CMS Measure ID: #356
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 a surgical procedure listed in the denominator is performed during the performance period ending November 30th. 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 surgical 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 an unplanned hospital readmission within 30 days of principal procedure
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: No
Capped at 7: No
Decile 0: 32.27 – 100
Decile 1: 8.67 – 32.26
Minimum: 6.12 – 8.66
Decile 3: 3.4 – 6.11
Decile 4: 1.82 – 3.39
Decile 5: 0.01 – 1.81
Decile 10: 0 – 0
Denominator
Patients aged 18 years and older undergoing a surgical procedure
Denominator Criteria (Eligible Cases):
All patients aged 18 years and older
AND
Patient procedure during the performance period (CPT): 11004, 11005, 11006, 15734, 15778, 15920, 15931, 15933, 15940, 15950, 19306, 20100, 20101, 20102, 21601, 21602, 21603, 21811, 21812, 21813, 22904, 22905, 27080, 35221, 35251, 35281, 35840, 36565, 36566, 37617, 38100, 38115, 38120, 38530, 38531, 38564, 38765, 39501, 39540, 39541, 39560, 43122, 43279, 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, 43772, 43773, 43774, 43775, 43800, 43810, 43820, 43825, 43830, 43831, 43832, 43840, 43843, 43845, 43846, 43847, 43848, 43860, 43865, 43870, 43880, 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, 45020, 45110, 45111, 45112, 45113, 45114, 45116, 45119, 45120, 45121, 45123, 45126, 45130, 45135, 45136, 45395, 45397, 45400, 45402, 45540, 45550, 45562, 45563, 45800, 45805, 47010, 47015, 47100, 47120, 47122, 47125, 47130, 47300, 47350, 47360, 47361, 47362, 47370, 47380, 47400, 47420, 47425, 47460, 47480, 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, 49322, 49323, 49402, 49425, 49429, 49553, 49557, 49596, 49616, 49617, 49618, 49621, 49622, 49900, 50205, 50500, 50740, 57305, 57307, 60200, 60254, 60270, 60540, 60545, 60650
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02
Numerator
Inpatient readmission to the same hospital for any reason or an outside hospital (if known to the surgeon), within 30 days of the principal surgical 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 Options:
Performance Met:
Unplanned hospital readmission within 30 days of principal procedure (G9310)
OR
Performance Not Met:
No unplanned hospital readmission within 30 days of principal procedure (G9309)
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