| Measure Type | High Priority Measure? | Collection Type(s) |
|---|---|---|
| Process | no | MIPS CQM |
Measure Description
Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision
Instructions
This measure is to be submitted each time an isolated CABG procedure is performed during the performance period. It is anticipated that eligible clinicians who provide services for isolated CABG will submit this measure. The timeframe for this measure includes the entire 24 hour period prior to the surgical incision time.
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
Isolated CABG surgeries for patients aged 18 years and older
Definition:
Isolated CABG – Refers to CABG using arterial and/or venous grafts only
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient procedure during the performance period (CPT): 00566, 00567, 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536
OR
Patient procedure during the performance period (CPT): 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536
AND
Patient procedure during the performance period (CPT): 33530
Numerator
Patients who received a beta-blocker within 24 hours prior to surgical incision of isolated CABG surgeries
Definition:
Medical Reason – Eligible clinician must document specific reason(s) for not administering beta- blockers
NUMERATOR NOTE: Denominator Exception(s) are determined on the date of the denominator eligible encounter.
Numerator Options:
Performance Met:
Beta blocker administered within 24 hours prior to surgical incision (4115F)
OR
Denominator Exception:
Documentation of medical reason(s) for not administering beta blocker within 24 hours prior to surgical incision (e.g., not indicated, contraindicated, other medical reason) (4115F with 1P)
OR
Performance Not Met:
Beta blocker not administered within 24 hours prior to surgical incision, reason not otherwise specified (4115F with 8P)