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2021 MIPS Measure #445: Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)

Quality ID 445
NQF 0119
High Priority Measure Yes
Specifications Registry
Measure Type Outcome
Specialty Thoracic Surgery

Measure Description

Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure

 

Instructions

This measure is to be submitted a minimum of once per performance period for patients undergoing isolated CABG during the performance period. 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.

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 patients undergoing isolated CABG

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Patient procedure during the performance period (CPT): 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536

OR

Patient procedure during the performance period (CPT): 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536

AND

Patient procedure during the performance period (CPT): 33530

 

Numerator

Number of patients undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the 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: Patient died including all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure (G9812)

OR

Performance Not Met: Patient did not die within 30 days of the procedure or during the index hospitalization (G9813)

 

Rationale

Quality measurement and outcome analysis of this common cardiac procedure will drive process improvement for providers and assist patients with decision-making related to treatment of coronary disease.


Clinical Recommendation Statements

Mortality is likely the single most important negative outcome that can be associated with a surgical procedure. Coronary artery bypass grafting is the most common cardiac surgery performed in the US.

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