MIPS Clinical Quality Measures (CQMS)
MEASURE TYPE: Outcome – High Priority
Description
Percent of asymptomatic patients undergoing Carotid Endarterectomy (CEA) who are discharged to home no later than post-operative day #2.
Instructions
This measure is to be submitted each time a CEA is performed during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who provide services of CEA, 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 carotid endarterectomy procedures
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient procedure during the performance period (CPT): 35301
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10
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 that are asymptomatic neurologically who were discharged alive, to home no later than post-operative day #2 following CEA
Definition:
Home – For purposes of submitting this measure, “home” is the point of origin prior to hospital admission for procedure of CEA. For example, if the patient comes from a skilled facility and returns to the skilled facility post CEA, this would meet criteria for discharged to home.
Numerator Options:
Performance Met: Patient discharged to home no later than post-operative day #2 following CEA (G8834)
OR
Performance Not Met: Patient not discharged to home by post-operative day #2 following CEA (G8838)
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