#259: Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2)

Quality ID

259

High Priority Measure

Yes

Specifications

Registry

Measure Type

Outcome

Specialty

Vascular Surgery

Measure Description

Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2)

 

Instructions

This measure is to be submitted each time an endovascular repair AAA is performed during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who provide services of AAA repair, as described in the measure, based on the services provided and the measure-specific denominator coding will submit this measure. This measure may be submitted by MIPS eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. 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 as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

 

Denominator

All endovascular repairs of non-ruptured, infrarenal abdominal aortic aneurysms

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Diagnosis for non-rupture, infrarenal abdominal aortic aneurysms (ICD-10-CM): I71.4

AND

Patient procedure during the performance period (CPT): 34701, 34703, 34705

AND NOT

DENOMINATOR EXCLUSIONS:

For women:

Aortic aneurysm 5.5 - 5.9 cm maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9003F

OR

Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9004F

OR

For men:

Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9004F

 

Numerator

Patients discharged to home no later than post-operative day #2 following EVAR of AAA

Definition:

Home – For purposes of submitting this measure, home is the point of origin prior to hospital admission prior to procedure of AAA. For example, if the patient comes from a skilled facility and returns to the skilled facility post AAA repair, this would meet criteria for discharged to home.

Numerator Options:

Performance Met: Patient discharged to home no later than post-operative day #2 following EVAR (G8826)

OR

Performance Not Met: Patient not discharged to home by post-operative day #2 following EVAR (G8833)

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