2017 MIPS Measure #255: Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure

Valid Data Submission Method(s) Measure Type High Priority Measure? NQS Domain Specialty Measure Sets
Claims, Registry Process No Effective Clinical Care Emergency Medicine

Measure Description

Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh- Immunoglobulin (Rhogam) in the emergency department (ED)

Instruction

This measure is to be reported each time a pregnant patient presents to the emergency department with complaints including blunt abdominal trauma, vaginal bleeding, ectopic pregnancy, and threatened or spontaneous abortion.

Registries may utilize claims data to determine the emergency department discharge. Patients who present to the emergency department with these complaints should have documentation in the medical record of receiving an order for Rh-Immunoglobulin (Rhogam). It is anticipated that eligible clinicians who provide care in the emergency department will submit this measure. For registries using claims data, the Part B claim form place of service field must indicate that the encounter has taken place in the emergency department.

Denominator

All pregnant female patients aged 14 to 50 years who are Rh-negative and at significant risk of fetal blood exposure

Denominator Criteria (Eligible Cases):
Female patients aged 14 to 50 years on date of encounter
AND
Diagnosis for Rh-Negative (ICD-10-CM): O36.0110, O36.0111, O36.0190, O36.0191, O36.0910, O36.0911,
O36.0990, O36.0991
AND
Diagnosis of High Risk Pregnancy Complications (ICD-10-CM): O00.8, O00.9, O02.1, O03.1, O03.6, O04.6, O07.1, O08.1, O20.0, O20.8, O20.9, O26.891, O43.011, O43.019, O44.10, O44.11, O45.001, O45.009, O45.011, O45.019, O45.021, O45.029, O45.091, O45.099, O45.8X1, O45.8X9, O45.90, O45.91, O46.001, O46.011, O46.021, O46.8X1, O46.8X9, O46.90, O46.91
AND
Patient encounter during the performance period (CPT): 99281, 99282, 99283, 99284, 99285, 99291
AND
Place of Service Indicator: 23
(The Part B claim form Place of Service field must indicate emergency department)

Numerator

Patients who receive an order for Rh-Immunoglobulin (Rhogam) in the ED

Numerator Instructions: This measure is to be reported each time a patient meets the requirements as indicated in the denominator. In the clinical event a patient has documented receipt of Rhogam report quality-data code G8810.

Numerator Options:
Performance Met: Rh-immunoglobulin (Rhogam) ordered (G8809)
OR
Denominator Exception: Rh-immunoglobulin (Rhogam) not ordered for reasons documented by clinician (e.g., patient had prior documented receipt of Rhogam within 12 weeks, patient refusal) (G8810)
OR
Performance Not Met: Documentation Rh-immunoglobulin (Rhogam) was not ordered, reason not given (G8811)

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