2019 MIPS Measure #446: Operative Mortality Stratified by the Five STS-EACTS Mortality Categories

Measure Description

Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool

Instructions

This measure is to be submitted for all pediatric and/or congenital heart patients each time a surgery is performed during the performance period.

This measure is intended to reflect the quality of services provided for patients with congenital heart disease. 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.

Mortality is only counted once - so the denominator is all patients having CHS and the numerator is 1) deaths occurring within the index acute care hospitalization and 2) Deaths occurring after discharge but within 30 days of surgery.

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.

THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:

1) Patients who undergo pediatric and/or congenital heart surgery that experience death during the index acute care hospitalization

OR

2) Patients who undergo pediatric and/or congenital heart surgery that experience death after discharge from the hospital but within 30 days post procedure

SUBMISSION CRITERIA 1: ALL DEATHS DURING HOSPITALIZATION

Denominator (Submission Criteria 1)

Number of index cardiac operations in each level of complexity stratification using the five STS-EACTS Mortality Levels, a multi-institutional validated complexity stratification tool

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases) 1:

Diagnosis for congenital heart disease (ICD-10-CM):

AND

Patient procedure during performance period (CPT): 15732, 15734, 19271, 19272, 21550, 21555, 21552, 21556, 21554, 21557, 21558, 21600, 21615, 21616, 21620, 21627, 21630, 21632, 21685, 21705, 21740, 21742, 21743, 21750, 21899, 31612, 31613, 31614, 31622, 31623, 31624, 31625, 31626, 31627, 31628, 31629, 31630, 31631, 31634, 31635, 31636, 31638, 31640, 31641, 31643, 31645, 31646, 31647, 31648, 31652, 31653, 31786, 32096, 32097, 32100, 32110, 32120, 32124, 32140, 32141, 32150, 32151, 32160, 32200, 32215, 32220, 32225, 32310, 32320, 32400, 32405, 32503, 32504, 32601, 32604, 32606, 32607, 32608, 32609, 32850*, 32851, 32852, 32853, 32854, 32855, 32856, 32900, 33010, 33011, 33015, 33025, 33030, 33031, 33050, 33120, 33130, 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33230, 33231, 33240, 33249, 33250, 33251, 33254, 33255, 33256, 33257, 33258, 33259, 33261, 33265, 33266, 33270, 33271, 33390, 33391, 33404, 33405, 33406, 33410, 33411, 33412, 33413, 33414, 33415, 33416, 33417, 33418, 33419, 33420, 33422, 33425, 33426, 33427, 33430, 33440, 33460, 33463, 33464, 33465, 33468, 33470, 33471, 33474, 33475, 33476, 33477, 33478, 33496, 33500, 33501, 33502, 33503, 33504, 33505, 33506, 33507, 33542, 33545, 33548, 33600, 33602, 33606, 33608, 33610, 33611, 33612, 33615, 33617, 33619, 33620, 33621, 33622, 33641, 33645, 33647, 33660, 33665, 33670, 33675, 33676, 33677, 33681, 33684, 33688, 33690, 33692, 33694, 33697, 33702, 33710, 33720, 33722, 33724, 33726, 33730, 33732, 33735, 33736, 33737, 33750, 33755, 33762, 33764, 33766, 33767, 33770, 33771, 33774, 33775, 33776, 33777, 33778, 33779, 33780, 33781, 33782, 33783, 33786, 33788, 33800, 33802, 33803, 33813, 33814, 33820, 33822, 33824, 33840, 33845, 33851, 33852, 33853, 33860, 33863, 33864, 33870, 33875, 33877, 33886, 33910, 33915, 33916, 33917, 33920, 33922, 33924, 33925, 33926, 33930*, 33933, 33935, 33940*, 33944, 33945, 33946, 33947, 33948, 33967, 33970, 33971, 33973, 33974, 33975, 33976, 33977, 33978, 33979, 33980, 33981, 33982, 33983, 33987, 33988, 33989, 33990, 33991, 33992, 33993, 33999, 59076, 59897, 71275, 74175, 75557, 75559, 75561, 75563, 75565, 75572, 75573, 75574, 76825, 76826, 76825, 92992, 92993, 93303, 93304, 93315, 93316, 93317, 93355, 93530, 93531, 93532, 93533, 93563, 93564, 93580, 93581, 93582, 93583

AND

STS-EACTS Mortality Level Tool Utilized

Numerator (Submission Criteria 1)

All deaths occurring during the index acute care hospitalization in which the procedure was performed (no matter how long post op) in which the procedure was performed stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool

Numerator Instructions:

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 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: Death occurring during the index acute care hospitalization (G9814)

OR

Performance Not Met: Death did not occur during the index acute care hospitalization (G9815)

OR

SUBMISSION CRITERIA 2: DEATHS OCCURING AFTER HOSPITAL DISCHARGE WITHIN 30 DAYS AFTER PROCEDURE

Denominator (Submission Criteria 2)

Number of index cardiac operations in each level of complexity stratification using the five STS-EACTS Mortality Levels, a multi-institutional validated complexity stratification tool

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases) 2:

Diagnosis for congenital heart disease (ICD-10-CM):

AND

Patient procedure during performance period (CPT): 15732, 15734, 19271, 19272, 21550, 21555, 21552, 21556, 21554, 21557, 21558, 21600, 21615, 21616, 21620, 21627, 21630, 21632, 21685, 21705, 21740, 21742, 21743, 21750, 21899, 31612, 31613, 31614, 31622, 31623, 31624, 31625, 31626, 31627, 31628, 31629, 31630, 31631, 31634, 31635, 31636, 31638, 31640, 31641, 31643, 31645, 31646, 31647, 31648, 31652, 31653, 31786, 32096, 32097, 32100, 32110, 32120, 32124, 32140, 32141, 32150, 32151, 32160, 32200, 32215, 32220, 32225, 32310, 32320, 32400, 32405, 32503, 32504, 32601, 32604, 32606, 32607, 32608, 32609, 32850*, 32851, 32852, 32853, 32854, 32855, 32856, 32900, 33010, 33011, 33015, 33025, 33030, 33031, 33050, 33120, 33130, 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33230, 33231, 33240, 33249, 33250, 33251, 33254, 33255, 33256, 33257, 33258, 33259, 33261, 33265, 33266, 33270, 33271, 33403, 33404, 33405, 33406, 33410, 33411, 33412, 33413, 33414, 33415, 33416, 33417, 33418, 33419, 33420, 33422, 33425, 33426, 33427, 33430, 33440, 33460, 33463, 33464, 33465, 33468, 33470, 33471, 33474, 33475, 33476, 33477, 33478, 33496, 33500, 33501, 33502, 33503, 33504, 33505, 33506, 33507, 33542, 33545, 33548, 33600, 33602, 33606, 33608, 33610, 33611, 33612, 33615, 33617, 33619, 33620, 33621, 33622, 33641, 33645, 33647, 33660, 33665, 33670, 33675, 33676, 33677, 33681, 33684, 33688, 33690, 33692, 33694, 33697, 33702, 33710, 33720, 33722, 33724, 33726, 33730, 33732, 33735, 33736, 33737, 33750, 33755, 33762, 33764, 33766, 33767, 33770, 33771, 33774, 33775, 33776, 33777, 33778, 33779, 33780, 33781, 33782, 33783, 33786, 33788, 33800, 33802, 33803, 33813, 33814, 33820, 33822, 33824, 33840, 33845, 33851, 33852, 33853, 33860, 33863, 33864, 33870, 33875, 33877, 33886, 33910, 33915, 33916, 33917, 33920, 33922, 33924, 33925, 33926, 33930*, 33933, 33935, 33940*, 33944, 33945, 33946, 33947, 33948, 33967, 33970, 33971, 33973, 33974, 33975, 33976, 33977, 33978, 33979, 33980, 33981, 33982, 33983, 33987, 33988, 33989, 33990, 33991, 33992, 33993, 33999, 59076, 59897, 71275, 74175, 75557, 75559, 75561, 75563, 75565, 75572, 75573, 75574, 76825, 76826, 76825, 92992, 92993, 93303, 93304, 93315, 93316, 93317, 93355, 93530, 93531, 93532, 93533, 93563, 93564, 93580, 93581, 93582, 93583

AND

STS-EACTS Mortality Level Tool Utilized

Numerator (Submission Criteria 2)

Those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool

Numerator Instructions:

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 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: Death occurring after discharge from the hospital but within 30 days post procedure (G9816)

OR

Performance Not Met: Death did not occur after discharge from the hospital within 30 days post procedure (G9817)