2023 # 354 Anastomotic Leak Intervention

CMS Measure ID: #354

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: Yes

High Priority: Yes

NQS Domain: Patient Safety

Measure Age: > 2 years

Instructions

This measure is to be submitted each time a procedure for anastomotic leak intervention following gastric bypass or colectomy surgery 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 gastric bypass or colectomy surgery within the performance period.

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

Description

Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: No
Capped at 7: No

Decile 0: 76.13 – 100
Decile 1: 17.15 – 76.12
Minimum: 8.5 – 17.14
Decile 3: 4.87 – 8.49
Decile 4: 1.06 – 4.86
Decile 5: 0.01 – 1.05
Decile 10: 0 – 0

Denominator

Patients aged 18 years and older undergoing gastric bypass or colectomy surgery

Denominator Criteria (Eligible Cases):

All patients aged 18 years and older

AND

Patient procedure during the performance period (CPT): 43644, 43645, 43775, 43845, 43846, 43847, 43848, 43860, 43865, 44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44155, 44156, 44157, 44158, 44160, 44204, 44205, 44206, 44207, 44208, 44210, 44211, 44212, 44626

WITHOUT

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

Numerator

Intervention (via return to operating room, interventional radiology, or interventional gastroenterology) for presence of leak of endoluminal contents (such as air, fluid, GI contents, or contrast material) through an anastomosis. The presence of an infection/abscess thought to be related to an anastomosis, even if the leak cannot be definitively identified as visualized during an operation, or by contrast extravasation would also be considered an anastomotic leak

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:

Intervention for presence of leak of endoluminal contents through an anastomosis required (G9306)

Performance Not Met:

Intervention for presence of leak of endoluminal contents through an anastomosis not required (G9305)