2024 MIPS Measure #168: Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration

2024 COLLECTION TYPE:

MIPS Clinical Quality Measures (CQMS)

MEASURE TYPE: Outcome – High Priority‌

‌Description

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason.

Instructions

This measure is to be submitted each time an isolated coronary artery bypass graft (CABG) procedure is performed during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who provide services for isolated CABG will submit this measure. This measure is intended to reflect the quality of the surgical services provided for isolated CABG or isolated reoperation CABG patients. Isolated CABG refers to CABG using arterial and/or venous grafts only.‌

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 undergoing isolated CABG surgery

Denominator Criteria (Eligible Cases):

All patients aged 18 years and older on date of surgery

AND

Patient procedure during the performance period (CPT): 33509, 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536

WITHOUT

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

OR

Patient procedure during the performance period (CPT): 33509, 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536

AND

Patient procedure during the performance period (CPT): 33530

WITHOUT

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

Numerator

Patients undergoing isolated CABG surgery who require a return to the OR during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason

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 to0%, 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: Re-exploration required due to mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason (G8577)

OR

‌Performance Not Met: Re-exploration not required due to mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason (G8578)