2024 MIPS Measure #393: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision

2024 COLLECTION TYPE:

MIPS Clinical Quality Measures (CQMS)

‌MEASURE TYPE: Outcome – High Priority

Description

Infection rate following CIED device implantation, replacement, or revision.

Instructions

This measure is to be submitted a minimum of once per performance period for patients with a CIED device implantation, replacement, or revision performed from January 1, 2024 through June 30, 2024 of 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 CIED implantation, replacement, or revision performed by June 30, 2024. This timeframe allows for evaluation of infection required within 180 days within the performance period. This will allow the evaluation of infection status post CIED implantation, replacement, or revision within the performance period.

Infection rates for new implants shall be calculated and submitted separately from device replacements and revisions.

Additional submitting stratification categories may be useful; however, these stratifications are not required for purposes of QPP submission:

• Device class (e.g., pacemaker, ICD) and type (e.g., single chamber, dual chamber);
• Advanced renal disease (CKD stages 4 and 5, ESRD);
• Diabetes;
• CIED infection requiring device removal within 180 days prior to index CIED procedures; and
• CIED-related surgical procedure within 180 days prior to current CIED procedure.

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.

There are two submission criteria for this measure:

1. Patients, regardless of age, with a new CIED

   OR

2. Patients, regardless of age, with a replaced or revised CIED

Submission Criteria 1:

Patients with a new CIED

Denominator (Submission Criteria 1)‌

All patients with a new CIED from January 1, 2024 through June 30, 2024 of the performance period

Definition:

CIEDs encompassed for this measure are the following devices:

• Pacemaker devices (single or dual chamber)
• Implantable cardioverter-defibrillators (ICDs, single or dual chamber)
• Cardiac resynchronization devices (pacemaker or ICD)
• Implantable loop recorders (ILRs)

Denominator Criteria (Eligible Cases) 1:

All patients, regardless of age

AND

Procedure code for implantation, replacement, or revision of a CIED (ICD-10-PCS): 0JH604Z, 0JH605Z, 0JH606Z, 0JH607Z, 0JH608Z, 0JH609Z, 0JH60PZ, 0JH634Z, 0JH635Z, 0JH636Z, 0JH637Z, 0JH638Z, 0JH639Z, 0JH63PZ, 0JH804Z, 0JH805Z, 0JH806Z, 0JH807Z, 0JH808Z, 0JH809Z, 0JH80PZ, 0JH834Z, 0JH835Z, 0JH836Z, 0JH837Z, 0JH838Z, 0JH83PZ, 0JPT0PZ, 0JPT3PZ, 0JWT0PZ, 0JWT3PZ

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10

AND/OR

Patient encounter during performance period (CPT): 33202, 33203, 33206, 33207, 33208, 33212, 33213, 33214, 33215, 33216, 33217, 33218, 33220, 33221, 33222, 33223, 33224, 33226, 33227, 33228, 33229, 33240, 33249, 33262, 33263, 33264, 33270

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10

AND

New CIED

AND NOT

Denominator Exclusion:

Procedure code for heart transplantation (ICD-10-PCS): 02YA0Z0, 02YA0Z1, 02YA0Z2

‌Numerator (Submission Criteria 1):

The number of patients from the denominator admitted with an infection requiring device removal or surgical revision within 180 days following CIED implantation, replacement, or revision

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 admitted within 180 days, status post CIED implantation, replacement, or revision with an infection requiring device removal or surgical revision (G9410)

OR

Performance Not Met: Patient not admitted within 180 days, status post CIED implantation, replacement, or revision with an infection requiring device removal or surgical revision (G9411)

OR

Submission Criteria 2:

Patients with a replaced CIED

Denominator (Submission Criteria 2)‌

All patients with replacement or revision of a CIED from January 1, 2024 through June 30, 2024 of the performance period

Definition:

CIEDs encompassed for this measure are the following devices:

• Pacemaker devices (single or dual chamber)
• Implantable cardioverter-defibrillators (ICDs, single or dual chamber)
• Cardiac resynchronization devices (pacemaker or ICD)
• Implantable loop recorders (ILRs)

Denominator Criteria (Eligible Cases) 2:

All patients, regardless of age

AND

Procedure code for implantation, replacement, or revision of a CIED (ICD-10-PCS): 0JH604Z, 0JH605Z, 0JH606Z, 0JH607Z, 0JH608Z, 0JH609Z, 0JH60PZ, 0JH634Z, 0JH635Z, 0JH636Z, 0JH637Z, 0JH638Z, 0JH639Z, 0JH63PZ, 0JH804Z, 0JH805Z, 0JH806Z, 0JH807Z, 0JH808Z, 0JH809Z, 0JH80PZ, 0JH834Z, 0JH835Z, 0JH836Z, 0JH837Z, 0JH838Z, 0JH83PZ, 0JPT0PZ, 0JPT3PZ, 0JWT0PZ, 0JWT3PZ

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10

AND/OR

Patient encounter during performance period (CPT): 33202, 33203, 33206, 33207, 33208, 33212, 33213, 33214, 33215, 33216, 33217, 33218, 33220, 33221, 33222, 33223, 33224, 33226, 33227, 33228, 33229, 33240, 33249, 33262, 33263, 33264, 33270

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10

AND

Replaced or revised CIED

AND NOT

Denominator Exclusion:

‌Procedure code for heart transplantation (ICD-10-PCS): 02YA0Z0, 02YA0Z1, 02YA0Z2

Numerator (Submission Criteria 2):

The number of patients from the denominator admitted with an infection requiring device removal or surgical revision within 180 days following CIED implantation, replacement, or revision

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 admitted within 180 days, status post CIED implantation, replacement, or revision with an infection requiring device removal or surgical revision (G9412)

OR

Performance Not Met: Patient not admitted within 180 days, status post CIED implantation, replacement, or revision with an infection requiring device removal or surgical revision (G9413)