2023 # 168 Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration

CMS Measure ID: #168

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: Yes

High Priority: Yes

NQS Domain: Effective Clinical Care

Measure Age: > 2 years

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. 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:

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 for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

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

2022 Benchmarks (from 2020 CMS data)

Registry

Topped out: No
Capped at 7: No

Minimum: 4.01 – 100
Decile 3: 3.47 – 4
Decile 4: 2.71 – 3.46
Decile 5: 2.06 – 2.7
Decile 6: 1.65 – 2.05
Decile 7: 1.29 – 1.64
Decile 8: 0.01 – 1.28
Decile 10: 0 – 0

Denominator

All patients undergoing isolated CABG surgery

Denominator Criteria (Eligible Cases):

All patients aged 18 years and older on date of encounter

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

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

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)


Tags

CQM-2023