CMS Measure ID: #357
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. 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 a surgical site infection (SSI)
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: No
Capped at 7: No
Decile 0: 80.07 – 100
Decile 1: 6.35 – 80.06
Minimum: 1.18 – 6.34
Decile 3: 0.01 – 1.17
Decile 10: 0 – 0
Denominator
Patients aged 18 years and older who have undergone 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, 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, 46200, 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
Number of patients with a surgical site infection
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.
Definitions:
Superficial Incisional SSI – “Superficial incision SSI” is an infection that occurs within 30 days after the operation and infection involves only skin or subcutaneous tissue of the incision and at least one of the following:
-
Purulent drainage, with or without laboratory confirmation, from the superficial incision
-
Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision
-
At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat AND superficial incision is deliberately opened by the surgeon, unless incision is culture-negative
-
Diagnosis of superficial incision SSI by the surgeon or attending physician
Deep Incisional SSI – “Deep Incision SSI” is an infection that occurs within 30 days after the operation and the infection appears to be related to the operation and infection involved deep soft tissues (for example, fascial and muscle layers) of the incision and at least one of the following:
-
Purulent drainage from the deep incision but not from the organ/space component of the surgical site
-
A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (> 38 C), localized pain, or tenderness, unless site is culture-negative
-
An abscess or other evidence of infection involving the deep incision is found on direct examination, during re-operation, or by histopathologic or radiologic examination
-
Diagnosis of a deep incision SSI by a surgeon or attending physician
Organ/Space SSI – “Organ/Space SSI” is an infection that occurs within 30 days after the operation and the infection appears to be related to the operation and the infection involves any part of the anatomy (for example, organs or spaces), other than the incision, which was opened or manipulated during an operation and at least one of the following:
-
Purulent drainage from a drain that is placed through a stab wound into the organ/space.
-
Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space
-
An abscess or other evidence of infection involving the organ/space that is found on direct examination, during re-operation, or by histopathologic or radiologic examination
-
Diagnosis of an organ/space SSI by a surgeon or attending physician
Numerator Options:
Performance Met:
Surgical site infection (G9312)
OR
Performance Not Met:
No surgical site infection (G9311)