2021 MIPS Measure #076: Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections

Measure Description

Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

Instructions

This measure is to be submitted each time a CVC insertion is performed during the performance period. There is no diagnosis associated with this measure. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who perform CVC insertion will submit this measure.

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, regardless of age, who undergo CVC insertion

Denominator Criteria (Eligible Cases):

Patient procedure during the performance period (CPT): 36555, 36556, 36557, 36558, 36560, 36561, 36563, 36565, 36566, 36568, 36569, 36570, 36571, 36572, 36573, 36578, 36580, 36581, 36582, 36583, 36584, 36585, 93503

Numerator

Patients for whom central venous catheter (CVC) was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

Definitions:

Maximal Sterile Barrier Technique – includes all of the following elements: Cap AND mask AND sterile gown AND sterile gloves AND sterile full body drape.

Sterile Ultrasound Techniques – require sterile gel and sterile probe covers.

Hand Hygiene—Washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR)

Numerator Options:

Performance Met:

All elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed (6030F)

OR

Denominator Exception:

Documentation of medical reason(s) for not following all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques during CVC insertion (including increased risk of harm to patient if adherence to aseptic technique would cause delay in CVC insertion) (6030F with 1P)

OR

Performance Not Met:

All elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques not followed, reason not otherwise specified (6030F with 8P)