59   Other venereal diseases due to Chlamydia, other specified site        ST
 099.8   Other specified venereal diseases                                     VENEREAL DISEASE NEC
 099.9   Venereal disease, unspecified                                         VENEREAL DISEASE NOS
 100.0   Leptospirosis icterohemorrhagica                                      LEPTOSPIROS ICTEROHEM
100.81   Leptospiral meningitis                                                LEPTOSPIRAL MENINGITIS
100.89   Other specified leptospiral infection                                 LEPTOSPIRAL INFECT NEC
 100.9   Leptospirosis, unspecified                                            LEPTOSPIROSIS NOS
  101    Vincent’s angina                                                      VINCENT'S ANGINA
 102.0   Yaws initial lesions                                                  INITIAL LESIONS YAWS
 102.1   Multiple papillomata and wet crab yaws                                MULTIPLE PAPILLOMATA
 102.2   Other early skin lesions                                              EARLY SKIN YAWS NEC
 102.3   Yaws hyperkeratosis                                                   HYPERKERATOSIS OF YAWS
                                                                               GUMMATA AND ULCERS,
 102.4   Yaws gummata an ulcers                                                YAWS
 102.5   Yaws gangosa                                                          GANGOSA
 102.6   Yaws bone and joint lesions                                           YAWS OF BONE & JOINT
                                                                               YAWS MANIFESTATIONS
 102.7   Yaws other manifestations                                             NEC
 102.8   Latent yaws                                                           LATENT YAWS
 102.9   Yaws, unspecified                                                     YAWS NOS
 103.0   Pinta primary lesions                                                 PINTA PRIMARY LESIONS
 103.1   Pinta intermediate lesions                                            PINTA INTERMED LESIONS
 103.2   Pinta late lesions                                                    PINTA LATE LESIONS
 103.3   Pinta mixed lesions                                                   PINTA MIXED LESIONS
 103.9   Pinta, unspecified                                                    PINTA NOS
                                                                               NONVENEREAL ENDEMIC
 104.0   Nonvenereal endemic syphilis                                          SYPH
 104.8   Other specified spirochetal infections                                SPIROCHETAL INFECT NEC
 104.9   Spirochetal infection, unspecified                                    SPIROCHETAL INFECT NOS
 130.0   Meningoencephalitis due to toxoplasmosis                              TOXOPLASM

  Medicaid Inpatient Quality Incentive Guidelines SFY2011                                    A- 34
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

                                                                                 MENINGOENCEPH
                                                                                 TOXOPLASMA
 130.4   Pneumonitis due to toxoplasmosis                                        PNEUMONITIS
 130.5   Hepatitis due to toxoplasmosis                                          TOXOPLASMA HEPATITIS
 130.7   Toxoplasmosis of other specified sites                                  TOXOPLASMOSIS SITE NEC
                                                                                 MULTISYSTEM
 130.8   Multisystemic disseminated toxoplasmosis                                TOXOPLASMOS
                                                                                 UROGENITAL TRICHOMON
131.00   Urogenital trichomoniasis, unspecified                                  NOS
131.01   Trichomonal vulvovaginitis                                              TRICHOMONAL VAGINITIS
131.02   Trichomonal urethritis                                                  TRICHOMONAL URETHRITIS
                                                                                 TRICHOMONAL
131.03   Trichomonal prostatitis                                                 PROSTATITIS
                                                                                 UROGENITAL TRICHOMON
131.09   Other urogenital trichomoniasis, unspecified                            NEC
 131.8   Trichomoniasis other specified sites                                    TRICHOMONIASIS NEC
 131.9   Trichomoniasis, unspecified                                             TRICHOMONIASIS NOS
 320.0   Hemophilus meningitis                                                   HEMOPHILUS MENINGITIS
                                                                                 PNEUMOCOCCAL
 320.1   Pneumococcal meningitis                                                 MENINGITIS
                                                                                 STREPTOCOCCAL
 320.2   Streptococcal meningitis                                                MENINGITIS
                                                                                 STAPHYLOCOCC
 320.3   Staphylococcal meningitis                                               MENINGITIS
 320.7   Meningitis in other bacterial diseases classified elsewhere             MENING IN OTH BACT DIS
320.81   Anaerobic meningitis                                                    ANAEROBIC MENINGITIS
                                                                                 MNINGTS GRAM-NEG BCT
320.82   Meningitis due to gram-negative bacteria, not elsewhere classified      NEC
                                                                                 MENINGITIS OTH SPCF
320.89   Meningitis due to other specified bacteria                              BACT
                                                                                 BACTERIAL MENINGITIS
 320.9   Meningitis due to unspecified bacterium                                 NOS
 322.9   Meningitis, unspecified                                                 MENINGITIS NOS
         Encephalitis, myelitis, and encephalomyelitis in rickettsial diseases   RICKETTSIAL
 323.1   classified elsewhere                                                    ENCEPHALITIS
 324.0   Intracranial abscess                                                    INTRACRANIAL ABSCESS
 324.1   Intraspinal abscess                                                     INTRASPINAL ABSCESS
 324.9   Abscess of unspecified site                                             CNS ABSCESS NOS
380.10   Infective otitis externa, unspecified                                   INFEC OTITIS EXTERNA NOS
                                                                                 ACUTE INFECTION OF
380.11   Acute infection of pinna                                                PINNA
380.12   Acute swimmer’s ear                                                     ACUTE SWIMMERS' EAR
                                                                                 AC INFECT EXTERN EAR
380.13   Other acute infections of external ear                                  NEC
                                                                                 MALIGNANT OTITIS
380.14   Malignant otitis externa                                                EXTERNA
                                                                                 CHR MYCOT OTITIS
380.15   Chronic mycotic otitis externa                                          EXTERNA
                                                                                 CHR INF OTIT EXTERNA
380.16   Other chronic infective otitis externa                                  NEC
                                                                                 CHOLESTEATOMA EXTERN
380.21   Cholesteatoma of external ear                                           EAR
                                                                                 ACUTE OTITIS EXTERNA
380.22   Other otitis externa                                                    NEC

  Medicaid Inpatient Quality Incentive Guidelines SFY2011                                        A- 35
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

380.23   Other chronic otitis externa                                        CHR OTITIS EXTERNA NEC
         Acute suppurative otitis media without spontaneous rupture of ear
382.00   drum                                                                AC SUPP OTITIS MEDIA NOS
         Acute suppurative otitis media with spontaneous rupture of ear
382.01   drum                                                                AC SUPP OM W DRUM RUPT
382.02   Acute suppurative otitis media in diseases classified elsewhere     AC SUPP OM IN OTH DIS
                                                                             CHR TUBOTYMPAN SUPPUR
 382.1   Chronic tubotympanic suppurative otitis media                       OM
                                                                             CHR ATTICOANTRAL SUP
 382.2   Chronic atticoantral suppurative otitis media                       OM
                                                                             AC/SUBAC BACT
 421.0   Acute and subacute bacterial endocarditis                           ENDOCARD
         Acute and subacute infective endocarditis in diseases classified    AC ENDOCARDIT IN OTH
 421.1   elsewhere                                                           DIS
                                                                             AC/SUBAC ENDOCARDIT
 421.9   Acute endocarditis, unspecified                                     NOS
 422.0   Acute myocarditis in diseases classified elsewhere                  AC MYOCARDIT IN OTH DIS
422.90   Acute myocarditis, unspecified                                      ACUTE MYOCARDITIS NOS
422.91   Idiopathic myocarditis                                              IDIOPATHIC MYOCARDITIS
422.92   Septic myocarditis                                                  SEPTIC MYOCARDITIS
422.93   Toxic myocarditis                                                   TOXIC MYOCARDITIS
422.99   Other acute myocarditis                                             ACUTE MYOCARDITIS NEC
  462    Acute pharyngitis                                                   ACUTE PHARYNGITIS
  463    Acute tonsillitis                                                   ACUTE TONSILLITIS
464.00   Acute laryngitis without mention of obstruction                     AC LARYNGITIS W/O OBST
                                                                             AC LARYNGITIS W
464.01   Acute laryngitis with obstruction                                   OBSTRUCT
                                                                             AC TRACHEITIS NO
464.10   Acute tracheitis without mention of obstruction                     OBSTRUC
                                                                             AC TRACHEITIS W
464.11   Acute tracheitis with obstruction                                   OBSTRUCT
                                                                             AC LARYNGOTRACH NO
464.20   Acute laryngotracheitis without mention of obstruction              OBSTR
                                                                             AC LARYNGOTRACH W
464.21   Acute laryngotracheitis with obstruction                            OBSTR
464.30   Acute epiglottitis without mention of obstruction                   AC EPIGLOTTITIS NO OBSTR
464.31   Acute epiglottitis with obstruction                                 AC EPIGLOTTITIS W OBSTR
                                                                             SUPRAGLOTTIS W/O OBS
464.50   Supraglottitis unspecified without mention of obstruction           NOS
                                                                             SUPRAGLOTTIS W OBSTR
464.51   Supraglottitis unspecified with obstruction                         NOS
  475    Peritonsillar abscess                                               PERITONSILLAR ABSCESS
 476.0   Chronic laryngitis                                                  CHRONIC LARYNGITIS
 476.1   Chronic laryngotracheitis                                           CHR LARYNGOTRACHEITIS
                                                                             PNEUMOCOCCAL
  481    Pneumococcal pneumonia                                              PNEUMONIA
                                                                             K. PNEUMONIAE
 482.0   Pneumonia due to Klebsiella pneumoniae                              PNEUMONIA
                                                                             PSEUDOMONAL
 482.1   Pneumonia due to Pseudomonas                                        PNEUMONIA
 482.2   Pneumonia due to Hemophilus influenzae                              H.INFLUENZAE PNEUMONIA
                                                                             STREPTOCOCCAL PNEUMN
482.30   Pneumonia due to Streptococcus, unspecified                         NOS
482.31   Pneumonia due to Streptococcus Group A                              PNEUMONIA

  Medicaid Inpatient Quality Incentive Guidelines SFY2011                                    A- 36
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

                                                                          STRPTOCOCCUS A
                                                                          PNEUMONIA
482.32   Pneumonia due to Streptococcus Group B                           STRPTOCOCCUS B
482.39   Pneumonia due to other Streptococcus                             PNEUMONIA OTH STREP
                                                                          STAPHYLOCOCCAL PNEU
482.40   Pneumonia due to Staphylococcus unspecified                      NOS
                                                                          METH SUS PNEUM D/T
482.41   Methicillin susceptible pneumonia due to Staphylococcus aureus   STAPH
482.42   Methicillin resistant pneumonia due to Staphylococcus aureus     METH RES PNEU D/T STAPH
482.49   Other Staphylococcus pneumonia                                   STAPH PNEUMONIA NEC
482.81   Pneumonia due to anaerobes                                       PNEUMONIA ANAEROBES
482.82   Pneumonia due to Escherichia coli                                PNEUMONIA E COLI
                                                                          PNEUMO OTH GRM-NEG
482.83   Pneumonia due to other gram-negative bacteria                    BACT
482.84   Legionnaires’ disease                                            LEGIONNAIRES' DISEASE
                                                                          PNEUMONIA OTH SPCF
482.89   Pneumonia due to other specified bacteria                        BACT
                                                                          BACTERIAL PNEUMONIA
 482.9   Bacterial pneumonia unspecified                                  NOS
                                                                          PNEU MYCPLSM
 483.0   Mycoplasma pneumonia                                             PNEUMONIAE
                                                                          PNEUMONIA D/T
 483.1   Pneumonia due to Chlamydia                                       CHLAMYDIA
                                                                          PNEUMON OTH SPEC
 483.8   Pneumonia due to other specified organism                        ORGNSM
                                                                          PNEUM W CYTOMEG INCL
 484.1   Pneumonia in cytomegalic inclusion disease                       DIS
                                                                          PNEUMONIA IN WHOOP
 484.3   Pneumonia in whooping cough                                      COUGH
 484.5   Pneumonia in anthrax                                             PNEUMONIA IN ANTHRAX
 484.6   Pneumonia in aspergillosis                                       PNEUM IN ASPERGILLOSIS
                                                                          PNEUM IN OTH SYS
 484.7   Pneumonia in other systemic mycoses                              MYCOSES
 484.8   Pneumonia in other infectious diseases classified elsewhere      PNEUM IN INFECT DIS NEC
                                                                          BRONCHOPNEUMONIA ORG
  485    Bronchopneumonia, organism unspecified                           NOS
                                                                          PNEUMONIA, ORGANISM
  486    Pneumonia, organism unspecified                                  NOS
                                                                          INFLUENZA WITH
 487.0   Influenza with pneumonia                                         PNEUMONIA
 487.1   Influenza with other respiratory manifestations                  FLU W RESP MANIFEST NEC
                                                                          FLU W MANIFESTATION
 487.8   Influenza with other manifestations                              NEC
  490    Bronchitis, not specified as acute or chronic                    BRONCHITIS NOS
 491.0   Simple chronic bronchitis                                        SIMPLE CHR BRONCHITIS
                                                                          MUCOPURUL CHR
 491.1   Mucopurulent chronic bronchitis                                  BRONCHITIS
         Obstructive chronic bronchitis without mention of acute          OBST CHR BRONC W/O
491.20   exacerbation                                                     EXAC
                                                                          OBS CHR BRONC W(AC)
491.21   Obstructive chronic bronchitis with acute exacerbation           EXAC
                                                                          OBS CHR BRONC W AC
491.22   Obstructive chronic bronchitis with acute bronchitis             BRONC
 491.8   Other chronic bronchitis                                         CHRONIC BRONCHITIS NEC


  Medicaid Inpatient Quality Incentive Guidelines SFY2011                                A- 37
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

 491.9   Unspecified chronic bronchitis                                      CHRONIC BRONCHITIS NOS
 510.0   Empyema with fistula                                                EMPYEMA WITH FISTULA
 510.9   Empyema without mention of fistula                                  EMPYEMA W/O FISTULA
 513.0   Abscess of lung                                                     ABSCESS OF LUNG
 513.1   Abscess of mediastinum                                              ABSCESS OF MEDIASTINUM
 540.0   Acute appendicitis with generalized peritonitis                     AC APPEND W PERITONITIS
 540.1   Acute appendicitis with peritoneal abscess                          ABSCESS OF APPENDIX
 540.9   Acute appendicitis without mention of peritonitis                   ACUTE APPENDICITIS NOS
  541    Appendicitis, unqualified                                           APPENDICITIS NOS
  542    Other appendicitis                                                  OTHER APPENDICITIS
                                                                             DVRTCLI SML INT W/O
562.01   Diverticulitis of small intestine (without mention of hemorrhage)   HMRG
                                                                             DVRTCLI COLON W/O
562.11   Diverticulitis of colon (without mention of hemorrhage)             HMRHG
562.13   Diverticulitis of colon with hemorrhage                             DVRTCLI COLON W HMRHG
  566    Abscess of anal and rectal regions                                  ANAL & RECTAL ABSCESS
567.21   Peritonitis (acute) generalized                                     PERITONITIS (ACUTE) GEN
567.22   Peritoneal abscess                                                  PERITONEAL ABSCESS
                                                                             SPONTAN BACT
567.23   Spontaneous bacterial peritonitis                                   PERITONITIS
                                                                             SUPPURAT PERITONITIS
567.29   Other suppurative peritonitis                                       NEC
567.31   Psoas muscle abscess                                                PSOAS MUSCLE ABSCESS
                                                                             RETROPERITON ABSCESS
567.38   Other retroperitoneal abscess                                       NEC
567.39   Other retroperitoneal infections                                    RETROPERITON INFECT NEC
567.81   Choleperitonitis                                                    CHOLEPERITONITIS
567.82   Sclerosing mesenteritis                                             SCLEROSING MESENTERITIS
567.89   Other specified peritonitis                                         PERITONITIS NEC
 567.9   Peritonitis                                                         PERITONITIS NOS
 569.5   Abscess of intestine                                                INTESTINAL ABSCESS
                                                                             COLOSTY/ENTEROST
569.61   Colostomy/enterostomy infection                                     INFECTN
 575.0   Acute cholecystitis                                                 ACUTE CHOLECYSTITIS
590.00   Chronic pyelonephritis without lesion of renal medullary necrosis   CHR PYELONEPHRITIS NOS
                                                                             CHR PYELONEPH W MED
590.01   Chronic pyelonephritis with lesion of renal medullary necrosis      NECR
590.10   Acute pyelonephritis without lesion of renal medullary necrosis     AC PYELONEPHRITIS NOS
                                                                             AC PYELONEPHR W MED
590.11   Acute pyelonephritis with lesion of renal medullary necrosis        NECR
                                                                             RENAL/PERIRENAL
 590.2   Renal and perinephric abscess                                       ABSCESS
 590.3   Pyeloureteritis cystica                                             PYELOURETERITIS CYSTICA
590.80   Pyelonephritis, unspecified                                         PYELONEPHRITIS NOS
590.81   Pyelitis or pyelonephritis in diseases classified elsewhere         PYELONEPHRIT IN OTH DIS
 590.9   Infection of kidney, unspecified                                    INFECTION OF KIDNEY NOS
 595.0   Acute cystitis                                                      ACUTE CYSTITIS
                                                                             URIN TRACT INFECTION
 599.0   Urinary Tract Infection, NOS                                        NOS
 601.0   Acute prostatitis                                                   ACUTE PROSTATITIS
 601.1   Chronic prostatitis                                                 CHRONIC PROSTATITIS
 601.2   Abscess of prostate                                                 ABSCESS OF PROSTATE
 601.3   Prostatocystitis                                                    PROSTATOCYSTITIS


  Medicaid Inpatient Quality Incentive Guidelines SFY2011                                   A- 38
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

 601.4   Prostatitis in diseases classified elsewhere                           PROSTATITIS IN OTH DIS
                                                                                PROSTATIC INFLAM DIS
 601.8   Other specified inflammatory diseases of prostate                      NEC
 601.9   Prostatitis, unspecified                                               PROSTATITIS NOS
 614.0   Acute salpingitis and oophoritis                                       AC SALPINGO-OOPHORITIS
 614.1   Chronic salpingitis and oophoritis                                     CHR SALPINGO-OOPHORITIS
         Salpingitis and oophoritis not specified as acute, subacute, or
 614.2   chronic                                                                SALPINGO-OOPHORITIS NOS
 614.3   Acute parametritis and pelvic cellulitis                               ACUTE PARAMETRITIS
 614.4   Chronic or unspecified parametritis and pelvic cellulitis              CHRONIC PARAMETRITIS
 614.5   Acute or unspecified pelvic peritonitis female                         AC PELV PERITONITIS-FEM
                                                                                CHR PELV PERITON NEC-
 614.7   Other chronic pelvic peritonitis, female                               FEM
 616.2   Cyst of Bartholin’s gland                                              BARTHOLIN'S GLAND CYST
                                                                                BARTHOLIN'S GLND
 616.3   Abscess of Bartholin’s gland                                           ABSCESS
 616.4   Other abscess of vulva                                                 ABSCESS OF VULVA NEC
         Genital tract and pelvic infections following abortion and ectopic
 639.0   and molar pregnancies                                                  POSTABORTION GU INFECT
                                                                                GU INFECT IN PREG-
646.60   Infections of genitourinary tract in pregnancy-unspecified             UNSPEC
646.61   Infections of genitourinary tract in pregnancy-delivered               GU INFECTION-DELIVERED
         Infections of genitourinary tract in pregnancy-delivered with
646.62   postpartum complication                                                GU INFECTION-DELIV W P/P
                                                                                GU INFECTION-
646.63   Infections of genitourinary tract in pregnancy-antepartum              ANTEPARTUM
                                                                                GU INFECTION-
646.64   Infections of genitourinary tract in pregnancy-postpartum              POSTPARTUM
         Major puerperal infection, unspecified, unspecified as to episode of
670.00   care or not applicable                                                 MAJ PUERP INF NOS-UNSP
         Major puerperal infection, unspecified, delivered, with mention of
670.02   postpartum complication                                                MAJ PUER INF NOS-DEL P/P
         Major puerperal infection, unspecified, postpartum condition or
670.04   complication                                                           MAJOR PUERP INF NOS-P/P
                                                                                OB SURG COMPL NEC-
674.30   Other complications of obstetrical surgical wounds-unspecified         UNSPEC
         Other complications of obstetrical surgical wounds-delivered with
674.32   postpartum complication                                                OB SURG COMPL-DEL W P/P
                                                                                OB SURG COMP NEC-
674.34   Other complications of obstetrical surgical wounds-postpartum          POSTPAR
 680.0   Carbuncle and furuncle of face                                         CARBUNCLE OF FACE
 680.1   Carbuncle and furuncle of neck                                         CARBUNCLE OF NECK
 680.2   Carbuncle and furuncle of trunk                                        CARBUNCLE OF TRUNK
 680.3   Carbuncle and furuncle of upper arm and forearm                        CARBUNCLE OF ARM
 680.4   Carbuncle and furuncle of hand                                         CARBUNCLE OF HAND
 680.5   Carbuncle and furuncle of buttock                                      CARBUNCLE OF BUTTOCK
 680.6   Carbuncle and furuncle of leg, except foot                             CARBUNCLE OF LEG
 680.7   Carbuncle and furuncle of foot                                         CARBUNCLE OF FOOT
 680.8   Carbuncle and furuncle of other specified sites                        CARBUNCLE, SITE NEC
 680.9   Carbuncle and furuncle of unspecified sites                            CARBUNCLE NOS
681.00   Cellulitis and abscess of finger, unspecified                          CELLULITIS, FINGER NOS
681.01   Felon                                                                  FELON
681.02   Onychia and paronychia of finger                                       ONYCHIA OF FINGER
681.10   Cellulitis and abscess, unspecified of toe                             CELLULITIS, TOE NOS

  Medicaid Inpatient Quality Incentive Guidelines SFY2011                                       A- 39
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

681.11   Onychia and paronychia of toe                                      ONYCHIA OF TOE
 681.9   Cellulitis and abscess of unspecified digit                        CELLULITIS OF DIGIT NOS
 682.0   Cellulitis and abscess of face                                     CELLULITIS OF FACE
 682.1   Cellulitis and abscess of neck                                     CELLULITIS OF NECK
 682.2   Cellulitis and abscess of trunk                                    CELLULITIS OF TRUNK
 682.3   Cellulitis and abscess of upper arm and forearm                    CELLULITIS OF ARM
 682.4   Cellulitis and abscess of hand, except fingers and thumb           CELLULITIS OF HAND
 682.5   Cellulitis and abscess of buttock                                  CELLULITIS OF BUTTOCK
 682.6   Cellulitis and abscess of leg, except foot                         CELLULITIS OF LEG
 682.7   Cellulitis and abscess of foot, except toes                        CELLULITIS OF FOOT
 682.8   Cellulitis and abscess of other specified sites                    CELLULITIS, SITE NEC
 682.9   Cellulitis and abscess of unspecified sites                        CELLULITIS NOS
  683    Acute lymphadenitis                                                ACUTE LYMPHADENITIS
  684    Impetigo                                                           IMPETIGO
                                                                            PILONIDAL CYST W
 685.0   Pilonidal cyst with abscess                                        ABSCESS
 685.1   Pilonidal cyst without mention of abscess                          PILONIDAL CYST W/O ABSC
686.00   Pyoderma, unspecified                                              PYODERMA NOS
                                                                            PYODERMA
686.01   Pyoderma gangrenosum                                               GANGRENOSUM
686.09   Other pyoderma                                                     PYODERMA NEC
 686.1   Pyogenic granuloma                                                 PYOGENIC GRANULOMA
                                                                            LOCAL SKIN INFECTION
 686.8   Other specified local infections of skin and subcutaneous tissue   NEC
                                                                            LOCAL SKIN INFECTION
 686.9   Unspecified local infection of skin and subcutaneous tissue        NOS
711.90   Unspecified infective arthritis, site unspecified                  INF ARTHRITIS NOS-UNSPEC
711.91   Unspecified infective arthritis, shoulder region                   INF ARTHRITIS NOS-SHLDER
711.92   Unspecified infective arthritis, upper arm                         INF ARTHRITIS NOS-UP/ARM
                                                                            INF ARTHRIT NOS-
711.93   Unspecified infective arthritis, forearm                           FOREARM
711.94   Unspecified infective arthritis, hand                              INF ARTHRIT NOS-HAND
711.95   Unspecified infective arthritis, pelvic region and thigh           INF ARTHRIT NOS-PELVIS
711.96   Unspecified infective arthritis, lower leg                         INF ARTHRIT NOS-L/LEG
711.97   Unspecified infective arthritis, ankle and foot                    INF ARTHRIT NOS-ANKLE
711.98   Unspecified infective arthritis, other specified sites             INF ARTHRIT NOS-OTH SITE
711.99   Unspecified infective arthritis, multiple sites                    INF ARTHRITIS NOS-MULT
                                                                            AC OSTEOMYELITIS-
730.00   Acute osteomyelitis, site unspecified                              UNSPEC
                                                                            AC OSTEOMYELITIS-
730.01   Acute osteomyelitis, shoulder region                               SHLDER
                                                                            AC OSTEOMYELITIS-
730.02   Acute osteomyelitis, upper arm                                     UP/ARM
                                                                            AC OSTEOMYELITIS-
730.03   Acute osteomyelitis, forearm                                       FOREARM
730.04   Acute osteomyelitis, hand                                          AC OSTEOMYELITIS-HAND
730.05   Acute osteomyelitis, pelvic region and thigh                       AC OSTEOMYELITIS-PELVIS
730.06   Acute osteomyelitis, lower leg                                     AC OSTEOMYELITIS-L/LEG
730.07   Acute osteomyelitis, ankle and foot                                AC OSTEOMYELITIS-ANKLE
730.08   Acute osteomyelitis, other specified sites                         AC OSTEOMYELITIS NEC
730.09   Acute osteomyelitis, multiple sites                                AC OSTEOMYELITIS-MULT
730.10   Chronic osteomyelitis, site unspecified                            CHR OSTEOMYELITIS-UNSP
730.11   Chronic osteomyelitis, shoulder region                             CHR OSTEOMYELIT-SHLDER


  Medicaid Inpatient Quality Incentive Guidelines SFY2011                                   A- 40
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

730.12   Chronic osteomyelitis, upper arm                                        CHR OSTEOMYELIT-UP/ARM
                                                                                 CHR OSTEOMYELIT-
730.13   Chronic osteomyelitis, forearm                                          FOREARM
730.14   Chronic osteomyelitis, hand                                             CHR OSTEOMYELIT-HAND
730.15   Chronic osteomyelitis, pelvic region and thigh                          CHR OSTEOMYELIT-PELVIS
730.16   Chronic osteomyelitis, lower leg                                        CHR OSTEOMYELIT-L/LEG
730.17   Chronic osteomyelitis, ankle and foot                                   CHR OSTEOMYELIT-ANKLE
730.18   Chronic osteomyelitis, other specified sites                            CHR OSTEOMYELIT NEC
730.19   Chronic osteomyelitis, multiple sites                                   CHR OSTEOMYELIT-MULT
                                                                                 OSTEOMYELITIS NOS-
730.20   Unspecified osteomyelitis, site unspecified                             UNSPEC
                                                                                 OSTEOMYELITIS NOS-
730.21   Unspecified osteomyelitis, shoulder region                              SHLDER
                                                                                 OSTEOMYELITIS NOS-
730.22   Unspecified osteomyelitis, upper arm                                    UP/ARM
                                                                                 OSTEOMYELIT NOS-
730.23   Unspecified osteomyelitis, forearm                                      FOREARM
730.24   Unspecified osteomyelitis, hand                                         OSTEOMYELITIS NOS-HAND
                                                                                 OSTEOMYELITIS NOS-
730.25   Unspecified osteomyelitis, pelvic region and thigh                      PELVIS
730.26   Unspecified osteomyelitis, lower leg                                    OSTEOMYELITIS NOS-L/LEG
                                                                                 OSTEOMYELITIS NOS-
730.27   Unspecified osteomyelitis, ankle and foot                               ANKLE
                                                                                 OSTEOMYELIT NOS-OTH
730.28   Unspecified osteomyelitis, other specified sites                        SITE
730.29   Unspecified osteomyelitis, multiple sites                               OSTEOMYELITIS NOS-MULT
730.30   Periositis without mention of osteomyelitis, site unspecified           PERIOSTITIS-UNSPEC
730.31   Periositis without mention of osteomyelitis, shoulder region            PERIOSTITIS-SHLDER
730.32   Periositis without mention of osteomyelitis, upper arm                  PERIOSTITIS-UP/ARM
730.33   Periositis without mention of osteomyelitis, forearm                    PERIOSTITIS-FOREARM
730.34   Periositis without mention of osteomyelitis, hand                       PERIOSTITIS-HAND
730.35   Periositis without mention of osteomyelitis, pelvic region and thigh    PERIOSTITIS-PELVIS
                                                                                 POLIO OSTEOPATHY-
730.70   Osteopathy resulting from poliomyelitis, site unspecified               UNSPEC
                                                                                 POLIO OSTEOPATHY-
730.71   Osteopathy resulting from poliomyelitis, shoulder region                SHLDER
                                                                                 POLIO OSTEOPATHY-
730.72   Osteopathy resulting from poliomyelitis, upper arm                      UP/ARM
                                                                                 POLIO OSTEOPATHY-
730.73   Osteopathy resulting from poliomyelitis, forearm                        FOREARM
730.74   Osteopathy resulting from poliomyelitis, hand                           POLIO OSTEOPATHY-HAND
730.75   Osteopathy resulting from poliomyelitis, pelvic region and thigh        POLIO OSTEOPATHY-PELVIS
730.76   Osteopathy resulting from poliomyelitis, lower leg                      POLIO OSTEOPATHY-L/LEG
730.77   Osteopathy resulting from poliomyelitis, ankle and foot                 POLIO OSTEOPATHY-ANKLE
730.78   Osteopathy resulting from poliomyelitis, other specified sites          POLIO OSTEOPATHY NEC
730.79   Osteopathy resulting from poliomyelitis, multiple sites                 POLIO OSTEOPATHY-MULT
         Other infections involving bone in disease classified elsewhere, site
730.80   unspecified                                                             BONE INFECT NEC-UNSPEC
         Other infections involving bone in disease classified elsewhere,
730.81   shoulder region                                                         BONE INFECT NEC-SHLDER
         Other infections involving bone in disease classified elsewhere,
730.82   upper arm                                                               BONE INFECT NEC-UP/ARM
         Other infections involving bone in disease classified elsewhere,        BONE INFECT NEC-
730.83   forearm                                                                 FOREARM

  Medicaid Inpatient Quality Incentive Guidelines SFY2011                                       A- 41
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
  Appendices

         Other infections involving bone in disease classified elsewhere,
730.84   hand                                                                   BONE INFECT NEC-HAND
         Other infections involving bone in disease classified elsewhere,
730.85   pelvic region and thigh                                                BONE INFECT NEC-PELVIS
         Other infections involving bone in disease classified elsewhere,
730.86   lower leg                                                              BONE INFECT NEC-L/LEG
         Other infections involving bone in disease classified elsewhere,
730.87   ankle and foot                                                         BONE INFECT NEC-ANKLE
         Other infections involving bone in disease classified elsewhere,
730.88   other specified sites                                                  BONE INFECT NEC-OTH SITE
         Other infections involving bone in disease classified elsewhere,
730.89   multiple sites                                                         BONE INFECT NEC-MULT
730.90   Unspecified infection of bone, site unspecified                        BONE INFEC NOS-UNSP SITE
730.91   Unspecified infection of bone, shoulder region                         BONE INFECT NOS-SHLDER
730.92   Unspecified infection of bone, upper arm                               BONE INFECT NOS-UP/ARM
                                                                                BONE INFECT NOS-
730.93   Unspecified infection of bone, forearm                                 FOREARM
730.94   Unspecified infection of bone, hand                                    BONE INFECT NOS-HAND
730.95   Unspecified infection of bone, pelvic region and thigh                 BONE INFECT NOS-PELVIS
730.96   Unspecified infection of bone, lower leg                               BONE INFECT NOS-L/LEG
730.97   Unspecified infection of bone, ankle and foot                          BONE INFECT NOS-ANKLE
730.98   Unspecified infection of bone, other specified sites                   BONE INFECT NOS-OTH SITE
730.99   Unspecified infection of bone, multiple sites                          BONE INFECT NOS-MULT
785.52   Septic shock                                                           SEPTIC SHOCK
 790.7   Bacteremia                                                             BACTEREMIA
         Infection and inflammatory reaction due to internal prosthetic
         device, implant, and graft, due to unspecified device, implant, and    REACTION-UNSP
996.60   graft                                                                  DEVIC/GRFT
         Infection and inflammatory reaction due to cardiac device, implant,    REACT-CARDIAC
996.61   and graft                                                              DEV/GRAFT
         Infection and inflammatory reaction due to other vascular device,      REACT-OTH VASC
996.62   implant, and graft                                                     DEV/GRAFT
         Infection and inflammatory reaction due to nervous system device,      REACT-NERV SYS
996.63   implant, and graft                                                     DEV/GRAFT
         Infection and inflammatory reaction due to indwelling urinary          REACT-INDWELL URIN
996.64   catheter                                                               CATH
         Infection and inflammatory reaction due to genitourinary device,       REACT-OTH GENITOURIN
996.65   implant, and graft                                                     DEV
996.66   Infection and inflammatory reaction due to internal joint prosthesis   REACT-INTER JOINT PROST
         Infection and inflammatory reaction due to other internal orthopedic
996.67   device, implant, and graft                                             REACT-OTH INT ORTHO DEV
         Infection and inflammatory reaction due to peritoneal dialysis         REACT- PERITON DIALY
996.68   catheter                                                               CATH
         Infection and inflammatory reaction due to other internal prosthetic
996.69   device, implant, and graft                                             REACT-INT PROS DEVIC NEC
                                                                                VENTLTR ASSOC
997.31   Ventilator associated pneumonia                                        PNEUMONIA
998.51   Infected postoperative seroma                                          INFECTED POSTOP SEROMA
998.59   Other postoperative infection                                          OTHER POSTOP INFECTION




  Medicaid Inpatient Quality Incentive Guidelines SFY2011                                       A- 42
  Discharges July 1, 2010 (3Q2010), through December 31, 2010 (4Q2010)
Appendices



                 B. Appendix B: Suggested Antibiotic List

Cefotetan, Cefazolin, Cefoxitin, Cefuroxime, or Ampicillin/Sulbactam

If Beta-Lactam allergy:
 Clindamycin + Aminoglycoside
 Clindamycin + Quinolone
 Clindamycin + Aztreonam
OR
Metronidazole + Aminoglycoside
Metronidazole + Quinolone




Medicaid Inpatient Quality Incentive Guidelines SFY2011                B-1
Discharges 10/01/09 (4Q2009) through 03/31/10 (1Q2010)
4 References

  National Quality Forum (NQF), National Voluntary Consensus Standards for Perinatal
  Care: A Consensus Report, Washington, DC: NQF; 2008

  American Medical Association, Care Transitions Performance Measurement Set, The
  Physician Consortium for Performance Improvement (PCPI), Approved June 2009.

  American College of Obstetrics and Gynecology, ACOG Practice Bulletin No. 84:
  prevention of deep vein thrombosis and pulmonary embolism, Obstet Gynecol, 2007;
  110(2 Pt 1): 429-440.

  American College of Obstetrics and Gynecology, ACOG Practice Bulletin No. 47:
  prophylactic antibiotics in labor and delivery, Obstet Gynecol, 2003; 102(4): 875-882.

  Dellinger EP, Gross PA, Barrett TL, et all, Quality standard for antimicrobial prophylaxis
  in surgical procedures, Clin Infect Disease, 1994; 18(3): 422-427.

  Geerts WH, Pineo GF, Heit JA, et al., Prevention of venous thromboembolism. The
  Seventh ACCP Conference on Antithrombotic Therapy, Chest, 2004, 126(3 Suppl):
  338S-400S.

  Laptook AR, Salhab W, Bhaskar B, Neonatal Research Network, Admission temperature
  of low birth weight infants: predictors and associated morbidities, Pediatrics, 2007;
  119(3): 3643-e649.

  American Journal of Obstetrics and Gynecology, Administration of cefazolin prior to
  skin incision is superior to cefazolin at cord clamping in preventing post cesarean
  infectious morbidity: a randomized, controlled trial, May 2007, p455.e1-455.e5.

  American College of Obstetrics and Gynecology, Guidelines for Perinatal Care sixth
  edition, 2007, p202.

  Specifications Manual for National Hospital Inpatient Quality Measures, Discharges 10-
  01-09 through 03-31-10, v3.0b.

  Specifications Manual for Hospital Outpatient Department Quality Measures, Encounter
  dates 07-01-09 through 12-31-09, v2.1b.

  Specifications Manual for Joint Commission National Quality Core Measures,
  Discharges 04-01-10 through 09-30-10.




  Medicaid Inpatient Quality Incentive Guidelines SFY2011                      Reference- 1
  Discharges July 1, 2010 (3Q2010) through December 31, 2010 (4Q2010)
This maTerial was prepared by The arkansas FoundaTion For medical care inc. (aFmc) under conTracT wiTh The arkansas deparTmenT oF human services, division oF medical services. The conTenTs presenTed do
                   noT necessarily reFlecT arkansas dhs policy. The arkansas deparTmenT oF human services is in compliance wiTh TiTles vi and vii oF The civil righTs acT. mp2-iQi.man3-8/10

                                                                                                                                                                                             revised 11/17/10

				
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