2023 # 344 Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)

CMS Measure ID: #344

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: Yes

High Priority: Yes

NQS Domain: Effective Clinical Care

Measure Age: > 2 years

Instructions

This measure is to be submitted each time a CAS is performed during the performance period. It is anticipated that eligible clinicians who provide services of CAS, 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 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:

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 for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

Description

Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2

Denominator

Patients aged 18 and older who are asymptomatic undergoing CAS

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):

Patients aged 18 and older

AND

Patient procedure during performance period (CPT): 37215, 37216*

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02

AND NOT

DENOMINATOR EXCLUSIONS:

Symptomatic carotid stenosis: Ipsilateral carotid territory TIA or stroke less than 120 days prior to procedure: 9006F

OR

Other carotid stenosis: Ipsilateral TIA or stroke 120 days or greater prior to procedure or any prior contralateral carotid territory or vertebrobasilar TIA or stroke: 9007F

Numerator

Patients discharged to home no later than post-operative day 2 following CAS

Definition:

Home – For purposes of submitting this measure, “home” is the point of origin prior to hospital admission prior to procedure. For example, if the patient comes from a skilled facility and returns to the skilled facility, this would meet criteria for discharged to home.

Numerator Options:

Performance Met:

Documentation of patient discharged to home no later than post-operative day 2 following CAS (G9255)

OR

Performance Not Met:

Documentation of patient discharged to home later than post-operative day 2 following CAS (G9254)