Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery

Measure description

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received an IMA graft

Instructions

This measure is to be submitted each time an isolated CABG procedure is performed during the performance period. It is anticipated that eligible clinicians who provide services for isolated CABG will submit this measure. This measure is intended to reflect the quality of the surgical services provided for isolated CABG patients. Isolated CABG refers to CABG using arterial and/or venous grafts only.

Measure Submission:

The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

Denominator

All patients undergoing isolated CABG

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Patient procedure during the performance period (CPT): 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536

Numerator

Patients undergoing isolated CABG who received an IMA graft

Numerator Options:

Performance Met: Internal mammary artery graft performed for primary, isolated coronary artery bypass graft procedure (CABG) (4110F)

OR

Denominator Exception: Documentation of medical reason(s) for not performing an internal mammary artery graft for primary, isolated coronary artery bypass graft procedure. Acceptable medical reasons include: subclavian stenosis, previous cardiac or thoracic surgery, previous mediastinal radiation, emergent or salvage procedure, no bypassable left anterior descending artery disease (4110F with 1P)

OR

Performance Not Met: Internal mammary artery graft not performed for primary, isolated coronary artery bypass graft procedure, reason not otherwise specified (4110F with 8P)