2019 MIPS Measure #346: Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive

Quality ID 346
NQF 1540
High Priority Measure Yes
Specifications Registry
Measure Type Outcome
Specialty Neurosurgery Vascular Surgery

Measure Description

Percent of asymptomatic patients undergoing CEA who are stroke free or discharged alive following surgery

 

Instructions

This measure is to be submitted each time a CEA is performed during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who provide services of CEA, 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

Patients aged 18 and older who are asymptomatic undergoing CEA

Denominator Criteria (Eligible Cases):

Patients aged 18 and older

AND

Patient procedure during performance period (CPT): 35301

AND NOT

DENOMINATOR EXCLUSIONS:

Symptomatic carotid stenosis: Ipsilateral carotid territory TIA or stroke less than 120 days prior to procedure: 9006F

OR

Other carotid stenosis: Ipsilateral TIA or stroke 120 days or greater prior to procedure or any prior contralateral carotid territory or vertebrobasilar TIA or stroke: 9007F

 

Numerator

Patients who are stroke free or discharged alive following CEA

Numerator Options:

Performance Met: Documentation of patient survival and absence of stroke following CEA (G9261)

OR

Performance Not Met: Documentation of patient stroke following CEA (G9258)

OR

Performance Not Met: Documentation of patient death following CEA (G9260)

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