Measure Description
Percentage of patients, regardless of age, who are admitted to an intensive care unit (ICU) for ≥48 hours and who received critical care services who have documentation by managing physician of
- attempted or actual identification of a surrogate decision maker,
- an advance directive, and
- the patient’s preference for cardiopulmonary resuscitation, within 48 hours of ICU admission
Denominator
All patients, regardless of age, who are admitted to an intensive care unit for ≥48 hours and who received critical care services
Denominator Criteria (Eligible Cases):
All patients, regardless of ageANDAdmitted to an intensive care unit for ≥48 hours: 10A58ANDReceived critical care services (CPT): 99291, 99468, 99469, 99471, 99472, 99475, 99476
Numerator
Patients who have documentation by managing physician of
- attempted or actual identification of a surrogate decision maker,
- an advance directive, and
- the patient’s preference for cardiopulmonary resuscitation, within the first 48 hours of ICU admission.
Numerator Note: To meet this measure, the managing physician must either document the required information or confirm that they have reviewed existing documentation of the information. Numerator Quality-Data Coding Options for Reporting Satisfactorily
Performance Met:
10A59 Patient has documentation by managing physician of
- attempted or actual identification of a surrogate decision maker,
- an advance directive, and
- the patient’s preference for cardiopulmonary resuscitation within the first 48 hours of ICU admission
ORDenominator Exception:10A60 Documentation of patient reason(s) for not documenting all three required numerator elements within the first 48 hours of ICU admission (e.g., patient declines, patient unable to participate in discussion, other patient reason(s))ORPerformance Not Met:10A61 Patient does not have documentation by managing physician of
- attempted or actual identification of a surrogate decision maker,
- an advance directive, and
- the patient’s preference for cardiopulmonary resuscitation within the first 48 hours of ICU admission
Numerator Exclusions
None
NQF ID Number
N/A
NQS Domain
Communication and Care Coordination
High Priority Measure
Yes
Includes Telehealth?
No
Inverse Measure
No
Proportional Measure
Yes
Continuous Variable Measure
No
Ratio Measure
No
Number of performance rates to be calculated and submitted
1
Risk-Adjusted Status?
No
Meaningful Measure
Care is Personalized and Aligned with Patient’s Goals
Measure Type
Process
Care Settings
Hospital Inpatient