2023 # 355 Unplanned Reoperation within the 30 Day Postoperative Period

CMS Measure ID: #355

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: Yes

High Priority: Yes

NQS Domain: Patient Safety

Measure Age: > 2 years

Instructions

This measure is to be submitted each time an operative procedure listed in the denominator is performed during the performance period. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Include only patients that have procedures through November 30th of the performance period. This will allow the evaluation of at least 30 days after the procedure within the performance period.

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 who had any unplanned reoperation within the 30 day postoperative period

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: No
Capped at 7: No

Decile 0: 40.01 – 100
Decile 1: 8.61 – 40
Minimum: 2.71 – 8.6
Decile 3: 1.09 – 2.7
Decile 4: 0.01 – 1.08
Decile 10: 0 – 0

Denominator

Patients aged 18 years and older undergoing an operative procedure

Denominator Criteria (Eligible Cases):

All patients aged 18 years and older

AND

Patient procedure during the performance period (CPT): 11004, 11005, 11006, 11450, 11451, 11462, 11463, 11470, 11471, 11770, 11771, 11772, 15734, 15778, 15920, 15931, 15933, 15940, 15950, 19020, 19101, 19110, 19112, 19120, 19125, 19300, 19301, 19302, 19303, 19305, 19306, 19307, 20100, 20101, 20102, 20200, 20205, 21552, 21554, 21555, 21556, 21557, 21558, 21601, 21602, 21603, 21811, 21812, 21813, 21931, 21932, 21933, 21935, 21936, 22900, 22901, 22902, 22903, 22904, 22905, 23071, 23073, 23075, 23076, 23077, 23078, 24071, 24073, 24075, 24076, 24077, 24079, 25071, 25075, 25077, 25078, 27043, 27045, 27047, 27048, 27049, 27080, 27327, 27328, 27329, 27337, 27339, 27615, 27616, 27632, 27634, 35221, 35251, 35281, 35840, 36561, 36563, 36565, 36566, 36571, 36576, 36590, 36818, 36819, 36820, 36821, 36825, 36830, 37617, 38100, 38115, 38120, 38308, 38500, 38520, 38525, 38530, 38531, 38550, 38555, 38564, 38740, 38745, 38760, 38765, 39501, 39540, 39541, 39560, 43122, 43279, 43280, 43281, 43282, 43286, 43287, 43288, 43325, 43327, 43330, 43332, 43333, 43336, 43337, 43340, 43497, 43500, 43501, 43502, 43510, 43520, 43605, 43610, 43611, 43620, 43621, 43622, 43631, 43632, 43633, 43634, 43640, 43641, 43644, 43645, 43651, 43652, 43653, 43770, 43771, 43772, 43773, 43774, 43775, 43800, 43810, 43820, 43825, 43830, 43831, 43832, 43840, 43843, 43845, 43846, 43847, 43848, 43860, 43865, 43870, 43880, 43886, 43887, 43888, 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, 44300, 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, 44900, 44950, 44960, 44970, 45000, 45005, 45020, 45100, 45108, 45110, 45111, 45112, 45113, 45114, 45116, 45119, 45120, 45121, 45123, 45126, 45130, 45135, 45136, 45150, 45160, 45171, 45172, 45395, 45397, 45400, 45402, 45505, 45540, 45541, 45550, 45562, 45563, 45800, 45805, 45900, 45905, 46040, 46045, 46060, 46080, 46500, 46250, 46255, 46257, 46258, 46260, 46261, 46262, 46270, 46275, 46280, 46285, 46288, 46700, 46761, 47010, 47015, 47100, 47120, 47122, 47125, 47130, 47300, 47350, 47360, 47361, 47362, 47370, 47371, 47380, 47400, 47420, 47425, 47460, 47480, 47562, 47563, 47564, 47570, 47600, 47605, 47610, 47612, 47620, 47711, 47712, 47715, 47720, 47721, 47740, 47741, 47760, 47765, 47780, 47785, 47800, 47801, 47900, 48000, 48001, 48020, 48100, 48105, 48120, 48140, 48145, 48146, 48148, 48150, 48152, 48153, 48154, 48155, 48500, 48510, 48520, 48540, 48545, 48547, 48548, 49000, 49002, 49010, 49013, 49014, 49020, 49040, 49060, 49062, 49084, 49203, 49204, 49205, 49215, 49255, 49320, 49321, 49322, 49323, 49324, 49325, 49402, 49421, 49422, 49425, 49426, 49429, 49436, 49505, 49507, 49520, 49521, 49525, 49540, 49550, 49553, 49555, 49557, 49591, 49592, 49593, 49594, 49595, 49596, 49613, 49614, 49615, 49616, 49617, 49618, 49621, 49622, 49650, 49651, 49900, 50205, 50500, 50740, 55520, 55540, 57305, 57307, 60200, 60210, 60212, 60220, 60225, 60240, 60252, 60254, 60260, 60270, 60271, 60500, 60502, 60520, 60540, 60545, 60650

WITHOUT

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

Numerator

Unplanned return to the operating room for a surgical procedure, for any reason, within 30 days of the principal operative procedure

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 to 0%, 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 NOTE: This measure intent is to capture patients who go back to the operating room within 30 days for a follow-up procedure based on complications of the principal (denominator eligible) operative procedure. Examples: Breast biopsies (19101) with return for re-excisions or insertion of port-a-cath for chemotherapy would not be considered an unplanned return to the operating room for a surgical procedure. If this patient had an open, incisional biopsy of breast tissue (19101) and subsequently had an appendectomy performed this would not be considered an unplanned return to the operating room for a surgical procedure. The return to the OR may occur at any hospital or surgical facility.

Numerator Options:

Performance Met:

Unplanned return to the operating room for a surgical procedure, for complications of the principal operative procedure, within 30 days of the principal operative procedure (G9308)

Performance Not Met:

No return to the operating room for a surgical procedure for complications of the principal operative procedure within 30 days of the principal operative procedure (G9307)