2023 # 392 HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation

CMS Measure ID: #392

Collection Type: CQM

Reporting Frequency: Once per patient per year

Outcome: Yes

High Priority: Yes

NQS Domain: Patient Safety

Measure Age: > 2 years

Instructions

This measure is to be submitted a minimum of once per performance period for patients with atrial fibrillation ablation performed 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.

NOTE: Include only patients that have had atrial fibrillation ablation performed by November 30, 2023, for evaluation of cardiac tamponade and/or pericardiocentesis occurring within 30 days within the performance period. This will allow the evaluation of cardiac tamponade and/or pericardiocentesis complications within the performance period. A minimum of 30 cases is recommended by the measure owner to ensure a volume of data that accurately reflects provider performance; however, this minimum number is not required for purposes of QPP submission.

This measure will be calculated with 5 performance rates:

• Females 18-64 years of age
• Males 18-64 years of age
• Females 65 years of age and older
• Males 65 years of age and older
• Overall percentage of patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days

Eligible clinicians should continue to submit the measure as specified, with no additional steps needed to account for multiple performance rates.

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

Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This measure is submitted as four rates stratified by age and gender:

• Submission Age Criteria 1: Females 18-64 years of age
• Submission Age Criteria 2: Males 18-64 years of age
• Submission Age Criteria 3: Females 65 years of age and older
• Submission Age Criteria 4: Males 65 years of age and older

Denominator

All patients aged 18 years and older with atrial fibrillation ablation performed during the reporting period

Denominator Criteria (Eligible Cases):

SUBMISSION CRITERIA 1: Females 18-64 years old

SUBMISSION CRITERIA 2: Males 18-64 years old

SUBMISSION CRITERIA 3: Females 65 years of age and older

SUBMISSION CRITERIA 4: Males 65 years of age and older

AND

Diagnosis code for atrial fibrillation (ICD-10-CM): I48.0, I48.11, I48.19, I48.20, I48.21, I48.91

AND

Procedure code for atrial fibrillation ablation (ICD-10-PCS): 02583ZZ, 02584ZZ

WITHOUT

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

AND/OR

Ablation procedures that have been performed by November 30 of current performance period (CPT): 93656

WITHOUT

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

Numerator

The number of patients from the denominator with cardiac tamponade and/or pericardiocentesis occurring within 30 days following atrial fibrillation ablation

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:

Patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days (G9408)

OR

Performance Not Met:

Patients without cardiac tamponade and/or pericardiocentesis occurring within 30 days (G9409)