How to Implement PC-07 eCQM (Severe Obstetric Complications)

I’m sure it will surprise no one to learn that there was a 200% increase in the overall rate of severe maternal morbidity (SMM) between 1993 and 2014. The most recent rate released was 144 complications per 10,000 deliveries and 17.4 deaths per 100,000 live births. These statistics rank the U.S. among the poorest performers among developed nations. Furthermore, the situation is even more dire for Black and Hispanic patients, who face a disproportionately higher risk of SMM.¹ Let’s just sit with those stats for a minute.

Now, what can we do to help? CMS is hoping Quality leaders will lead the charge (like always). PC-07 is an Electronic Clinical Quality Measure (eCQM) that measures how many moms had severe obstetric complications (morbidity and mortality) during an inpatient delivery.

CMS has mandated that all hospitals report PC-07 as a required eCQM under the Inpatient Quality Reporting (IQR) program. Your hospital’s performance on this measure will be publicly reported on Care Compare.

This measure is extremely important, and it’s also complex to implement and get valid results — but that’s why we’re here to help. Below, we’ve walked you through the steps to successfully implement the PC-07 eCQM for your hospital, but don’t forget to check out the full CMS breakdown for the finer details, and don’t hesitate to contact us with further questions. Now, let’s dive in.

What does the PC-07 eCQM measure?

PC-07 measures patients with severe obstetric complications, which occur during inpatient delivery hospitalization. It tracks more than 20 complications that can occur during delivery, and are classified as severe obstetric complications, per the CDC:

PC-07 is also a stratified, risk-adjusted measure. It’s stratified to measure obstetric complications with and without blood transfusion, and risk-adjusted to report individuals with pre-existing conditions that put them at a higher risk of complications during delivery—but more on that later.

One more thing to note, PC-07 is an inverse measure, so you do not want patients in the numerator. In other words, the lower the score, the better.

Who falls under the PC-07 eCQM populations?

Let’s take a deeper look at PC-07’s specification to help you better understand how a patient makes their way into the measure population.

Initial Population

Layman’s description:

The Initial Population (IP) for the PC-07 eCQM is any inpatient encounter with a delivery procedure for patients between the ages of 8 and 64.

Simplified logic:

• Inpatient delivery, hospitalization
• Patient age >=8 and < 65 years

Workflow:

Denominator

Layman’s description:

Your denominator should include any patient in the initial population who delivers a live birth or stillborn* at 20 weeks or later.

Simplified logic:

Gestational Age > 20 weeks*

*Please note: You will not see the live vs stillborn outcome designation in the logic. CMS said their intent is to capture any delivery encounter that is 20 or more weeks gestation, regardless of the outcome. 

Workflow:

Denominator Exclusions

Layman’s description:

The denominator exclusion for PC-07 is any patient who had both a COVID-19 diagnosis AND a COVID-related respiratory diagnosis or a confirmed COVID diagnosis with a COVID-related respiratory procedure. These patients can be excluded from the denominator.

Simplified logic:

COVID Diagnosis and COVID-Related Respiratory Diagnosis

or

COVID Diagnosis and COVID-Related Respiratory Procedure

Workflow:

Numerator

Layman’s description:

PC-07 asks you to track over 20 severe obstetric complications that are NOT “Present on Admission”—any one of these would put an individual into the numerator population. Reference the list above. Your numerator should include encounters with either:

1. A severe obstetric complication, diagnosis or procedure
2. An expired discharge disposition

If your patient’s complication is a pre-existing condition, be sure their “Present on Admission” code equals “Yes” to ensure they aren’t counted in your score.

Simplified Logic:

Encounters with Severe Obstetric Complications, Diagnosis* or Procedure, or with Expired Discharge Disposition, or with Blood Transfusion

*Present on Admission = No or Unknown

Workflow:

Stratification

Layman’s description:

PC-07 is scored as a rate per 10,000 delivery hospitalizations, but CMS will stratify, and risk adjust your performance rate to account for moms who had conditions that put them at a higher risk of these complications.

PC-07 is calculated as two separate rates. Both rates will be risk-adjusted. One will be an unstratified rate and the other is calculated as a stratified rate.

Your stratified rate excludes any encounter in which a blood transfusion was the ONLY complication.

So, if an individual ONLY had a blood transfusion during delivery, then they are counted as a numerator in your unstratified rate, NOT as a numerator in your stratified rate. Remember, this is an inverse measure, so the lower the score the better.

Simplified logic:

Encounters with Severe Obstetric Complications Diagnosis* or Procedure NOT including encounters where transfusion was the only complication

*Present on Admission = No or Unknown

Risk Adjustment

As we mentioned earlier, PC-07 is risk-adjusted to report individuals with pre-existing conditions that put them at a higher risk of complications during delivery. These are provided as a list of almost 30 Present-on-Admission variables (see below) that CMS has flagged for you. To be considered, CMS requires you to track and submit these pre-existing conditions. So, don’t forget to include your risk-adjusted data in your QDRA files when submitting – like we do for our clients.

Other risk variables to include:

• Maternal Age
• Vitals and Labs - report the first resulted value 24 hours prior to start of encounter and before time of delivery in units specified:
• Heart rate: {beats}/min
• Systolic blood pressure: mm[Hg]
• White blood cell count: 10*3/uL
• Hematocrit: %

Workflow:

How is the PC-07 eCQM scored?

Scoring

Equation: (Numerator / (Denominator - Denominator Exclusions) x 10,000

In this measure, you do NOT want patients in your numerator. Those who are in your numerator have either experienced a severe obstetric complication during delivery (excluding a transfusion) or have sadly passed away.

Because you will have included your risk-adjusted data in your submission, CMS will then provide you with a risk-adjusted unstratified rate AND a risk-adjusted stratified rate. These scores will still be measured as a rate per 10,000 delivery hospitalizations.

Tips for Getting Started with the PC-07 eCQM

• Review all recommended best practices from CMS in its PC-07 Clinical Recommendation Statement. Informing your labor and delivery teams about this information can help to ensure better delivery experiences in your hospital.
• From different EHRs across the delivery lifecycle to guaranteeing accurate time and date stamps, the perinatal measures have proven to be somewhat complicated. Luckily, we’ve complied some of the most common pitfalls of PC eCQMs to help you not only be aware of them, but avoid them too.
• Do you need additional support as you work through this measure, or do you just want some peace of mind that there won’t be any last-minute scrambling or fears of missing data? Your Medisolv Clinical Quality Advisor is here for you. Don’t have one yet? Contact us to get connected.

Research from the rationale statement of the PC-07 eCQM found here: https://ecqi.healthit.gov/ecqm/eh/2023/cms1028v1#quicktabs-tab-tabs_measure-1