v.12.4 special report: unexpected newborn complications

V.12.4 Special Report: Unexpected Newborn Complications Update

(NQF #716 “Healthy Term Newborn”)

I. Introduction

This special report is based on the work of the California Maternal Quality Care Collaborative

(CQMCC), the measure steward for National Quality Forum (NQF) measure #716: Healthy

Term Newborn.i As the measure steward, CQMCC developed this measure in response to a need

for a composite measure to identify the most important outcome for families having a birth --

taking home a healthy baby. While there are several measures looking at specific clinical

practices and outcomes in preterm infants, there were no other measures for outcomes in term

babies (who represent 90% of all births).

Initially endorsed by NQF in January, 2011 the Healthy Term Newborn measure identified the

percent of babies without preexisting conditions (no premature infants, multiple gestations, birth

defects, or other fetal conditions) and who are normally grown and were not exposed to maternal

drug use, that did NOT have any severe or moderate complications. Feedback to the measure

developers has initiated an update to the measure to reverse the numerator and measure

“Unexpected Newborn Complications”, those newborns without preexisting complications who

do have a severe or moderate morbidity.

The source of the data for this measure is administrative claims data, using a combination of

ICD-9 diagnosis and procedure codes and neonatal length of stay (LOS) to categorize

complications. This measure is a key balance to other NQF endorsed measures that examine

obstetric care in this population such as cesarean section and episiotomy rates. Most families

would value having a low chance of unexpected newborn complications and low to medium rates

of these obstetric procedures.

Denominator: Babies without preexisting conditions are identified using patient discharge data.

The denominator (Flow chart: Figures 1 & 2) is comprised of singleton live born babies who are

at least 37.0 weeks of gestation, ≥ 2500 grams in birth weight (normally grown), do not have any

congenital malformations or fetal conditions, and are not exposed to maternal drug use or to

selected maternal conditions (see Flow Chart and Appendices 1 and 2 for a list of ICD-9 codes

and descriptions). This is a group who are expected to do well and go home routinely with the

mother.

Numerator: The numerator (Flow chart: Figures 3 & 4) is divided into two categories: severe

complications and moderate complications. Severe complications (Appendix 3) include

neonatal death, transfer to another hospital for higher level of care, extremely low Apgar score ≤

3 at either 5 or 10 minutes of life), severe birth injuries such as intracranial hemorrhage or nerve

injury, neurologic damage, severe respiratory, neurologic or infectious complications. Parents of

such babies may often worry about short or long term infant outcomes. Moderate complications

(Appendix 4) include diagnoses or procedures that raise concern but at a lower level than the list

for severe (e.g. use of CPAP or bone fracture). Most require an infant LOS that exceeds that of

the mother, validating that these are indeed significant complications. Examples include less

severe respiratory complications (e.g. transient tachypnea of the newborn), or infections with a

long LOS but not sepsis. As a “safety net” to capture cases who were under-coded, the

numerator also includes cases from these seemingly normal infants who has a LOS >5 days with

neither any form of jaundice nor a social reason for staying in the hospital (e.g. family disruption

or adoption; Appendix 5).

Measure Calculation: In this analysis, the measure is reported as the percent of Total

Unexpected Newborn Complications (per 100 births) subdivided into serious and moderate

complications (further details are in the Flow Chart and Appendices).

II. Description of Tables and Graphs

The V12.4 Special Report: Unexpected Newborn Complications (UNC) Update (NQF # 716

“Healthy Term Newborn”) is designed to provide you with an understanding of the data and

analysis of unexpected severe and moderate newborn complications. The tables in this analysis

display data for your hospital compared to NPIC/QAS subgroup and database averages. The

report includes data for discharge date range 1/1/12 – 12/31/12. Medical record numbers for

the cases contributing to your hospital’s rates are available by emailing [email protected].

We are happy to answer any questions you may have regarding this report.

Table 1: Overview displays UNC measure population information and rates. (See Flow Chart

and Appendices for measure specification details).

Section A: Inborns shows the count of total inborns for the time period and the percent of total

inborns with valid APGAR 5 information. Apgar score at five minutes is included in the UNC

rate calculations (Total and Severe). If your hospital did not submit valid APGAR 5 information

these rates may be understated. This section also displays the number of inborns that were

excluded from the measure population because they did not meet the initial criteria for inclusion

(preterm inborns or multiple gestations are excluded).

Section B: Denominator begins with the count of inborns in the UNC “starting denominator”

The starting denominator includes all inborn singletons with birthweight ≥ 2500 grams and

gestational age ≥ 37 weeks (birthweight and gestational age were determined using the numeric

and coded information provided in the NPIC/QAS data submission from each hospital). The next

display is the total inborns excluded due to “preexisting” complications (congenital

malformations and genetic disorders, other specified fetal and maternal conditions, and maternal

drug use) shown as a count and as a percent of the starting denominator. The number of

remaining inborns in the measure population (without preexisting complications) is then

displayed as the UNC Final Denominator.

Section C: Unexpected Newborn Complication Rates displays the Total UNC Numerator (the

number of inborns identified with severe or moderate complications in the measure population)

and the Total UNC Rate. This information is then divided into two sub measures, Severe

(includes just those inborns identified with severe complications) and Moderate (inborns with

moderate complications only).

mailto:[email protected]

Graph 1: Comparative Unexpected Newborn Complication Rates is a bar graph showing

your hospital’s Total UNC Rate with a 95% confidence interval compared to the other hospitals

in your subgroup. The bar displays the percent of severe and moderate complications within the

Total UNC Rate. The average Total UNC Rate for the subgroup and the database are displayed

by two horizontal lines.

Graph 2: Comparative Unexpected Newborn Complication Rates Summary by Subgroup

displays the average Total UNC Rate with the percent of severe and moderate complications for

each NPIC/QAS subgroup and the entire database.

Table 2: Severe Complications by Category provides information for the inborns in the UNC

numerator identified with severe complications.

Section A: Overview shows case counts for the UNC Final Denominator and the Severe UNC

numerator (inborns in the measure population with severe complications) and then displays the

Severe UNC Rate. This section also displays the percent of inborns with severe complications

admitted to a special care nursery (defined as inborn discharges with neonatal intensive care

(NICU) or neonatal intermediate care (NINT) accommodation days or charges on the data

submission).

Section B: Numerator Inclusions: Severe Complications by mutually exclusive categories

displays the case counts for each of the five categories of severe complications included in the

UNC numerator( as described in Figure 3 of the Flow Chart); died, transferred out to a higher

level of care (within 1 day of birth), Apgar score ≤ 3 at five minutes, severe ICD-9 coding

(includes specific diagnosis and procedure codes for birth trauma, hypoxia/asphyxia, shock and

resuscitation, respiratory complications, infection, and neurological complications) and inborns

coded with Septicemia (dx 771.81) with a length of stay greater than four days. The percent of

total severe complications is also displayed for each category. The shaded area shows the

distribution of cases within the code groups of the severe ICD-9 coding category (see

Appendices, Numerator Specifications for ICD -9 code lists). Cases with multiple codes may be

included in more than one of these groups but are only counted once in the numerator.

Table 3: Moderate Complications by Category provides information for the inborns in the

UNC numerator identified with moderate complications.

Section A: Overview shows case counts for the UNC Final Denominator and the Moderate

UNC numerator (inborns in the measure population with moderate complications) and then

displays the Moderate UNC Rate. This section also displays the percent of inborns with

moderate complications admitted to a special care nursery (defined as inborn discharges with

neonatal intensive care (NICU) or neonatal intermediate care (NINT) accommodation days or

charges on the data submission).

Section B: Numerator Inclusions: Moderate Complications by mutually exclusive

categories displays the case counts for each of the three categories of moderate complications

included in the UNC numerator (as described in Figure 4 of the Flow Chart); moderate

complications without a length of stay (LOS) requirement to validate severity, moderate

complications with specific LOS requirements (LOS > 2 days for inborns delivered vaginally;

LOS > 4 days for inborns delivered by c- section; LOS ≤ 4 days for inborns coded with

septicemia) and inborns with LOS > 5 days (inborns with specific codes for neonatal jaundice or

social indications for prolonged hospitalization are excluded). The percent of total moderate

complications is also displayed for each category. The shaded areas show the distribution of

cases within the diagnosis and procedure code groups of the Moderate Complication (with or

without LOS requirement) categories. (see Appendices, Numerator Specifications for ICD-9

code lists). Cases with multiple codes may be included in more than one group but are only

counted once in the numerator.

III. Specifications Flow Chart and Appendices (ICD-9 codes)

1. Denominator Inclusions

2. Denominator Exclusions

3. Severe Complications Numerator

4. Moderate Complications Denominator

5. Moderate Complications Numerator- Long LOS i California Maternal Quality Care Collaborative (CQMCC) document; shared by Elliott Main, MD with

NPIC/QAS, Jan. 2013

Hospital Subgroup Database

SAMPLE Average Average

A. Inborns

Total Inborns 3,673 4,305 4,123

Percent of total inborns with valid APGAR 5 1

73.9% 83.1% 84.8%

Inborns not in measure population 2

634 793 679

B. Denominator

Inborns included in starting denominator 3

3,039 3,512 3,443

Inborns with preexisting complications (excluded) 4

167 224 194

Inborns with preexisting complications as a percent of starting denominator 5.5% 6.3% 5.7%

UNC Final Denominator:

Inborns in measure population without preexisting complications 2,872 3,288 3,249

C. Unexpected Newborn Complication Rates

Total UNC Numerator: Inborns with severe or moderate complications 104 124 124

Total Unexpected Newborn Complication Rate 3.6% 3.8% 3.7%

Severe UNC Numerator: Inborns with severe complications 39 50 48

Severe Unexpected Newborn Complication Rate 1.4% 1.6% 1.6%

Moderate UNC Numerator: Inborns with moderate complications 65 74 76

Moderate Unexpected Newborn Complication Rate 2.3% 2.2% 2.1%

1 If your hospital did not submit valid APGAR 5 data, your total and severe UNC rates may be understated.

2 Preterm and multiple gestation.

3 Singletons; birthweight ≥ 2500 grams; gestational age ≥ 37 weeks.

4 Fetal malformations; maternal/fetal complications; exposure to maternal drug use (see Appendices).

V12.4 Special Report: Unexpected Newborn Complications (UNC) Update


Table 1: Overview

Date Range of Hospital Data: 1/1/2012 - 12/31/2012

Subgroup: AR - Academic, Regional Perinatal Centers

Date Range of Comparison Data: 1/1/2012 - 12/31/2012




0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

Subgroup Total UNC Average Rate (3.8%)

Database Total UNC Average Rate (3.7%)

Graph 1: Comparative Unexpected Newborn Complication Rates

NPIC ID: SAMPLE

Hospital Total UNC Rate with 95% Confidence Interval: 3.6%

Hospital Severe UNC Rate (1.4%)

Hospital Moderate UNC Rate (2.3%)

Graph 2: Comparative Unexpected Newborn Complication (UNC) RatesSummary by Subgroup

Subgroup Total UNC RateSevere UNC RateModerate UNC Rate

AO 0.0449 0.0143 0.0306

AR 0.0378 0.0156 0.0222

NL 0.0314 0.0153 0.016

NS 0.029 0.0161 0.0129

C 0.0323 0.0142 0.0181

G 0.0429 0.0203 0.0227

Database 0.0366 0.0155 0.021

AO AR NL NS C G

Total UNC Rate 4.5% 3.8% 3.1% 2.9% 3.2% 4.3% 3.7%

Severe UNC Rate 1.4% 1.6% 1.5% 1.6% 1.4% 2.0% 1.6%

Moderate UNC Rate 3.1% 2.2% 1.6% 1.3% 1.8% 2.3% 2.1%

SubgroupDatabase

Average

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

AO AR NL NS C G Database

AverageSubgroup

Moderate Complication Rate Severe Complication Rate

Graph 2: Comparative Unexpected Newborn Complication (UNC) Rates

Summary by Subgroup


A. Overview

UNC Final Denominator

Severe UNC Numerator: Inborns with severe complications

Severe Unexpected Newborn Complication Rate

Inborns with severe complications admitted to special care nursery

B. Numerator Inclusions: Severe Complications by mutually

exclusive categories# % # % # %

Died 1 2.6% 0 0.5% 0 0.5%

Transferred out to a higher level of care (within 1 day of birth) 1 2.6% 3 5.0% 4 7.8%

APGAR5 ≤ 3 4 10.3% 3 5.3% 3 6.1%

Severe ICD-9 Code 1 23 59.0% 32 63.1% 30 61.6%

Severe Birth Trauma 7 30.4% 6 18.1% 5 18.5%

Hypoxia Asphyxia 0 0.0% 1 1.8% 1 3.2%

Shock and Resuscitation 0 0.0% 0 0.8% 0 1.0%

Severe Respiratory Complications 14 60.9% 22 70.1% 19 64.0%

Severe Infection 0 0.0% 3 10.1% 4 13.1%

Severe Neurological Complications 2 8.7% 2 7.5% 2 7.9%

Septicemia (dx code 771.81) and LOS > 4 days 10 25.6% 13 25.9% 12 25.0%

1 The shaded area displays the distribution of cases within the diagnosis and procedure code groups of the Severe ICD-9 Code category (see Appendices,

Numerator Specifications for ICD-9 code lists). Cases that are included in more than one of these groups are only counted once in the numerator.



Table 2: Severe Complications by Category

Hospital

SAMPLE

2,872

39

Database

Average

3,249

48

Subgroup

Average

3,288

50

1.6% 1.6%

79.0%

1.4%

69.2% 82.1%




A. Overview

UNC Final Denominator

Moderate UNC Numerator: Inborns with moderate complications

Moderate Unexpected Newborn Complication Rate

Inborns with moderate complications admitted to Special Care Nursery

B. Numerator Inclusions: Moderate Complications by mutually

exclusive categories# % # % # %

Moderate Complications not requiring LOS to validate severity 1 29 44.6% 35 47.0% 38 50.1%

Moderate Birth Trauma 10 34.5% 6 17.8% 7 17.4%

Moderate Respiratory Complications (procedure codes) 20 69.0% 29 82.1% 33 85.4%

Moderate Neurological Complications (procedure codes) 0 0.0% 0 0.9% 0 0.6%

Moderate Complications requiring LOS to validate severity 1, 2 29 44.6% 31 41.6% 31 40.4%

Moderate Birth Trauma with specific LOS requirement 3 10.3% 2 7.3% 2 6.3%

Moderate Respiratory Complications with specific LOS requirement

(diagnosis codes)27 93.1% 27 86.2% 27 89.1%

Moderate Respiratory Complications with specific LOS requirement

(procedure codes)1 3.5% 0 0.7% 1 1.9%

Moderate Infection with specific LOS requirement 0 0.0% 4 11.4% 4 12.2%

Inborns with prolonged LOS (> 5 days) not excluded due to

jaundice or social reasons7 10.8% 8 11.4% 8 10.7%

1 The shaded areas display the distribution of cases within the diagnosis and procedure code groups of the Moderate Complication (with or without LOS

requirement) categories (see Appendices, Numerator Specifications for ICD-9 code lists). Cases that are included in more than one of these groups are only

counted once in the numerator.



Table 3: Moderate Complications by Category

2 LOS > 2 days for inborns delivered vaginally; LOS > 4 days for inborns delivered by c-section; LOS ≤ 4 days for all inborns with

Septicemia (dx code 771.81).

Hospital

SAMPLE

2,872

65

2.3%

30.8%

Subgroup

Average

3,288

74

2.2%

59.5%

Database

Average

3,249

76

2.1%

62.6%




Revised Specifica7ons NQF #716: Unexpected Newborn Complica7ons

(aka Healthy Term Newborn) Figure 1: Denominator Inclusions

BWt ≥2.5kg?

Hospital Discharge Diagnosis File

Use Birth Cer7ficate or Medical Record: Birthweight

Not in Measure Popula7on

Yes

GA ≥37wks?

GA ≥37wks?

BWt ≥3kg?

GA Unknown

Yes

Yes

Yes

GA Unknown

No

No

No

Star7ng Denominator

Use Birth Cer7ficate or Medical Record: Best Obstetric Es7mate of Gesta7onal Age

Use Birth Cer7ficate or Medical Record: LMP‐based Gesta7onal Age

Use Birth Cer7ficate or Medical Record: Birthweight

Singleton Livebirth?

No or Unknown

Screen for ICD‐9 Diagnosis Codes V3000 or V3001

Yes

v2.0 Dec 2012

No or Unknown

C A L I F O R N I A M A T E R N A LQUALITY CARE COLLABORATIVE

These represent back‐up criteria. If Best

Obstetric Es7mate of GA iden7fies >99% of cases then these two steps may be omided


(aka Healthy Term Newborn) Figure 2: Denominator Exclusions

Congenital malforma7ons?

Star7ng Denominator

Use Pa7ent Discharge Diagnosis Data, examining both Primary and Other Diagnosis fields for specific ICD‐9

Codes defining a wide array of Fetal Malforma7ons and Gene7c Disorders (see Appendix 2, Group A)

Exclusions

No

Other Fetal Condi7ons?

Maternal Drug Use?

No

No

Yes

Yes

Final Denominator

Use Pa7ent Discharge Diagnosis Data, examining both Primary and Other Diagnosis fields for specific ICD‐9 Codes defining an array of other Maternal and Fetal

Condi7ons (see Appendix 2, Group B)

Use Pa7ent Discharge Diagnosis Data, examining both Primary and Other Diagnosis fields for specific ICD‐9

Codes defining an array of Maternal Drug Use Diagnoses (see Appendix 2, Group C)

v2.0 Dec 2012

Yes


In summary, the Final Denominator excludes most serious fetal condi7ons that are “preexis7ng” (present before labor), including: prematurity, mul7ple gesta7ons, poor fetal growth, congenital malforma7ons and gene7c disorders, other specified fetal and maternal condi7ons and maternal drug use.


(aka Healthy Term Newborn) Figure 3: Numerator Inclusions: Severe Complica=ons

Neonatal Transfer?

Use Pa7ent Discharge Diagnosis Data: Disposi7on Code for Transfer to Higher Level of Care

Numerator: Severe Complica7ons

No

5’ or 10’ Apgar ≤3?

Severe ICD‐9 Code?

Sepsis and LOS >4 days?

No

No

Yes

Yes

Yes

Star7ng Popula7on for Moderate Complica7ons Analysis

Use Birth Cer7ficate or Medical Record: Apgar Score at 5 minutes or 10 minutes ≤3

Use Pa7ent Discharge Diagnosis Data, examining both Primary and Other Diagnosis and Procedure fields for specific ICD‐9 Codes defining a array of specific Severe Complica7ons,

included selected codes from the categories of: Birth Injuries, Hypoxia/Asphyxia, Shock/Complica7ons, Respiratory Complica7ons/Procedures, Infec7ons, Neurologic Complica7ons. (see Appendix 3, Groups A thru F)

Use Pa7ent Discharge Diagnosis Data, examining both Primary and Other Diagnosis fields for the specific ICD‐9 Code defining sepsis but also requiring a neonatal Length of Stay >4 days.

(see Appendix 3, Group G)

Neonatal Death?

Use Pa7ent Discharge Diagnosis Data: Disposi7on Code for Death

No

v2.0 Dec 2012


Final Denominator

Yes

Yes

No


(aka Healthy Term Newborn) Figure 4: Numerator Inclusions: Moderate Complica=ons

LOS >4d CS or LOS >2d Vag?

Use Pa7ent Discharge Diagnosis Data for LOS and for ICD‐9 Diagnosis Codes V3000 (vaginal birth) or V3001 (Cesarean

birth)

Numerator: Moderate Complica7ons

Yes

Moderate Comps (with LOS)?

LOS>5d?

Jaundice or Social codes?

No

Yes

Yes

No

Star7ng Popula7on for Moderate Complica7ons Analysis

Use Pa7ent Discharge Diagnosis Data to determine LOS

Use Pa7ent Discharge Diagnosis Data, examining both Primary and Other Diagnosis and Procedure fields for the specific ICD‐9

Code defining Neonatal Jaundice or Social Indica7ons for prolonged hospitaliza7on. (see Appendix 5, Groups A thru C)

Moderate Comps (No LOS)?

Use Pa7ent Discharge Diagnosis Data, examining both Primary and Other Diagnosis and Procedure fields for specific ICD‐9 Code defining a specific Moderate Complica7on, that do not require a prolonged LOS (see Appendix 4, Groups A thru C)

No

v2.0 Dec 2012


Yes

Use Pa7ent Discharge Diagnosis Data, examining both Primary and Other Diagnosis and Procedure fields for specific ICD‐9 Codes defining a array of specific Moderate Complica7ons,

included selected codes from the categories of: Birth Injuries, Hypoxia/Asphyxia, Shock/Resuscita7on, Respiratory Complica7ons/Procedures, Infec7ons, Neurologic Complica7ons. (see Appendix 4, Groups D thru G)

Not in Numerator

No

Yes

No

Appendicies for Unexpected Newborn Complica7ons (NQF #716)

Denominator Specifica7ons

Appendix 1: Denominator Inclusions (ICD‐9 Codes)Singleton Inborn (Diagnosis Codes)V30.00 Single liveborn, born in hospital, delivered without men:on of cesarean sec:onV30.01 Single liveborn, born in hospital, delivered by cesarean sec:on

Appendix 2: Denominator Exclusions (ICD‐9 Codes)

Group A: Congenital Malforma7ons (Diagnosis Codes)740.0 Anencephalus740.1 Craniorachischisis740.2 Iniencephaly741.00 Spina bifida with hydrocephalus, unspecified region741.01 Spina bifida with hydrocephalus, cervical region741.02 Spina bifida with hydrocephalus, dorsal (thoracic) region741.03 Spina bifida with hydrocephalus, lumbar region741.90 Spina bifida without men:on of hydrocephalus, unspecified region741.91 Spina bifida without men:on of hydrocephalus, cervical region741.92 Spina bifida without men:on of hydrocephalus, dorsal (thoracic) region741.93 Spina bifida without men:on of hydrocephalus, lumbar region742.0 Encephalocele742.1 Microcephalus742.2 Congenital reduc:on deformi:es of brain742.3 Congenital hydrocephalus742.4 Other specified congenital anomalies of brain742.51 Diastematomyelia742.53 Hydromyelia742.59 Other specified congenital anomalies of spinal cord742.8 Other specified congenital anomalies of nervous system742.9 Unspecified congenital anomaly of brain, spinal cord, and nervous system743.00 Clinical anophthalmos, unspecified743.03 Cys:c eyeball, congenital743.06 Cryptophthalmos743.10 Microphthalmos, unspecified743.11 Simple microphthalmos743.12 Microphthalmos associated with other anomalies of eye and adnexa743.20 Buphthalmos, unspecified743.21 Simple buphthalmos743.22 Buphthalmos associated with other ocular anomalies743.30 Congenital cataract, unspecified743.31 Congenital capsular and subcapsular cataract743.32 Congenital cor:cal and zonular cataract743.33 Congenital nuclear cataract743.34 Total and subtotal cataract, congenital743.35 Congenital aphakia

There are 3 "groups" of diagnoses that lead to exclusion: fetal congenital anomalies, other chronic fetal condi:ons that are not anomalies, and maternal drug use. A wide array of ICD‐9 diagnosis codes are used (each of which is infrequent) with the goal to ensure that the remaining denominator infants are expected to do well.

743.36 Congenital anomalies of lens shape743.37 Congenital ectopic lens743.39 Other congenital cataract and lens anomalies743.41 Congenital anomalies of corneal size and shape743.42 Corneal opaci:es, interfering with vision, congenital743.43 Other corneal opaci:es, congenital743.44 Specified congenital anomalies of anterior chamber, chamber angle, and related structures743.45 Aniridia743.46 Other specified congenital anomalies of iris and ciliary body743.47 Specified congenital anomalies of sclera743.48 Mul:ple and combined congenital anomalies of anterior segment743.49 Other congenital anomalies of anterior segment743.51 Vitreous anomalies743.52 Fundus coloboma743.53 Choriore:nal degenera:on, congenital743.54 Congenital folds and cysts of posterior segment743.55 Congenital macular changes743.56 Other re:nal changes, congenital743.57 Specified congenital anomalies of op:c disc743.58 Vascular anomalies743.59 Other congenital anomalies of posterior segment743.61 Congenital ptosis743.62 Congenital deformi:es of eyelids743.63 Other specified congenital anomalies of eyelid743.64 Specified congenital anomalies of lacrimal gland743.65 Specified congenital anomalies of lacrimal passages743.66 Specified congenital anomalies of orbit743.69 Other congenital anomalies of eyelids, lacrimal system, and orbit743.8 Other specified anomalies of eye743.9 Unspecified anomaly of eye745.0 Common truncus745.10 Complete transposi:on of great vessels745.11 Double outlet right ventricle745.12 Corrected transposi:on of great vessels745.19 Other transposi:on of great vessels745.2 Tetralogy of fallot745.3 Common ventricle745.4 Ventricular septal defect745.5 Os:um secundum type atrial septal defect745.60 Endocardial cushion defect, unspecified type745.61 Os:um primum defect745.69 Other endocardial cushion defects745.7 Cor biloculare745.8 Other bulbus cordis anomalies and anomalies of cardiac septal closure745.9 Unspecified defect of septal closure746.00 Congenital pulmonary valve anomaly, unspecified746.01 Atresia of pulmonary valve, congenital746.02 Stenosis of pulmonary valve, congenital746.09 Other congenital anomalies of pulmonary valve746.1 Tricuspid atresia and stenosis, congenital746.2 Ebstein's anomaly746.3 Congenital stenosis of aor:c valve746.4 Congenital insufficiency of aor:c valve

746.5 Congenital mitral stenosis746.6 Congenital mitral insufficiency746.7 Hypoplas:c le^ heart syndrome746.81 Subaor:c stenosis746.82 Cor triatriatum746.83 Infundibular pulmonic stenosis746.84 Obstruc:ve anomalies of heart, not elsewhere classified746.85 Coronary artery anomaly746.86 Congenital heart block746.87 Malposi:on of heart and cardiac apex746.89 Other specified congenital anomalies of heart746.9 Unspecified congenital anomaly of heart747.0 Patent ductus arteriosus747.10 Coarcta:on of aorta (preductal) (postductal)747.11 Interrup:on of aor:c arch747.20 Anomaly of aorta, unspecified747.21 Anomalies of aor:c arch747.22 Atresia and stenosis of aorta747.29 Other anomalies of aorta747.31 Pulmonary artery coarcta:on and atresia747.32 Pulmonary arteriovenous malforma:on747.39 Other anomalies of pulmonary artery and pulmonary circula:on747.40 Anomaly of great veins, unspecified747.41 Total anomalous pulmonary venous connec:on747.42 Par:al anomalous pulmonary venous connec:on747.49 Other anomalies of great veins748.0 Choanal atresia748.1 Other anomalies of nose748.2 Web of larynx748.3 Other anomalies of larynx, trachea, and bronchus748.4 Congenital cys:c lung748.5 Agenesis, hypoplasia, and dysplasia of lung748.60 Anomaly of lung, unspecified748.61 Congenital bronchiectasis748.69 Other congenital anomalies of lung748.8 Other specified anomalies of respiratory system748.9 Unspecified anomaly of respiratory system749.00 Cle^ palate, unspecified749.01 Cle^ palate, unilateral, complete749.02 Cle^ palate, unilateral, incomplete749.03 Cle^ palate, bilateral, complete749.04 Cle^ palate, bilateral, incomplete749.10 Cle^ lip, unspecified749.11 Cle^ lip, unilateral, complete749.12 Cle^ lip, unilateral, incomplete749.13 Cle^ lip, bilateral, complete749.14 Cle^ lip, bilateral, incomplete749.20 Cle^ palate with cle^ lip, unspecified749.21 Cle^ palate with cle^ lip, unilateral, complete749.22 Cle^ palate with cle^ lip, unilateral, incomplete749.23 Cle^ palate with cle^ lip, bilateral, complete749.24 Cle^ palate with cle^ lip, bilateral, incomplete749.25 Other combina:ons of cle^ palate with cle^ lip

750.3 Tracheoesophageal fistula, esophageal atresia and stenosis750.4 Other specified anomalies of esophagus750.5 Congenital hypertrophic pyloric stenosis750.6 Congenital hiatus hernia750.7 Other specified anomalies of stomach750.8 Other specified anomalies of upper alimentary tract750.9 Unspecified anomaly of upper alimentary tract751.0 Meckel's diver:culum751.1 Atresia and stenosis of small intes:ne751.2 Atresia and stenosis of large intes:ne, rectum, and anal canal751.3 Hirschsprung's disease and other congenital func:onal disorders of colon751.4 Anomalies of intes:nal fixa:on751.5 Other anomalies of intes:ne751.60 Unspecified anomaly of gallbladder, bile ducts, and liver751.61 Biliary atresia751.62 Congenital cys:c disease of liver751.69 Other anomalies of gallbladder, bile ducts, and liver751.7 Anomalies of pancreas751.8 Other specified anomalies of diges:ve system751.9 Unspecified anomaly of diges:ve system753.0 Renal agenesis and dysgenesis753.10 Cys:c kidney disease, unspecified753.11 Congenital single renal cyst753.12 Polycys:c kidney, unspecified type753.13 Polycys:c kidney, autosomal dominant753.14 Polycys:c kidney, autosomal recessive753.15 Renal dysplasia753.16 Medullary cys:c kidney753.17 Medullary sponge kidney753.19 Other specified cys:c kidney disease753.20 Unspecified obstruc:ve defect of renal pelvis and ureter753.21 Congenital obstruc:on of ureteropelvic junc:on753.22 Congenital obstruc:on of ureterovesical junc:on753.23 Congenital ureterocele753.29 Other obstruc:ve defects of renal pelvis and ureter753.3 Other specified anomalies of kidney753.5 Exstrophy of urinary bladder753.6 Atresia and stenosis of urethra and bladder neck753.8 Other specified anomalies of bladder and urethra753.9 Unspecified anomaly of urinary system754.0 Congenital musculoskeletal deformi:es of skull, face, and jaw754.1 Congenital musculoskeletal deformi:es of sternocleidomastoid muscle754.2 Congenital musculoskeletal deformi:es of spine754.30 Congenital disloca:on of hip, unilateral754.31 Congenital disloca:on of hip, bilateral754.32 Congenital subluxa:on of hip, unilateral754.33 Congenital subluxa:on of hip, bilateral754.35 Congenital disloca:on of one hip with subluxa:on of other hip754.40 Genu recurvatum754.41 Congenital disloca:on of knee (with genu recurvatum)754.42 Congenital bowing of femur754.43 Congenital bowing of :bia and fibula754.44 Congenital bowing of unspecified long bones of leg

754.50 Talipes varus754.51 Talipes equinovarus754.52 Metatarsus primus varus754.53 Metatarsus varus754.59 Other varus deformi:es of feet754.60 Talipes valgus754.61 Congenital pes planus754.62 Talipes calcaneovalgus754.69 Other valgus deformi:es of feet754.70 Talipes, unspecified754.71 Talipes cavus754.79 Other deformi:es of feet754.81 Pectus excavatum754.82 Pectus carinatum754.89 Other specified nonteratogenic anomalies757.1 Ichthyosis congenita758.0 Down's syndrome758.1 Patau's syndrome758.2 Edwards' syndrome758.31 Cri‐du‐chat syndrome758.32 Velo‐cardio‐facial syndrome758.33 Other microdele:ons758.39 Other autosomal dele:ons758.5 Other condi:ons due to autosomal anomalies758.6 Gonadal dysgenesis758.81 Other condi:ons due to sex chromosome anomalies758.89 Other condi:ons due to chromosome anomalies758.9 Condi:ons due to anomaly of unspecified chromosome759.5 Tuberous sclerosis759.6 Other hamartoses, not elsewhere classified759.7 Mul:ple congenital anomalies, so described759.81 Prader‐Willi syndrome759.82 Marfan syndrome759.83 Fragile X syndrome759.89 Other specified congenital anomalies255.2 Adrenogenital disorders

Group B: Other Fetal Placental Condi7ons (Diagnosis Codes)762.0 Placenta previa affec:ng fetus or newborn762.1 Other forms of placental separa:on and hemorrhage affec:ng fetus or newborn762.6 Other and unspecified condi:ons of umbilical cord affec:ng fetus or newborn764.00 Light‐for‐dates without men:on of fetal malnutri:on, unspecified [weight]764.01 Light‐for‐dates without men:on of fetal malnutri:on, less than 500 grams764.02 Light‐for‐dates without men:on of fetal malnutri:on, 500‐749 grams764.03 Light‐for‐dates without men:on of fetal malnutri:on, 750‐999 grams764.04 Light‐for‐dates without men:on of fetal malnutri:on, 1,000‐ 1,249 grams764.05 Light‐for‐dateswithout men:on of fetal malnutri:on, 1,250‐ 1,499 grams764.06 Light‐for‐dates without men:on of fetal malnutri:on, 1,500‐ 1,749 grams764.07 Light‐for‐dates without men:on of fetal malnutri:on, 1,750‐ 1,999 grams764.08 Light‐for‐dates without men:on of fetal malnutri:on, 2,000‐ 2,499 grams764.09 Light‐for‐dates without men:on of fetal malnutri:on, 2,500 grams and over764.10 Light‐for‐dates with signs of fetal malnutri:on, unspecified [weight]764.11 Light‐for‐dates with signs of fetal malnutri:on, less than 500 grams

764.12 Light‐for‐dateswith signs of fetal malnutri:on, 500‐749 grams764.13 Light‐for‐dates with signs of fetal malnutri:on, 750‐999 grams764.14 Light‐for‐dates with signs of fetal malnutri:on, 1,000‐1,249 grams764.15 Light‐for‐dates with signs of fetal malnutri:on, 1,250‐1,499 grams764.16 Light‐for‐dates with signs of fetal malnutri:on, 1,500‐1,749 grams764.17 Light‐for‐dates with signs of fetal malnutri:on, 1,750‐1,999 grams764.18 Light‐for‐dateswith signs of fetal malnutri:on, 2,000‐2,499 grams764.19 Light‐for‐dateswith signs of fetal malnutri:on, 2,500 grams and over764.90 Fetal growth retarda:on, unspecified, unspecified [weight]764.91 Fetal growth retarda:on, unspecified, less than 500 grams764.92 Fetal growth retarda:on, unspecified, 500‐749 grams764.93 Fetal growth retarda:on, unspecified, 750‐999 grams764.94 Fetal growth retarda:on, unspecified, 1,000‐1,249 grams764.95 Fetal growth retarda:on, unspecified, 1,250‐1,499 grams764.96 Fetal growth retarda:on, unspecified, 1,500‐1,749 grams764.97 Fetal growth retarda:on, unspecified, 1,750‐1,999 grams764.98 Fetal growth retarda:on, unspecified, 2,000‐2,499 grams764.99 Fetal growth retarda:on, unspecified, 2,500 grams and over773.0 Hemoly:c disease of fetus or newborn due to Rh isoimmuniza:on773.2 Hemoly:c disease of fetus or newborn due to other and unspecified isoimmuniza:on773.3 Hydrops fetalis due to isoimmuniza:on778.0 Hydrops fetalis not due to isoimmuniza:on

Group C: Maternal Drug Use (Diagnosis Codes)760.70 Unspecified noxious substance affec:ng fetus or newborn via placenta or breast milk760.71 Alcohol affec:ng fetus or newborn via placenta or breast milk760.72 Narco:cs affec:ng fetus or newborn via placenta or breast milk760.73 Hallucinogenic agents affec:ng fetus or newborn via placenta or breast milk760.74 An:‐infec:ves affec:ng fetus or newborn via placenta or breast milk760.75 Cocaine affec:ng fetus or newborn via placenta or breast milk760.76 Diethyls:lbestrol [DES] affec:ng fetus or newborn via placenta or breast milk760.77 An:convulsants affec:ng fetus or newborn via placenta or breast milk760.78 An:metabolic agents affec:ng fetus or newborn via placenta or breast milk760.79 Other noxious influences affec:ng fetus or newborn via placenta or breast milk779.5 Drug withdrawal syndrome in newborn

Numerator Specifica7onsAppendix 3: Severe Complica7ons Numerator (ICD‐9 Codes)

Group A: Severe Birth Trauma (Diagnosis Codes)767.0 Subdural and cerebral hemorrhage767.11 Epicranial subaponeuro:c hemorrhage (massive)767.3 Other injuries to skeleton due to birth trauma767.4 Injury to spine and spinal cord due to birth trauma767.5 Facial nerve injury due to birth trauma767.6 Injury to brachial plexus due to birth trauma767.7 Other cranial and peripheral nerve injuries due to birth trauma

Group B: Hypoxia Asphyxia (Diagnosis Codes)768.5 Severe birth asphyxia768.6 Mild or moderate birth asphyxia

768.70 Hypoxic‐ischemic encephalopathy, unspecified768.71 Mild hypoxic‐ischemic encephalopathy768.72 Moderate hypoxic‐ischemic encephalopathy768.73 Severe hypoxic‐ischemic encephalopathy768.9 Unspecified severity of birth asphyxia in liveborn infant343.0 Congenital diplegia343.1 Congenital hemiplegia343.2 Congenital quadriplegia343.3 Congenital monoplegia343.4 Infan:le hemiplegia343.8 Other specified infan:le cerebral palsy343.9 Infan:le cerebral palsy, unspecified

Group C: Shock and Resuscita7on (Diagnosis Codes)776.2 Disseminated intravascular coagula:on in newborn777.50 Necro:zing enterocoli:s in newborn, unspecified777.51 Stage I necro:zing enterocoli:s in newborn777.52 Stage II necro:zing enterocoli:s in newborn777.53 Stage III necro:zing enterocoli:s in newborn785.50 Shock, unspecified785.51 Cardiogenic shock785.52 Sep:c shock785.59 Other shock without men:on of trauma584.5 Acute kidney failure with lesion of tubular necrosis

Group D: Severe Respiratory Complica7ons (Diagnosis Codes)747.83 Persistent fetal circula:on769. Respiratory distress syndrome in newborn770.12 Meconium aspira:on with respiratory symptoms770.2 Inters::al emphysema and related condi:ons770.3 Pulmonary hemorrhage

Group E: Severe Infec7on (Diagnosis Codes)770.0 Congenital pneumonia771.83 Bacteremia of newborn995.92 Severe sepsis

Group F: Severe Neurological Complica7on (Diagnosis Codes)772.10 Intraventricular hemorrhage unspecified grade772.11 Intraventricular hemorrhage, grade I772.12 Intraventricular hemorrhage, grade II772.13 Intraventricular hemorrhage, grade III772.14 Intraventricular hemorrhage, grade IV772.2 Subarachnoid hemorrhage of fetus or newborn779.0 Convulsions in newborn345.3 Grand mal status779.2 Cerebral depression, coma, and other abnormal cerebral signs in fetus or newborn779.7 Periventricular leukomalacia779.85 Cardiac arrest of newborn427.5 Cardiac arrest348.30 Encephalopathy, unspecified348.31 Metabolic encephalopathy348.39 Other encephalopathy

348.5 Cerebral edema

Group G: Sep7cemia (Diagnosis Codes)This code requires a minimum infant hospital Length of Stay of >4 days to ensure that it represents a truly serious diagnosis.

771.81 Sep:cemia [sepsis] of newborn

Appendix 4: Moderate Complica7ons Numerator (ICD‐9 Codes)Groups A thru C do not require any neonatal LOS length to validate their severity.

Group A: Moderate Birth Trauma (Diagnosis Code)767.2 Fracture of clavicle due to birth trauma

93.90 Non‐invasive mechanical ven:la:on (e.g. CPAP)

87.03 Computerized axial tomography of head87.04 Other tomography of head88.91 Magne:c resonance imaging of brain and brain stem

Groups D thru G addi:onally require an infant LOS to be >2 days for a vaginal birth and >4 days for a Cesarean birth to validate their severity.

Group D: Moderate Birth Trauma with specific LOS requirement (Diagnosis Codes)763.0 Breech delivery and extrac:on affec:ng fetus or newborn

763.1Other malpresenta:on, malposi:on, and dispropor:on during labor and delivery affec:ng fetus or newborn

763.2 Forceps delivery affec:ng fetus or newborn763.3 Delivery by vacuum extractor affec:ng fetus or newborn763.4 Cesarean delivery affec:ng fetus or newborn763.5 Maternal anesthesia and analgesia affec:ng fetus or newborn767.8 Other specified birth trauma

Group E: Moderate Respiratory Complica7ons with specific LOS requirement (Diagnosis Codes)770.14 Aspira:on of clear amnio:c fluid with respiratory symptoms770.4 Primary atelectasis770.5 Other and unspecified atelectasis770.6 Transitory tachypnea of newborn770.81 Primary apnea of newborn770.82 Other apnea of newborn770.83 Cyano:c alacks of newborn770.84 Respiratory failure of newborn770.86 Aspira:on of postnatal stomach contents with respiratory symptoms770.87 Respiratory arrest of newborn770.88 Hypoxemia of newborn770.89 Other respiratory problems a^er birth

93.91 Intermilent posi:ve pressure breathing [IPPB]93.93 Nonmechanical methods of resuscita:on93.94 Respiratory medica:on administered by nebulizer

Group B: Moderate Respiratory Complica7on (Procedure Code)

Group C: Moderate Neurological Complica7on (Procedure Codes)

Group F: Moderate Respiratory Complica7ons with specific LOS requirement (Procedure Codes)

93.95 Hyperbaric oxygena:on93.96 Other oxygen enrichment93.98 Other control of atmospheric pressure and composi:on93.99 Other respiratory procedures

771.81 Sep:cemia of the newbornThis group includes babies with this code that have a shorter LOS than those in Apendix 3, Group G where the LOS has to be >4 days.

Appendix 5: Moderate Complica7ons Numerator‐‐Long LOS (ICD‐9 Codes)A^er an infant LOS >5 days has been iden:ied, the codes in Groups A thru C are used to exclude cases for jaundice or social reasons for their prolonged LOS.

Group A: Jaundice (Diagnosis Codes)773.1 Hemoly:c disease of fetus or newborn due to ABO isoimmuniza:on774.0 Perinatal jaundice from hereditary hemoly:c anemias774.1 Perinatal jaundice from other excessive hemolysis774.2 Neonatal jaundice associated with preterm delivery774.30 Neonatal jaundice due to delayed conjuga:on, cause unspecified774.31 Neonatal jaundice due to delayed conjuga:on in diseases classified elsewhere774.39 Other neonatal jaundice due to delayed conjuga:on from other causes774.4 Perinatal jaundice due to hepatocellular damage774.5 Perinatal jaundice from other causes774.6 Unspecified fetal and neonatal jaundice774.7 Kernicterus of fetus or newborn not due to isoimmuniza:on

Group B: Jaundice (Procedure Code)99.83 Other phototherapy

Group C: Social Problems (Diagnosis Codes)V60.0 Lack of housingV60.1 Inadequate housingV60.2 Inadequate material resourcesV60.3 Person living aloneV60.4 No other household member able to render careV60.6 Person living in residen:al ins:tu:onV60.81 Foster care (status)V60.89 Other specified housing or economic circumstancesV60.9 Unspecified housing or economic circumstanceV61.05 Family disrup:on due to child in welfare custodyV61.06 Family disrup:on due to child in foster care or in care of non‐parental family member

Group G: Moderate Infec7on with specific LOS requirement (Diagnosis Code)

v.12.4 special report: unexpected newborn complications

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