2024 MIPS Measure #421: Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal

2024 COLLECTION TYPE:

MIPS Clinical Quality Measures (CQMS)

‌MEASURE TYPE: Process

Description

‌Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal, or the inability to contact the patient with at least two attempts.

Instructions

This measure is to be submitted each time for patients with an IVC filter procedure 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 IVC filter placement through September 30 of the performance period. This will allow the evaluation of at least 90 days of IVC filter removal within the performance period.

‌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 patients who have a retrievable IVC filter placed with the intent for potential removal at time of placement

Denominator Criteria (Eligible Cases):

All patients, regardless of age

AND

Patient procedure during the performance period (CPT): 37191

WITHOUT

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

AND

Intent for Potential Removal at Time of Placement: G9539

AND

Patient alive 3 Months Post Procedure: G9540

Numerator

Number of patients that have appropriate IVC filter follow-up

Definition:

Appropriate IVC Filter follow-up – For the purposes of this measure, the appropriate follow-up would include:

• Filter removed OR
• Documentation of re-assessment for the appropriateness of filter removal OR
• Documentation of at least two attempts to reach the patient to arrange a clinical re-assessment for the appropriateness of filter removal

NUMERATOR NOTE: The procedure for removal of an intravascular filter from the vena cava (CPT 37193) within three months would be considered performance met.

Numerator Options:

Performance Met: Filter removed within 3 months of placement (G9541)

OR

Performance Met: Documented re-assessment for the appropriateness of filter removal within 3 months of placement (G9542)

OR

Performance Met: Documentation of at least two attempts to reach the patient to arrange a clinical re-assessment for the appropriateness of filter removal within 3 months of placement (G9543)

OR

‌Performance Not Met: Patients that do not have the filter removed, documented re-assessment for the appropriateness of filter removal, or documentation of at least two attempts to reach the patient to arrange a clinical re-assessment for the appropriateness of filter removal within 3 months of placement (G9544)