CBE ID
0470
Endorsement Status
1.0 New or Maintenance
1.1 Measure Structure
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Fall 2026
1.6 Measure Description
Percentage of vaginal deliveries (excluding those coded with shoulder dystocia) during which an episiotomy is performed.
Measure Specs
General Information
1.7 Measure Type
1.3 Electronic Clinical Quality Measure (eCQM)
1.8 Level of Analysis
1.20 Types of Data Sources
Numerator
1.14 Numerator
Number of episiotomy procedures (ICD-9 code 72.1, 72.21, 72.31, 72.71, 73.6; ICD-10 PCS:0W8NXZZ performed on women undergoing a vaginal delivery (excluding those with shoulder dystocia ICD-10; O66.0) during the analytic period- monthly,quarterly, yearly etc.
Denominator
1.15 Denominator
All vaginal deliveries during the analytic period- monthly, quarterly, yearly etc. excluding those coded with a shoulder dystocia ICD-10: O66.0).
Exclusions
Exclusions
Women who have a coded complication of shoulder dystocia. In the case of shoulder dystocia, an episiotomy is performed to free the shoulder and prevent/mitigate birth injury to the infant.
Measure Record
Most Recent Endorsement Activity
Endorsed Perinatal and Women's Health Fall Cycle 2020
Initial Endorsement
Last Updated
Point of Contact
Steward Organization
Christiana Care Health System
Steward POC email
mhoffman@christianacare.org
Importance
Equity
Feasibility
Scientific Acceptability
Risk Adjustment
Risk Adjustment
Use & Usability
Use
Planned Use
6.1.2 Current or Planned Use(s)
6.1.3 Current Use(s)
Public Comments