Measure Description
Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure
Instructions
This measure is to be submitted each time a surgical procedure listed in the denominator 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 that have procedures through November 30th of the performance period. This will allow the evaluation of at least 30 days after the surgical 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 aged 18 years and older undergoing a surgical procedure
Denominator Criteria (Eligible Cases):
All patients aged 18 years and older
AND
Patient procedure during the performance period (CPT): 11004, 11005, 11006, 15734, 15920, 15931, 15933, 15940, 15950, 19306, 20100, 20101, 20102, 21811, 21812, 21813, 22904, 22905, 27080, 35221, 35251, 35281, 35840, 36565, 36566, 37617, 38100, 38115, 38120, 38530, 38531, 38564, 38765, 39501, 39540, 39541, 39560, 43122, 43279, 43281, 43282, 43286, 43287, 43288, 43325, 43327, 43330, 43332, 43333, 43336, 43337, 43340, 43500, 43501, 43502, 43510, 43520, 43605, 43610, 43611, 43620, 43621, 43622, 43631, 43632, 43633, 43634, 43640, 43641, 43644, 43645, 43651, 43652, 43653, 43772, 43773, 43774, 43775, 43800, 43810, 43820, 43825, 43830, 43831, 43832, 43840, 43843, 43845, 43846, 43847, 43848, 43850, 43860, 43865, 43870, 43880, 44005, 44010, 44020, 44021, 44025, 44050, 44055, 44110, 44111, 44120, 44125, 44126, 44127, 44130, 44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44155, 44156, 44157, 44158, 44160, 44180, 44186, 44187, 44188, 44202, 44204, 44205, 44206, 44207, 44208, 44210, 44211, 44212, 44227, 44300, 44310, 44312, 44314, 44316, 44320, 44322, 44340, 44345, 44346, 44602, 44603, 44604, 44605, 44615, 44620, 44625, 44626, 44640, 44650, 44660, 44661, 44680, 44700, 44800, 44820, 44850, 44900, 44950, 44960, 44970, 45000, 45020, 45110, 45111, 45112, 45113, 45114, 45116, 45119, 45120, 45121, 45123, 45126, 45130, 45135, 45136, 45395, 45397, 45400, 45402, 45540, 45550, 45562, 45563, 45800, 45805, 47010, 47015, 47100, 47120, 47122, 47125, 47130, 47300, 47350, 47360, 47361, 47362, 47370, 47380, 47400, 47420, 47425, 47460 ,47480, 47564, 47570, 47600, 47605, 47610, 47612, 47620, 47711, 47712, 47715, 47720, 47721, 47740, 47741, 47760, 47765, 47780, 47785, 47800, 47801, 47900, 48000, 48001, 48020, 48100, 48105, 48120, 48140, 48145, 48146, 48148, 48150, 48152, 48153, 48154, 48155, 48500, 48510, 48520, 48540, 48545, 48547, 48548, 49000, 49002, 49010, 49020, 49040, 49060, 49062, 49084, 49203, 49204, 49205, 49215, 49255, 49320, 49322, 49323, 49402, 49425, 49429, 49553, 49557, 49561, 49565, 49566, 49900, 50205, 50500, 50740, 57305, 57307, 60200, 60254, 60270, 60540, 60545, 60650
Numerator
Inpatient readmission to the same hospital for any reason or an outside hospital (if known to the surgeon), within 30 days of the principal surgical procedure
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: Unplanned hospital readmission within 30 days of principal procedure (G9310)
OR
Performance Not Met: No unplanned hospital readmission within 30 days of principal procedure (G9309)
Rationale
This is an adverse surgical outcome, which is often a preventable cause of harm, thus it is important to measure and report. It is feasible to collect the data and produce reliable and valid results about the quality of care. It is useful and understandable to stakeholders. This measure was developed in a collaborative effort by the American College of Surgeons and the American Board of Surgery. This measure addresses the National Quality Strategy Priorities, and was identified by an expert panel of physician providers to be a critical outcome for this procedure. This measure addresses a high-impact condition as it is one of the most common procedures performed in the U.S. The measure aligns well with the intended use. The care settings include Acute Care Facilities/Hospitals. Data are being collected in a clinical registry that has been in existence for over 10 years, with over 5500 current, active users. Thus, we are requesting consideration of this measure in the MIPS CQM reporting option. The level of analysis is the clinician/individual. All populations are included, except children. The measure allows measurement across the person-centered episode of care out to 30 days after the procedure whether an inpatient, outpatient, or readmitted. The measure addresses disparities in care. The risk adjustment is performed with a parsimonious dataset and aims to allow efficient data collection resources and data reporting. The measure has been harmonized when possible.
Clinical Recommendation Statements
A modified-Delphi methodology using an expert panel of surgeons who are Directors of the American Board of Surgery identified this to be a critical outcome for this surgical procedure (Surgeon Specific Registry Report on Project for ABS MOC Part IV. Unpublished study by the American College of Surgeons in conjunction with the American Board of Surgery, 2011).