2021 MIPS Measure #358: Patient-Centered Surgical Risk Assessment and Communication

Measure Description

Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon

Instructions

This measure is to be submitted each time a procedure is performed during the performance period for patients who undergo non-emergency surgical procedures. There is no diagnosis associated with this measure. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the listed surgical procedures as specified in the denominator coding 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

The total number of adult patients (age 18 and over) having had non-emergency surgery

Denominator Instructions:
CPT Category I procedure codes billed by surgeons performing surgery on the same patient, submitted with modifier 62 (indicating two surgeons, i.e., dual procedures) will be included in the denominator population, therefore both surgeons will be fully accountable for the clinical action described in the measure.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Patient encounter during the performance period (CPT): 10121, 10140, 10160, 10180, 11000, 11004, 11005, 11006, 11010, 11011, 11042, 11043, 11044, 11401, 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 11601, 11602, 11603, 11960, 14301, 15040, 15150, 15155, 15200, 15220, 15240, 15260, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15730, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15769, 15770, 15771, 15773, , 15830, 15920, 15922, 15931, 15933, 15934, 15935, 15936, 15937, 15940, 15941, 15944, 15945, 15946, 15950, 15951, 15953, 15956, 15958, 19020, 19101, 19110, 19120, 19125, 19296, 19298, 19300, 19301, 19302, 19303, 19305, 19306, 19307, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19499, 20100, 20101, 20102, 20103, 20150, 20696, 20900, 20902, 20910, 20922, 20955, 20956, 20999, 21011, 21012, 21013, 21014, 21015, 21016, 21025, 21026, 21034, 21040, 21044, 21045, 21046, 21047, 21048, 21049, 21139, 21154, 21235, 21299, 21360, 21395, 21462, 21465, 21499, 21501, 21502, 21510, 21552, 21554, 21555, 21556, 21557, 21558, 21600, 21601, 21602, 21603, 21615, 21616, 21620, 21627, 21630, 21632, 21685, 21700, 21705, 21740, 21742, 21743, 21750, 21825, 21899, 21920, 21925, 21930, 21931, 21932, 21933, 21935, 21936, 22010, 22015, 22100, 22101, 22102, 22110, 22112, 22114, 22206, 22207, 22210, 22212, 22214, 22220, 22222, 22224, 22318, 22319, 22325, 22326, 22327, 22532, 22533, 22548, 22551, 22554, 22556, 22558, 22586, 22590, 22595, 22600, 22610, 22612, 22630, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22849, 22850, 22852, 22855, 22856, 22857, 22861, 22862, 22864, 22865, 22899, 22900, 22901, 22902, 22903, 22904, 22905, 22999, 23000, 23020, 23030, 23031, 23035, 23040, 23044, 23071, 23073, 23075, 23076, 23077, 23078, 23101, 23106, 23107, 23120, 23125, 23130, 23140, 23146, 23150, 23156, 23170, 23180, 23182, 23184, 23190, 23195, 23200, 23210, 23220, 23395, 23397, 23400, 23405, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 23470, 23472, 23480, 23485, 23491, 23515, 23530, 23532, 23550, 23552, 23585, 23615, 23616, 23630, 23660, 23670, 23680, 23800, 23802, 23900, 23920, 23929, 23935, 24000, 24006, 24065, 24066, 24071, 24073, 24075, 24076, 24077, 24079, 24102, 24105, 24116, 24120, 24125, 24130, 24134, 24136, 24140, 24145, 24149, 24150, 24152, 24201, 24301, 24310, 24320, 24330, 24332, 24340, 24341, 24342, 24344, 24345, 24346, 24358, 24359, 24360, 24361, 24363, 24365, 24366, 24400, 24430, 24435, 24495, 24498, 24515, 24516, 24538, 24545, 24546, 24575, 24579, 24586, 24587, 24615, 24635, 24665, 24666, 24685, 24800, 24802, 24900, 24920, 24925, 24999, 25000, 25001, 25020, 25023, 25024, 25025, 25040, 25065, 25066, 25071, 25073, 25075, 25076, 25077, 25078, 25085, 25101, 25105, 25107, 25110, 25111, 25112, 25115, 25116, 25118, 25120, 25125, 25130, 25135, 25136, 25145, 25150, 25151, 25170, 25210, 25215, 25230, 25240, 25248, 25260, 25263, 25265, 25270, 25274, 25275, 25280, 25290, 25295, 25301, 25310, 25312, 25315, 25320, 25332, 25337, 25350, 25355, 25360, 25375, 25390, 25391, 25392, 25400, 25405, 25415, 25420, 25430, 25431, 25440, 25442, 25443, 25445, 25446, 25447, 25449, 25490, 25515, 25525, 25526, 25545, 25574, 25575, 25607, 25608, 25609, 25628, 25645, 25652, 25670, 25676, 25685, 25695, 25900, 25905, 25909, 25920, 25927, 25999, 26111, 26113, 26115, 26116, 26117, 26118, 26121, 26123, 26130, 26145, 26180, 26350, 26352, 26356, 26357, 26358, 26370, 26372, 26373, 26390, 26392, 26410, 26415, 26418, 26420, 26426, 26433, 26434, 26437, 26440, 26442, 26445, 26449, 26450, 26455, 26460, 26471, 26477, 26478, 26480, 26483, 26485, 26489, 26490, 26492, 26496, 26497, 26498, 26500, 26502, 26510, 26520, 26525, 26530, 26531, 26535, 26536, 26540, 26541, 26542, 26545, 26546, 26548, 26561, 26565, 26567, 26568, 26587, 26591, 26593, 26615, 26650, 26665, 26676, 26685, 26686, 26715, 26727, 26735, 26746, 26765, 26776, 26785, 26952, 26989, 26990, 26991, 26992, 27000, 27001, 27005, 27006, 27025, 27027, 27030, 27033, 27035, 27036, 27040, 27041, 27043, 27045, 27047, 27048, 27049, 27054, 27057, 27059, 27060, 27062, 27065, 27066, 27070, 27071, 27075, 27076, 27077, 27078, 27080, 27086, 27087, 27097, 27110, 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165, 27170, 27176, 27177, 27179, 27181, 27187, 27202, 27226, 27227, 27228, 27235, 27236, 27238, 27244, 27245, 27248, 27253, 27254, 27258, 27259, 27267, 27269, 27280, 27290, 27295, 27299, 27301, 27303, 27305, 27307, 27310, 27327, 27328, 27329, 27331, 27332, 27333, 27334, 27335, 27337, 27339, 27340, 27345, 27347, 27350, 27355, 27356, 27357, 27360, 27364, 27365, 27372, 27380, 27381, 27385, 27386, 27390, 27392, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 27427, 27428, 27429, 27430, 27435, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27448, 27450, 27454, 27455, 27457, 27465, 27466, 27468, 27470, 27472, 27477, 27485, 27486, 27487, 27488, 27495, 27496, 27497, 27498, 27499, 27506, 27507, 27509, 27511, 27513, 27514, 27519, 27524, 27535, 27536, 27540, 27556, 27557, 27566, 27580, 27590, 27591, 27592, 27594, 27596, 27598, 27599, 27600, 27601, 27602, 27603, 27604, 27605, 27606, 27607, 27610, 27612, 27615, 27616, 27618, 27619, 27620, 27625, 27626, 27630, 27632, 27634, 27635, 27637, 27638, 27640, 27641, 27645, 27646, 27647, 27650, 27652, 27654, 27656, 27658, 27659, 27664, 27665, 27675, 27676, 27680, 27681, 27685, 27686, 27687, 27695, 27696, 27698, 27700, 27702, 27703, 27704, 27705, 27707, 27709, 27715, 27720, 27722, 27724, 27725, 27726, 27745, 27756, 27758, 27759, 27766, 27769, 27784, 27792, 27814, 27822, 27823, 27826, 27827, 27828, 27829, 27832, 27846, 27848, 27880, 27881, 27882, 27884, 27886, 27888, 27889, 27892, 27893, 27894, 27899, 28002, 28003, 28039, 28041, 28043, 28045, 28046, 28047, 28192, 28193, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28415, 28420, 28445, 28446, 28465, 28485, 28505, 28525, 28531, 28555, 28585, 28615, 28645, 28675, 28705, 28715, 28725, 28730, 28735, 28737, 28800, 28805, 28810, 28820, 28825, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29827, 29828, 29834, 29835, 29837, 29838, 29844, 29846, 29847, 29850, 29855, 29862, 29866, 29867, 29868, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29893, 29895, 29897, 29898, 29904, 29905, 29906, 29907, 29914, 29915, 29916, 29999, 31300, 31360, 31365, 31367, 31370, 31375, 31380, 31382, 31390, 31395, 31400, 31420, 31580, 31587, 31590, 31599, 31611, 31614, 31750, 31755, 31760, 31775, 31780, 31781, 31785, 31786, 31800, 31820, 31825, 31899, 32035, 32036, 32100, 32110, 32120, 32124, 32140, 32141, 32150, 32151, 32160, 32200, 32215, 32220, 32225, 32310, 32320, 32440, 32442, 32445, 32480, 32482, 32484, 32486, 32488, 32491, 32503, 32504, 32505, 32540, 32560, 32650, 32651, 32652, 32653, 32654, 32655, 32656, 32658, 32659, 32661, 32662, 32663, 32664, 32665, 32666, 32669, 32670, 32671, 32672, 32800, 32810, 32815, 32820, 32900, 32905, 32906, 32940, 32999, 33020, 33025, 33030, 33031, 33050, 33300, 33310, 33320, 33875, 33877, 33880, 33881, 33883, 33886, 33889, 33891, 34001, 34051, 34101, 34111, 34151, 34201, 34203, 34401, 34421, 34451, 34471, 34490, 34501, 34502, 34510, 34520, 34530, 34701, 34703, 34705, 34707, 34710, 34712, 34718, 34830, 34831, 34832, 35001, 35002, 35005, 35011, 35013, 35021, 35045, 35081, 35082, 35091, 35092, 35102, 35103, 35111, 35112, 35121, 35122, 35131, 35132, 35141, 35142, 35151, 35152, 35184, 35189, 35190, 35201, 35206, 35207, 35211, 35216, 35221, 35226, 35231, 35236, 35246, 35251, 35256, 35261, 35266, 35271, 35281, 35286, 35301, 35302, 35303, 35304, 35305, 35311, 35321, 35331, 35341, 35351, 35355, 35361, 35363, 35371, 35372, 35501, 35506, 35508, 35509, 35510, 35512, 35515, 35516, 35518, 35521, 35522, 35523, 35525, 35526, 35531, 35533, 35535, 35536, 35537, 35538, 35539, 35540, 35556, 35558, 35560, 35563, 35565, 35566, 35570, 35571, 35583, 35585, 35587, 35601, 35606, 35612, 35616, 35621, 35623, 35626, 35631, 35632, 35633, 35634, 35636, 35637, 35638, 35642, 35645, 35646, 35647, 35650, 35654, 35656, 35661, 35663, 35665, 35666, 35671, 35691, 35693, 35694, 35695, 35701, 35702, 35703,35800, 35820, 35840, 35860, 35870, 35875, 35876, 35879, 35881, 35883, 35884, 35901, 35903, 35905, 35907, 36465, 36466, 36473, 36475, 36478, 36482, 36818, 36819, 36830, 36838, 36902, 36905, 37140, 37160, 37180, 37181, 37215, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37246, 37248, 37500, 37565, 37605, 37607, 37615, 37616, 37617, 37618, 37650, 37660, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799, 38100, 38101, 38115, 38120, 38129, 38230, 38305, 38308, 38380, 38381, 38382, 38542, 38550, 38555, 38562, 38564, 38570, 38571, 38572, 38573, 38589, 38700, 38720, 38724, 38740, 38745, 38760, 38765, 38770, 38780, 38999, 39000, 39010, 39200, 39220, 39499, 39501, 39503, 39540, 39541, 39545, 39560, 39561, 39599, 40510, 40520, 40525, 40530, 40652, 40800, 40801, 40810, 40812, 40814, 40816, 41000, 41005, 41006, 41007, 41008, 41009, 41016, 41017, 41018, 41110, 41112, 41113, 41114, 41116, 41120, 41130, 41135, 41140, 41145, 41150, 41153, 41155, 41599, 41806, 41820, 41822, 41823, 41825, 41826, 41830, 41850, 42104, 42106, 42107, 42120, 42140, 42145, 42160, 42210, 42300, 42305, 42330, 42335, 42340, 42408, 42409, 42410, 42415, 42420, 42425, 42426, 42440, 42450, 42500, 42505, 42507, 42665, 42699, 42700, 42720, 42725, 42808, 42810, 42815, 42821, 42826, 42831, 42836, 42842, 42844, 42845, 42870, 42890, 42892, 42894, 42950, 42953, 42955, 42960, 42961, 42962, 42972, 42999, 43020, 43030, 43045, 43100, 43101, 43107, 43108, 43112, 43113, 43116, 43117, 43118, 43121, 43122, 43123, 43124, 43130, 43135, 43279, 43280, 43281, 43282, 43286, 43287, 43288, 43289, 43300, 43305, 43310, 43312, 43313, 43320, 43325, 43327, 43328, 43330, 43331, 43332, 43333, 43334, 43335, 43336, 43337, 43340, 43341, 43351, 43352, 43360, 43361, 43400, 43405, 43410, 43415, 43420, 43425, 43496, 43500, 43501, 43502, 43510, 43520, 43605, 43610, 43611, 43620, 43621, 43622, 43631, 43632, 43633, 43634, 43640, 43641, 43644, 43645, 43651, 43652, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43800, 43810, 43820, 43825, 43832, 43840, 43843, 43845, 43846, 43847, 43848, 43850, 43855, 43860, 43865, 43870, 43880, 43886, 43887, 43888, 43999, 44005, 44010, 44020, 44021, 44025, 44050, 44055, 44110, 44111, 44120, 44125, 44126, 44127, 44130, 44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44155, 44156, 44157, 44158, 44160, 44180, 44186, 44187, 44188, 44202, 44204, 44205, 44206, 44207, 44208, 44210, 44211, 44212, 44227, 44238, 44310, 44312, 44314, 44316, 44320, 44322, 44340, 44345, 44346, 44602, 44603, 44604, 44605, 44615, 44620, 44625, 44626, 44640, 44650, 44660, 44661, 44680, 44700, 44800, 44820, 44850, 44899, 44900, 44950, 44960, 44970, 44979, 45000, 45005, 45020, 45108, 45110, 45111, 45112, 45113, 45114, 45116, 45119, 45120, 45121, 45123, 45126, 45130, 45135, 45136, 45150, 45160, 45190, 45395, 45397, 45399, 45400, 45402, 45499, 45500, 45505, 45540, 45541, 45550, 45560, 45562, 45563, 45800, 45805, 45820, 45825, 45905, 45910, 45999, 46020, 46030, 46040, 46045, 46060, 46080, 46250, 46255, 46257, 46258, 46260, 46261, 46262, 46270, 46275, 46280, 46285, 46288, 46700, 46705, 46706, 46710, 46712, 46715, 46730, 46735, 46740, 46744, 46748, 46750, 46753, 46760, 46761, 46924, 46930, 46940, 46942, 46945, 46946, 46947, 46948, 46999, 47010, 47015, 47100, 47120, 47122, 47125, 47130, 47300, 47350, 47360, 47361, 47362, 47370, 47371, 47379, 47380, 47381, 47382, 47399, 47400, 47420, 47425, 47460, 47480, 47490, 47562, 47563, 47564, 47570, 47579, 47600, 47605, 47610, 47612, 47620, 47700, 47711, 47712, 47715, 47720, 47721, 47740, 47741, 47760, 47765, 47780, 47785, 47800, 47802, 47900, 47999, 48000, 48020, 48100, 48105, 48120, 48140, 48145, 48146, 48148, 48150, 48152, 48153, 48154, 48155, 48500, 48510, 48520, 48540, 48545, 48547, 48548, 48999, 49000, 49002, 49010, 49020, 49040, 49060, 49062, 49203, 49204, 49205, 49215, 49250, 49255, 49321, 49322, 49323, 49324, 49325, 49329, 49402, 49418, 49419, 49421, 49422, 49425, 49426, 49505, 49507, 49520, 49521, 49525, 49540, 49550, 49553, 49555, 49557, 49560, 49561, 49565, 49566, 49570, 49572, 49580, 49582, 49585, 49587, 49590, 49600, 49606, 49650, 49651, 49652, 49653, 49654, 49655, 49656, 49657, 49659, 49900, 49904, 49906, 49999, 50010, 50020, 50060, 50065, 50075, 50120, 50130, 50135, 50205, 50220, 50225, 50230, 50234, 50236, 50240, 50250, 50280, 50290, 50389, 50400, 50405, 50500, 50540, 50541, 50542, 50543, 50544, 50545, 50546, 50548, 50549, 50610, 50630, 50650, 50660, 50700, 50715, 50725, 50727, 50728, 50740, 50750, 50760, 50770, 50780, 50782, 50783, 50785, 50800, 50810, 50815, 50820, 50825, 50830, 50840, 50845, 50860, 50900, 50940, 50945, 50947, 50948, 50949, 51040, 51045, 51050, 51060, 51065, 51080, 51500, 51525, 51530, 51535, 51550, 51555, 51565, 51570, 51575, 51580, 51585, 51590, 51595, 51596, 51597, 51800, 51820, 51840, 51841, 51845, 51860, 51865, 51880, 51900, 51920, 51960, 51980, 51999, 52234, 52235, 52240, 52320, 52341, 52342, 52344, 52345, 52346, 52400, 52402, 52450, 52500, 52601, 52630, 52640, 52647, 52648, 52649, 52700, 53000, 53010, 53040, 53210, 53215, 53220, 53230, 53235, 53240, 53260, 53265, 53400, 53405, 53410, 53415, 53420, 53425, 53431, 53440, 53442, 53444, 53445, 53446, 53447, 53449, 53450, 53460, 53505, 53510, 53520, 53852, 53854, 53899, 54015, 54050, 54057, 54065,54110, 54111, 54112, 54115, 54120, 54125, 54130, 54135, 54300, 54308, 54324, 54326, 54340, 54344, 54348, 54352, 54360, 54420, 54430, 54435, 54440, 54520, 54522, 54530, 54535, 54550, 54600, 54620,54640, 54650, 54660, 54670, 54680, 54690, 54692, 54840, 54860, 54861, 54901, 55040, 55041, 55060, 55100, 55110, 55120, 55150, 55175, 55180, 55200, 55530, 55535, 55540, 55550, 55600, 55680, 55801, 55810, 55812, 55815, 55821, 55831, 55840, 55842, 55845, 55862, 55866, 55873, 55874, 55876, 55899, 56405, 56420, 56440, 56501, 56515, 56620, 56625, 56630, 56631, 56632, 56633, 56634, 56637, 56640, 56740, 56800, 56810, 57000, 57010, 57065, 57106, 57107, 57109, 57110, 57120, 57130, 57135, 57200, 57210, 57240, 57250, 57260, 57265, 57268, 57270, 57280, 57282, 57283, 57284, 57285, 57288, 57289, 57291, 57292, 57295, 57296, 57300, 57305, 57307, 57308, 57310, 57311, 57320, 57330, 57335, 57423, 57425, 57522, 57530, 57531, 57540, 57550, 57555, 57556, 57720, 58120, 58140, 58145, 58146, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58150,58291, 58292, 58294, 58356, 58400, 58520, 58540, 58541, 58542, 58543, 58544, 58545, 58546, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58575, 58578, 58579, 58700, 58720, 58740, 58750, 58752, 58760, 58770, 58800, 58805, 58820, 58822, 58825, 58920, 58925, 58940, 58943, 58950, 58951, 58952, 58953, 58954, 58956, 58957, 58958, 58960, 59120, 59121, 59130, 59136, 59140, 59150, 59151, 59350, 60200, 60210, 60212, 60220, 60225, 60240, 60252, 60254, 60260, 60270, 60271, 60280, 60281, 60500, 60502, 60505, 60520, 60521, 60522, 60540, 60545, 60600, 60605, 60650, 60659, 60699, 61304, 61305, 61312, 61313, 61314, 61315, 61320, 61321, 61322, 61323, 61330, 61333, 61340, 61343, 61345, 61450, 61458, 61460, 61500, 61501, 61510, 61512, 61514, 61516, 61518, 61519, 61520, 61521, 61522, 61524, 61526, 61530, 61531, 61533, 61534, 61535, 61536, 61537, 61538, 61539, 61540, 61541, 61545, 61546, 61548, 61556, 61557, 61566, 61570, 61575, 61590, 61613, 61680, 61682, 61684, 61686, 61690, 61692, 61697, 61698, 61700, 61702, 61703, 61705, 61710, 61711, 61860, 61880, 61885, 61886, 61888, 62000, 62005, 62010, 62100, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, 63047, 63050, 63051, 63055, 63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170, 63172, 63173, 63185, 63190, 63191, 63194, 63195, 63196, 63197, 63198, 63199, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63700, 63707, 63709, 64702, 64704, 64708, 64713, 64722, 64755, 64760, 64804, 64809, 64818, 64856, 64862, 69511, 69530, 69601, 69602, 69603, 69604, 69610, 69631, 69632, 69633, 69635, 69636, 69637, 69642, 69644, 69645, 69646, 69801, 0184T, 0202T, 0236T, 0238T

AND NOT 

DENOMINATOR EXCLUSION: Emergency surgery: G9752

Numerator

Documentation of empirical, personalized risk assessment based on the patient’s risk factors with a validated risk calculator using multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient and/or family

Numerator Instructions:
The number of adult patients (age 18 and over) having had non-emergency surgery as defined by CPT codes during the performance period who had their personalized risk of procedure-specific, 30-day postoperative complications assessed and documented by their surgeon prior to surgery using a clinical data-based, patient-specific risk-calculator* and who had a documented personal discussion with their surgeon about these risks.

The procedure-specific, patient-specific, data-based risk calculator should be based on a validated, risk- adjusted statistical model predicting 30-day postoperative complications (detailed below) for the procedure that the patient is to undergo. Risk calculations should be based on preoperative patient-specific clinical data, and should include the following groups of variables: patient demographic characteristics (e.g., age, gender); relevant lifestyle and clinical risk factors (e.g., smoking status, American Society of Anesthesiologists class, body mass index); patient comorbidities (e.g., diabetes; neurologic event/disease; disseminated cancer); and procedure type.

Postoperative complications should include 30-day risk-adjusted mortality, 30-day risk-adjusted overall morbidity (superficial surgical site infection, deep incisional surgical site infection, wound dehiscence, pneumonia, deep venous thrombosis; pneumonia; renal failure; urinary tract infection; prolonged ventilator dependence; bleeding complications; sepsis; and pulmonary embolism), serious complications (cardiac arrest; myocardial infarction, pneumonia; progressive renal insufficiency; acute renal failure; pulmonary embolism; deep venous thrombosis; return to the operating room deep incisional surgical site infection; organ space surgical site infection; systemic sepsis; unplanned intubation; urinary tract infection; and wound dehiscence), surgical site infection, and average length of stay.

Risk calculators based on multi-institutional, validated clinical data are acceptable for this measure. ACS NSQIP now offers a risk calculator, which can be used for operations in many surgical subspecialty (Risk calculator link). Other risk calculators are available and acceptable for this measure, including but not limited to the risk calculator from the Society of Thoracic Surgeons.

Numerator Options:

Performance Met:

Documentation of patient-specific risk assessment with a risk calculator based on multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient or family (G9316)

OR

Performance Not Met:

Documentation of patient-specific risk assessment with a risk calculator based on multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient or family not completed (G9317)

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