Heart Failure Core Measures
**Patients are included in the Heart Failure core measure when they are assigned a heart failure
diagnosis code upon discharge, which is determined by the coding department. Please note that
even if a patient is not admitted with a primary diagnosis of heart failure, this may end up as the
assigned diagnosis code.
As a reminder, the coding department and core measure abstractors cannot interpret physician
documentation. There are specific rules that must be followed that are defined by the Joint
Commission.
Left Ventricular Function Assessment:
 Documentation that left ventricular systolic function (LVSF) was assessed either
prior to arrival, during hospitalization, or is planned for after discharge or reason
documented by physician/advanced practice nurse/physician assistant
(physician/APN/PA) for not assessing LVSF.
Medication (ACE/ARB) for LVSD at Discharge:
 A patient with an EF <40 will be included in this measure. If a range (eg. 35-40)
is documented, abstracters take an average (eg. 37.5) of the range.
 Please note that the abstractors use the LAST documentation of left ventricular
dysfunction in the medical record
 ACE/ARB must be prescribed at discharge and documented on patient’s
discharge instructions, which are signed by the patient
 If ACE/ARB is not prescribed at discharge, must document contraindication
Discharge Instructions:
 Address Activity: WRITTEN discharge instructions/educational material given to
patient/caregiver address the patient's activity level after discharge.
 Address Diet: WRITTEN discharge instructions/educational material given to
patient/caregiver address diet/fluid intake instructions after discharge.
 Address Follow-up: WRITTEN discharge instructions or other documentation of
educational material given to the patient/caregiver address follow-up with a
physician/APN/PA after discharge.
 Address Medications: WRITTEN discharge instructions/educational material
given to patient/caregiver address discharge medications.
 Address Symptoms Worsening: WRITTEN discharge instructions/educational
material given to patient/caregiver address what to do if heart failure symptoms
worsen after discharge.
 Address Weigh Monitoring: WRITTEN discharge instructions/educational
material given to patient/caregiver address weight monitoring instructions after
discharge.
Smoking Cessation Counseling
 In order to be included in this measure, there must be documentation that the
patient has smoked in the previous year.
 No documentation of smoking history assumes that the patient does not smoke.
Acute Myocardial Infarction Core Measures
**Patients are included in the AMI core measure when they are assigned an AMI diagnosis code
upon discharge, which is determined by the coding department. Please note, if the patient is
admitted as “r/o MI” and there is no further documentation in the chart that they were ruled out,
these patients will be assigned an AMI diagnosis code. There must be explicit MD
documentation that the MI was ruled out.
As a reminder, the coding department and core measure abstractors cannot interpret physician
documentation. There are specific rules that must be followed that are defined by the Joint
Commission.
Aspirin Given at Arrival:
 ASA may be given within 24 hours before or 24 hours after hospital arrival
 If patient is currently taking ASA at home, documentation of “current home
medication” suffices as appropriate documentation
 If ASA not given at arrival, must document contraindication
Aspirin Prescribed at Discharge:
 ASA must be prescribed at discharge and documented on patient’s discharge
instructions, which are signed by the patient
 If ASA is not prescribed at discharge, must document contraindication
Beta-blocker Prescribed at Discharge:
 Beta-blocker must be prescribed at discharge and documented on patient’s
discharge instructions, which are signed by the patient
 If Beta-blocker is not prescribed at discharge, must document contraindication
Medication (ACE/ARB) for LVSD at Discharge:
 A patient with an EF <40 will be included in this measure. If a range (eg. 35-40)
is documented, abstracters take an average (eg. 37.5) of the range.
 Please note that the abstractors use the LAST documentation of left ventricular
dysfunction in the medical record
 ACE/ARB must be prescribed at discharge and documented on patient’s
discharge instructions, which are signed by the patient
 If ACE/ARB is not prescribed at discharge, must document contraindication
Angioplasty within 90 mins of arrival
 Door (ED triage time or time first seen by UHCMC staff) to balloon (angioplasty)
time must be less than 90 mins.
Smoking Cessation Counseling
 In order to be included in this measure, there must be documentation that the
patient has smoked in the previous year.
 No documentation of smoking history assumes that the patient does not smoke.
Pneumonia Core Measures
**Patients are included in the Pneumonia core measure when they are assigned a pneumonia
DRG upon discharge, which is determined by the coding department. Please note that even if a
patient is not admitted with a primary diagnosis of pneumonia, this may end up as the assigned
DRG.
As a reminder, the coding department and core measure abstractors cannot interpret physician
documentation. There are specific rules that must be followed that are defined by the Joint
Commission.
Inclusion criteria: Documentation of the diagnosis of pneumonia either as the Emergency
Department final diagnosis/impression, or as an admission diagnosis/impression for the direct
admit patient.
Antibiotic administered within 6 hours of arrival:
 Documentation that an antibiotic has been administered within 6 hours of arrival
is mandatory.
 This is only applicable for patients who come through UHCMC ED or directly
admitted.
 Exclusions to the measure apply only if the patient has allergies, sensitivities or
intolerance to beta-lactam/penicillin antibiotic or cephalosporin medications.
Appropriate antibiotic selection for immunocompetent patient:
 See Appendix A
Influenza vaccination (Oct – Dec, Jan – Feb):
 Documentation of the patient's vaccination status during this flu season.
 If found to be a candidate for the vaccine, documentation that the influenza
vaccine was given during this hospitalization.

Acceptable contraindications:
 Influenza vaccine was given during this hospitalization.
 Influenza vaccine was received prior to admission during the current flu
season*, not during this hospitalization.
Documentation of patient's refusal of influenza vaccine.
There was documentation of an allergy/sensitivity to influenza vaccine
OR is medically contraindicated because of bone marrow transplant
within the past 12 months OR prior history of Guillian- Barré syndrome.
Pneumonia screen/vaccination:
 Documentation of the patient's pneumococcal vaccination status.
 If found to be a candidate for the vaccine, documentation that the pneumococcal
vaccine was given during this hospitalization.
 Acceptable values
 Pneumococcal vaccine was given during this hospitalization.
 The patient received pneumococcal vaccine anytime in the past.
 Documentation of patient's refusal of pneumococcal vaccine.
 There is documentation of an allergy/sensitivity to pneumococcal vaccine
OR is medically contraindicated because of a bone marrow transplant
within the past 12 months OR currently receiving a scheduled course of
chemotherapy or radiation therapy, or received chemotherapy or
radiation during this hospitalization.


Pneumonia Core Measures cont.
Blood cultures before antibiotic in ED:
 Documentation in the medical record that a blood culture was collected the day
prior to arrival, the day of arrival, or within 24 hours after arrival to the hospital.
This includes blood cultures drawn in the emergency room or in observation beds
prior to admission order, as well as after the patient's admission to inpatient
status.
 A blood culture can be defined as a culture of microorganisms from specimens of
blood to determine the presence and nature of bacteremia.
Smoking Cessation Counseling
 In order to be included in this measure, there must be documentation that the
patient has smoked in the previous year.
 No documentation of smoking history assumes that the patient does not smoke.