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Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate (PSI 12)

CBE ID
0450
1.4 Project
Patient Safety
Endorsed
Endorsement Status
Endorsement Removed
1.1 New or Maintenance
Maintenance
E&M Cycle
Spring 2020
Is Under Review
No
1.3 Measure Description

Perioperative pulmonary embolism or proximal deep vein thrombosis (secondary diagnosis) per 1,000 surgical discharges for patients ages 18 years and older. Excludes discharges with a principal diagnosis of pulmonary embolism or proximal deep vein thrombosis; with a secondary diagnosis of pulmonary embolism or proximal deep vein thrombosis present on admission; in which interruption of the vena cava or a pulmonary arterial thromboectomy occurs before or on the same day as the first operating room procedure; with extracorporeal membrane oxygenation; with acute brain or spinal injury present on admission; and obstetric cases.

[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 in-hospital deaths per 1,000 hospital discharges.]

    • 1.14 Numerator

      Discharges, among cases meeting the inclusion and exclusion rules for the denominator, with a secondary ICD-10-CM diagnosis code for proximal deep vein thrombosis (DEEPVIB) or a secondary ICD-10-CM diagnosis code for pulmonary embolism (PULMOID).

    • 1.15 Denominator

      Surgical discharges, (Appendix E: SURGI2R) for patients ages 18 years and older, with any-listed ICD-10-PCS procedure codes for an operating room procedure (Appendix A: ORPROC). Surgical discharges are defined by specific MS-DRG codes.

    • Exclusions

      Exclude cases:
      • with a principal ICD-10-CM diagnosis code (or secondary diagnosis present on admission) for proximal deep vein thrombosis (DEEPVIB), among patients otherwise qualifying for the numerator
      • with a principal ICD-10-CM diagnosis code (or secondary diagnosis present on admission) for pulmonary embolism (PULMOID), among patients otherwise qualifying for the numerator
      • where a procedure for interruption of vena cava occurs before or on the same day as the first operating room procedure* (VENACIP)
      • where the only operating room procedure was for interruption of vena cava (VENACIP)
      • with any-listed ICD-10-CM diagnosis code present on admission for acute brain or spinal injury (NEURTRAD)
      • with any-listed ICD-10-PCS procedure code for extracorporeal membrane oxygenation (ECMO) (ECMOP)
      • where a procedure for pulmonary arterial thrombectomy occurs before or on the same day as the first operating room procedure (THROMP)
      • where the only operating room procedure was for pulmonary arterial thrombectomy (THROMP)
      • MDC 14 (pregnancy, childbirth, and puerperium)
      • with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing), or principal diagnosis (DX1=missing)

      * If day of procedure is not available in the input data file, the rate may be slightly lower than if the information was available.

    • Most Recent Endorsement Activity
      Measure Retired and Endorsement Removed Patient Safety Spring Cycle 2020
      Initial Endorsement
      Last Updated
      Removal Date