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Pressure Ulcer Rate (PDI 2)

CBE ID
0337
1.4 Project
Patient Safety
Endorsed
Endorsement Status
Endorsement Removed
1.1 New or Maintenance
Maintenance
E&M Cycle
Fall 2019
Is Under Review
No
1.3 Measure Description

Stage III, IV, or unstageable pressure ulcers (secondary diagnosis) per 1,000 surgical and medical discharges among patients 17 years of age and younger. Discharges are grouped by risk category. Includes metrics for discharges grouped by risk category. Excludes neonates; stays less than three (3) days; obstetric discharges; discharges with diseases of the skin; and discharges with principal diagnosis or secondary diagnosis present on admission for Stage III, IV or unstageable pressure ulcer.

[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report events per 1,000 hospital discharges.]

    • 1.14 Numerator

      Discharges, among cases meeting the inclusion and exclusion rules for the denominator, with any secondary ICD-10-CM diagnosis codes for pressure ulcer stage III or IV (or unstageable) (DECUBVD).
      [Note: The numerator definition is identical for High-Risk and Low-Risk Categories and Overall.]

    • 1.15 Denominator

      Surgical (Appendix C) and medical (Appendix E) discharges, for patients ages 17 years and younger. Surgical and medical discharges are defined by specific MS-DRG codes.
      Denominator High Risk Category: Patients otherwise qualifying for overall denominator with any-listed ICD-10-CM diagnosis codes for hemiplegia, paraplegia, or quadriplegia (HEMIPID) or any-listed ICD-10-CM diagnosis codes for spina bifida (SPINABD) or any-listed ICD-10-CM diagnosis codes for anoxic brain damage (ANOXBD) or any-listed ICD-10-PCS procedure codes for continuous mechanical ventilation (CMVENP).
      Denominator Low Risk Category: Patients otherwise qualifying for overall denominator without any-listed ICD-10-CM diagnosis codes for hemiplegia, paraplegia, or quadriplegia (HEMIPID) or without any-listed ICD-10-CM diagnosis codes for spina bifida (SPINABD) or without any-listed ICD-10-CM diagnosis codes for anoxic brain damage (ANOXBD) or without any-listed ICD-10-PCS procedure codes for continuous mechanical ventilation (CMVENP).

    • Exclusions

      Exclude cases:
      • with a principal ICD-10-CM diagnosis code for pressure ulcer (DECUBVD) among patients otherwise qualifying for numerator
      • with any secondary ICD-10-CM diagnosis codes for pressure ulcer stage III or IV (or unstageable) present on admission (DECUBVD). If more than one pressure ulcer is reported, all pressure ulcers must be present on admission for the record to be excluded.
      • neonates (Appendix I)
      • with length of stay of less than three (3) days
      • with any ICD-10-CM diagnosis code for severe burns (=20% body surface area) (BURNDX) or with any ICD-10-CM diagnosis code for exfoliative disorders of the skin (=20% body surface area) (EXFOLIATXD)
      • with a Major Diagnostic Category for Pregnancy, Childbirth and Puerperium, (MDC 14)
      • with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)

      [NOTE: Exclusions are identical for high and low risk strata.]

    • Most Recent Endorsement Activity
      Measure Retired and Endorsement Removed Patient Safety Fall Cycle 2019
      Initial Endorsement
      Last Updated
      Removal Date