2021 MIPS Measure #258: Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)

Quality ID 258
High Priority Measure Yes
Specifications Registry
Measure Type Outcome
Specialty Vascular Surgery

Measure Description

Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms (AAA) who do not experience a major complication (discharge to home no later than post-operative day #7)

 

Instructions

This measure is to be submitted each time an open 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 open repairs of non-ruptured, infrarenal abdominal aortic aneurysms

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Patient procedure during the performance period (CPT): 35081, 35102

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 #7

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 discharge to home no later than post-operative day #7 (G8818)

OR

Performance Not Met: Patient not discharged to home by post-operative day #7 (G8825)​​​​​​​

 

Rationale

Elective repair of a small or moderate sized AAA is a prophylactic procedure and the mortality/morbidity of the procedure must be contrasted with the risk of rupture over time. Surgeons should select patients for intervention who have a reasonable life expectancy and who do not have a high surgical risk. Discharge to home within one week of open AAA repair is an indicator of patients who were not frail prior to the procedure and who did not experience a major complication. The proposed measure will therefore serve as an indicator of both appropriateness and overall outcome.

 

Clinical Recommendation Statements

The Care of Patients with an Abdominal Aortic Aneurysm: The Society for Vascular Surgery Practice Guidelines. (Chaikof et al, J Vasc Surg, 50:4, supplement, 2009)

Elective repair is recommended for patients that present with a fusiform AAA ≥ 5.5 cm in maximum diameter, in the absence of significant co-morbidities

Level of recommendation: Strong

Quality of evidence: High

Surveillance is recommended for most patients with a fusiform AAA in the range of 4.0 cm to 5.4 cm in maximum diameter.

Level of recommendation: Strong

Quality of evidence: Moderate

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