Measure Description
Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure
Instructions
This measure is to be submitted each time an endovascular lower extremity revisualization procedure is performed during the performance period. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
NOTE: Include only patients undergoing an endovascular lower extremity revascularization procedure through December 29 of the performance period. This will allow the evaluation of at least 48 hours of the procedure within the performance period.
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 undergoing endovascular lower extremity revascularization
Denominator Criteria (Eligible Cases):
All patients, regardless of age
AND
Patient procedure during the performance period (CPT): 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231
AND NOT
DENOMINATOR EXCLUSION:
Documentation of planned hybrid or staged procedure: G9640
Numerator
Number of patients undergoing major amputation or open surgical bypass within 48 hours of the index endovascular lower extremity revascularization procedure
Definition:
Major Amputation – An amputation at the level of the ankle or above
Numerator Instruction:
INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that is trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.
Numerator Options:
Performance Met: Major amputation or open surgical bypass required within 48 hours of the index endovascular lower extremity revascularization procedure (G9641)
OR
Performance Not Met: Major amputation or open surgical bypass not required within 48 hours of the index endovascular lower extremity revascularization procedure (G9639)