2023 # 358 Patient-Centered Surgical Risk Assessment and Communication

CMS Measure ID: #358

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: No

High Priority: Yes

NQS Domain: Person and Caregiver-Centered Experience Outcomes

Measure Age: > 2 years

Instructions

This measure is to be submitted each time a procedure is performed during the performance period for patients who undergo non-emergency surgical procedures. There is no diagnosis associated with this measure. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the listed surgical procedures as specified in the denominator coding will submit this measure.

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 who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: Yes
Capped at 7: Yes

Decile 0: 0 – 0.49
Decile 1: 0.5 – 9.25
Minimum: 9.26 – 66
Decile 3: 66.01 – 93.74
Decile 4: 93.75 – 98.39
Decile 5: 98.4 – 99.75
Decile 6: 99.76 – 99.99
Decile 10: 100 – 100

Denominator

The total number of adult patients (age 18 and over) having had non-emergency surgery

Denominator Instructions:
CPT Category I procedure codes billed by surgeons performing surgery on the same patient, submitted with modifier 62 (indicating two surgeons, i.e., dual procedures) will be included in the denominator population, therefore both surgeons will be fully accountable for the clinical action described in the measure.

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Patient encounter during the performance period (CPT): 10121, 10140, 10160, 10180, 11000, 11004, 11005, 11006, 11010, 11042, 11043, 11044, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 11601, 11602, 11603, 11960, 14301, 15040, 15150, 15155, 15200, 15220, 15240, 15260, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15730, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15769, 15770, 15771, 15773, 15778, 15830, 15920, 15922, 15931, 15933, 15934, 15935, 15936, 15937, 15940, 15941, 15944, 15945, 15946, 15950, 15951, 15953, 15956, 15958, 19020, 19101, 19110, 19120, 19125, 19296, 19298, 19300, 19301, 19302, 19303, 19305, 19306, 19307, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19499, 20100, 20101, 20102, 20103, 20150, 20696, 20900, 20902, 20910, 20922, 20955, 20956, 20999, 21011, 21012, 21013, 21014, 21015, 21016, 21025, 21026, 21034, 21040, 21044, 21045, 21046, 21047, 21048, 21049, 21139, 21154, 21235, 21299, 21360, 21395, 21462, 21465, 21499, 21501, 21502, 21510, 21552, 21554, 21555, 21556, 21557, 21558, 21600, 21601, 21602, 21603, 21615, 21616, 21620, 21627, 21630, 21632, 21685, 21700, 21705, 21740, 21742, 21743, 21750, 21825, 21899, 21920, 21925, 21930, 21931, 21932, 21933, 21935, 21936, 22010, 22015, 22100, 22101, 22102, 22110, 22112, 22114, 22206, 22207, 22210, 22212, 22214, 22220, 22222, 22224, 22318, 22319, 22325, 22326, 22327, 22532, 22533, 22548, 22551, 22554, 22556, 22558, 22586, 22590, 22595, 22600, 22610, 22612, 22630, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22849, 22850, 22852, 22855, 22856, 22857, 22861, 22862, 22864, 22865, 22899, 22900, 22901, 22902, 22903, 22904, 22905, 22999, 23000, 23020, 23030, 23031, 23035, 23040, 23044, 23071, 23073, 23075, 23076, 23077, 23078, 23101, 23106, 23107, 23120, 23125, 23130, 23140, 23146, 23150, 23156, 23170, 23180, 23182, 23184, 23190, 23195, 23200, 23210, 23220, 23395, 23397, 23400, 23405, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 23470, 23472, 23480, 23485, 23491, 23515, 23530, 23532, 23550, 23552, 23585, 23615, 23616, 23630, 23660, 23670, 23680, 23800, 23802, 23900, 23920, 23929, 23935, 24000, 24006, 24065, 24066, 24071, 24073, 24075, 24076, 24077, 24079, 24102, 24105, 24116, 24120, 24125, 24130, 24134, 24136, 24140, 24145, 24149, 24150, 24152, 24201, 24301, 24310, 24320, 24330, 24332, 24340, 24341, 24342, 24344, 24345, 24346, 24358, 24359, 24360, 24361, 24363, 24365, 24366, 24400, 24430, 24435, 24495, 24498, 24515, 24516, 24538, 24545, 24546, 24575, 24579, 24586, 24587, 24615, 24635, 24665, 24666, 24685, 24800, 24802, 24900, 24920, 24925, 24999, 25000, 25001, 25020, 25023, 25024, 25025, 25040, 25065, 25066, 25071, 25073, 25075, 25076, 25077, 25078, 25085, 25101, 25105, 25107, 25110, 25111, 25112, 25115, 25116, 25118, 25120, 25125, 25130, 25135, 25136, 25145, 25150, 25151, 25170, 25210, 25215, 25230, 25240, 25248, 25260, 25263, 25265, 25270, 25274, 25275, 25280, 25290, 25295, 25301, 25310, 25312, 25315, 25320, 25332, 25337, 25350, 25355, 25360, 25375, 25390, 25391, 25392, 25400, 25405, 25415, 25420, 25430, 25431, 25440, 25442, 25443, 25445, 25446, 25447, 25449, 25490, 25515, 25525, 25526, 25545, 25574, 25575, 25607, 25608, 25609, 25628, 25645, 25652, 25670, 25676, 25685, 25695, 25900, 25905, 25909, 25920, 25927, 25999, 26111, 26113, 26115, 26116, 26117, 26118, 26121, 26123, 26130, 26145, 26180, 26350, 26352, 26356, 26357, 26358, 26370, 26372, 26373, 26390, 26392, 26410, 26415, 26418, 26420, 26426, 26433, 26434, 26437, 26440, 26442, 26445, 26449, 26450, 26455, 26460, 26471, 26477, 26478, 26480, 26483, 26485, 26489, 26490, 26492, 26496, 26497, 26498, 26500, 26502, 26510, 26520, 26525, 26530, 26531, 26535, 26536, 26540, 26541, 26542, 26545, 26546, 26548, 26561, 26565, 26567, 26568, 26587, 26591, 26593, 26615, 26650, 26665, 26676, 26685, 26686, 26715, 26727, 26735, 26746, 26765, 26776, 26785, 26952, 26989, 26990, 26991, 26992, 27000, 27001, 27005, 27006, 27025, 27027, 27030, 27033, 27035, 27036, 27040, 27041, 27043, 27045, 27047, 27048, 27049, 27054, 27057, 27059, 27060, 27062, 27065, 27066, 27070, 27071, 27075, 27076, 27077, 27078, 27080, 27086, 27087, 27097, 27110, 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165, 27170, 27176, 27177, 27179, 27181, 27187, 27202, 27226, 27227, 27228, 27235, 27236, 27238, 27244, 27245, 27248, 27253, 27254, 27258, 27259, 27267, 27269, 27280, 27290, 27295, 27299, 27301, 27303, 27305, 27307, 27310, 27327, 27328, 27329, 27331, 27332, 27333, 27334, 27335, 27337, 27339, 27340, 27345, 27347, 27350, 27355, 27356, 27357, 27360, 27364, 27365, 27372, 27380, 27381, 27385, 27386, 27390, 27392, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 27427, 27428, 27429, 27430, 27435, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27448, 27450, 27454, 27455, 27457, 27465, 27466, 27468, 27470, 27472, 27477, 27485, 27486, 27487, 27488, 27495, 27496, 27497, 27498, 27499, 27506, 27507, 27509, 27511, 27513, 27514, 27519, 27524, 27535, 27536, 27540, 27556, 27557, 27566, 27580, 27590, 27591, 27592, 27594, 27596, 27598, 27599, 27600, 27601, 27602, 27603, 27604, 27605, 27606, 27607, 27610, 27612, 27615, 27616, 27618, 27619, 27620, 27625, 27626, 27630, 27632, 27634, 27635, 27637, 27638, 27640, 27641, 27645, 27646, 27647, 27650, 27652, 27654, 27656, 27658, 27659, 27664, 27665, 27675, 27676, 27680, 27681, 27685, 27686, 27687, 27695, 27696, 27698, 27700, 27702, 27703, 27704, 27705, 27707, 27709, 27715, 27720, 27722, 27724, 27725, 27726, 27745, 27756, 27758, 27759, 27766, 27769, 27784, 27792, 27814, 27822, 27823, 27826, 27827, 27828, 27829, 27832, 27846, 27848, 27880, 27881, 27882, 27884, 27886, 27888, 27889, 27892, 27893, 27894, 27899, 28002, 28003, 28039, 28041, 28043, 28045, 28046, 28047, 28192, 28193, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28415, 28420, 28445, 28446, 28465, 28485, 28505, 28525, 28531, 28555, 28585, 28615, 28645, 28675, 28705, 28715, 28725, 28730, 28735, 28737, 28800, 28805, 28810, 28820, 28825, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29827, 29828, 29834, 29835, 29837, 29838, 29844, 29846, 29847, 29850, 29855, 29862, 29866, 29867, 29868, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29893, 29895, 29897, 29898, 29904, 29905, 29906, 29907, 29914, 29915, 29916, 29999, 31300, 31360, 31365, 31367, 31370, 31375, 31380, 31382, 31390, 31395, 31400, 31420, 31580, 31587, 31590, 31599, 31611, 31614, 31750, 31755, 31760, 31775, 31780, 31781, 31785, 31786, 31800, 31820, 31825, 31899, 32035, 32036, 32100, 32110, 32120, 32124, 32140, 32141, 32150, 32151, 32160, 32200, 32215, 32220, 32225, 32310, 32320, 32440, 32442, 32445, 32480, 32482, 32484, 32486, 32488, 32491, 32503, 32504, 32505, 32540, 32560, 32650, 32651, 32652, 32653, 32654, 32655, 32656, 32658, 32659, 32661, 32662, 32663, 32664, 32665, 32666, 32669, 32670, 32671, 32672, 32800, 32810, 32815, 32820, 32900, 32905, 32906, 32940, 32999, 33020, 33025, 33030, 33031, 33050, 33300, 33310, 33320, 33875, 33877, 33880, 33881, 33883, 33886, 33889, 33891, 34001, 34051, 34101, 34111, 34151, 34201, 34203, 34401, 34421, 34451, 34471, 34490, 34501, 34502, 34510, 34520, 34530, 34701, 34703, 34705, 34707, 34710, 34712, 34718, 34830, 34831, 34832, 35001, 35002, 35005, 35011, 35013, 35021, 35045, 35081, 35082, 35091, 35092, 35102, 35103, 35111, 35112, 35121, 35122, 35131, 35132, 35141, 35142, 35151, 35152, 35184, 35189, 35190, 35201, 35206, 35207, 35211, 35216, 35221, 35226, 35231, 35236, 35246, 35251, 35256, 35261, 35266, 35271, 35281, 35286, 35301, 35302, 35303, 35304, 35305, 35311, 35321, 35331, 35341, 35351, 35355, 35361, 35363, 35371, 35372, 35501, 35506, 35508, 35509, 35510, 35512, 35515, 35516, 35518, 35521, 35522, 35523, 35525, 35526, 35531, 35533, 35535, 35536, 35537, 35538, 35539, 35540, 35556, 35558, 35560, 35563, 35565, 35566, 35570, 35571, 35583, 35585, 35587, 35601, 35606, 35612, 35616, 35621, 35623, 35626, 35631, 35632, 35633, 35634, 35636, 35637, 35638, 35642, 35645, 35646, 35647, 35650, 35654, 35656, 35661, 35663, 35665, 35666, 35671, 35691, 35693, 35694, 35695, 35701, 35702, 35703, 35800, 35820, 35840, 35860, 35870, 35875, 35876, 35879, 35881, 35883, 35884, 35901, 35903, 35905, 35907, 36465, 36466, 36473, 36475, 36478, 36482, 36818, 36819, 36830, 36836, 36837, 36838, 36902, 36905, 37140, 37160, 37180, 37181, 37215, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37246, 37248, 37500, 37565, 37605, 37607, 37615, 37616, 37617, 37618, 37650, 37660, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799, 38100, 38101, 38115, 38120, 38129, 38230, 38305, 38308, 38380, 38381, 38382, 38542, 38550, 38555, 38562, 38564, 38570, 38571, 38572, 38573, 38589, 38700, 38720, 38724, 38740, 38745, 38760, 38765, 38770, 38780, 38999, 39000, 39010, 39200, 39220, 39499, 39501, 39503, 39540, 39541, 39545, 39560, 39561, 39599, 40510, 40520, 40525, 40530, 40652, 40800, 40801, 40810, 40812, 40814, 40816, 41000, 41005, 41006, 41007, 41008, 41009, 41016, 41017, 41018, 41110, 41112, 41113, 41114, 41116, 41120, 41130, 41135, 41140, 41145, 41150, 41153, 41155, 41599, 41806, 41820, 41822, 41823, 41825, 41826, 41830, 41850, 42104, 42106, 42107, 42120, 42140, 42145, 42160, 42210, 42300, 42305, 42330, 42335, 42340, 42408, 42409, 42410, 42415, 42420, 42425, 42426, 42440, 42450, 42500, 42505, 42507, 42665, 42699, 42700, 42720, 42725, 42808, 42810, 42815, 42821, 42826, 42831, 42836, 42842, 42844, 42845, 42870, 42890, 42892, 42894, 42950, 42953, 42955, 42960, 42961, 42962, 42972, 42999, 43020, 43030, 43045, 43100, 43101, 43107, 43108, 43112, 43113, 43116, 43117, 43118, 43121, 43122, 43123, 43124, 43130, 43135, 43279, 43280, 43281, 43282, 43286, 43287, 43288, 43289, 43300, 43305, 43310, 43312, 43313, 43320, 43325, 43327, 43328, 43330, 43331, 43332, 43333, 43334, 43335, 43336, 43337, 43340, 43341, 43351, 43352, 43360, 43361, 43400, 43405, 43410, 43415, 43420, 43425, 43496, 43497, 43500, 43501, 43502, 43510, 43520, 43605, 43610, 43611, 43620, 43621, 43622, 43631, 43632, 43633, 43634, 43640, 43641, 43644, 43645, 43651, 43652, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43800, 43810, 43820, 43825, 43832, 43840, 43843, 43845, 43846, 43847, 43848, 43860, 43865, 43870, 43880, 43886, 43887, 43888, 43999, 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, 44238, 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, 44899, 44900, 44950, 44960, 44970, 44979, 45000, 45005, 45020, 45108, 45110, 45111, 45112, 45113, 45114, 45116, 45119, 45120, 45121, 45123, 45126, 45130, 45135, 45136, 45150, 45160, 45190, 45395, 45397, 45399, 45400, 45402, 45499, 45500, 45505, 45540, 45541, 45550, 45560, 45562, 45563, 45800, 45805, 45820, 45825, 45905, 45910, 45999, 46020, 46030, 46040, 46045, 46060, 46080, 46250, 46255, 46257, 46258, 46260, 46261, 46262, 46270, 46275, 46280, 46285, 46288, 46700, 46705, 46706, 46710, 46712, 46715, 46730, 46735, 46740, 46744, 46748, 46750, 46753, 46760, 46761, 46924, 46930, 46940, 46942, 46945, 46946, 46947, 46948, 46999, 47010, 47015, 47100, 47120, 47122, 47125, 47130, 47300, 47350, 47360, 47361, 47362, 47370, 47371, 47379, 47380, 47381, 47382, 47399, 47400, 47420, 47425, 47460, 47480, 47490, 47562, 47563, 47564, 47570, 47579, 47600, 47605, 47610, 47612, 47620, 47700, 47711, 47712, 47715, 47720, 47721, 47740, 47741, 47760, 47765, 47780, 47785, 47800, 47802, 47900, 47999, 48000, 48020, 48100, 48105, 48120, 48140, 48145, 48146, 48148, 48150, 48152, 48153, 48154, 48155, 48500, 48510, 48520, 48540, 48545, 48547, 48548, 48999, 49000, 49002, 49010, 49020, 49040, 49060, 49062, 49203, 49204, 49205, 49215, 49250, 49255, 49321, 49322, 49323, 49324, 49325, 49329, 49402, 49418, 49419, 49421, 49422, 49425, 49426, 49505, 49507, 49520, 49521, 49525, 49540, 49550, 49553, 49555, 49557, 49591, 49592, 49593, 49594, 49595, 49596, 49600, 49606, 49613, 49614, 49615, 49616, 49617, 49618, 49621, 49622, 49650, 49651, 49659, 49900, 49904, 49906, 49999, 50010, 50020, 50060, 50065, 50075, 50120, 50130, 50135, 50205, 50220, 50225, 50230, 50234, 50236, 50240, 50250, 50280, 50290, 50389, 50400, 50405, 50500, 50540, 50541, 50542, 50543, 50544, 50545, 50546, 50548, 50549, 50610, 50630, 50650, 50660, 50700, 50715, 50725, 50727, 50728, 50740, 50750, 50760, 50770, 50780, 50782, 50783, 50785, 50800, 50810, 50815, 50820, 50825, 50830, 50840, 50845, 50860, 50900, 50940, 50945, 50947, 50948, 50949, 51040, 51045, 51050, 51060, 51065, 51080, 51500, 51525, 51530, 51535, 51550, 51555, 51565, 51570, 51575, 51580, 51585, 51590, 51595, 51596, 51597, 51800, 51820, 51840, 51841, 51845, 51860, 51865, 51880, 51900, 51920, 51960, 51980, 51990, 51992, 51999, 52234, 52235, 52240, 52320, 52341, 52342, 52344, 52345, 52346, 52400, 52402, 52450, 52500, 52601, 52630, 52640, 52647, 52648, 52649, 52700, 53000, 53010, 53040, 53210, 53215, 53220, 53230, 53235, 53240, 53260, 53265, 53400, 53405, 53410, 53415, 53420, 53425, 53431, 53440, 53442, 53444, 53445, 53446, 53447, 53449, 53450, 53460, 53505, 53510, 53520, 53852, 53854, 53899, 54015, 54050, 54057, 54065, 54110, 54111, 54112, 54115, 54120, 54125, 54130, 54135, 54300, 54308, 54324, 54326, 54340, 54344, 54348, 54352, 54360, 54420, 54430, 54435, 54440, 54520, 54522, 54530, 54535, 54550, 54600, 54620, 54640, 54650, 54660, 54670, 54680, 54690, 54692, 54840, 54860, 54861, 54901, 55040, 55041, 55060, 55100, 55110, 55120, 55150, 55175, 55180, 55200, 55530, 55535, 55540, 55550, 55600, 55680, 55801, 55810, 55812, 55815, 55821, 55831, 55840, 55842, 55845, 55862, 55866, 55867, 55873, 55874, 55876, 55880, 55899, 56405, 56420, 56440, 56501, 56515, 56620, 56625, 56630, 56631, 56632, 56633, 56634, 56637, 56640, 56740, 56800, 56810, 57000, 57010, 57065, 57106, 57107, 57109, 57110, 57120, 57130, 57135, 57200, 57210, 57240, 57250, 57260, 57265, 57268, 57270, 57280, 57282, 57283, 57284, 57285, 57288, 57289, 57291, 57292, 57295, 57296, 57300, 57305, 57307, 57308, 57310, 57311, 57320, 57330, 57335, 57423, 57425, 57522, 57530, 57531, 57540, 57550, 57555, 57556, 57720, 58120, 58140, 58145, 58146, 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58294, 58356, 58400, 58520, 58540, 58541, 58542, 58543, 58544, 58545, 58546, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58575, 58578, 58579, 58700, 58720, 58740, 58750, 58752, 58760, 58770, 58800, 58805, 58820, 58822, 58825, 58920, 58925, 58940, 58943, 58950, 58951, 58952, 58953, 58954, 58956, 58957, 58958, 58960, 59120, 59121, 59130, 59136, 59140, 59150, 59151, 59350, 60200, 60210, 60212, 60220, 60225, 60240, 60252, 60254, 60260, 60270, 60271, 60280, 60281, 60500, 60502, 60505, 60520, 60521, 60522, 60540, 60545, 60600, 60605, 60650, 60659, 60699, 61304, 61305, 61312, 61313, 61314, 61315, 61320, 61321, 61322, 61323, 61330, 61333, 61340, 61343, 61345, 61450, 61458, 61460, 61500, 61501, 61510, 61512, 61514, 61516, 61518, 61519, 61520, 61521, 61522, 61524, 61526, 61530, 61531, 61533, 61534, 61535, 61536, 61537, 61538, 61539, 61540, 61541, 61545, 61546, 61548, 61556, 61557, 61566, 61570, 61575, 61590, 61613, 61680, 61682, 61684, 61686, 61690, 61692, 61697, 61698, 61700, 61702, 61703, 61705, 61710, 61711, 61860, 61880, 61885, 61886, 61888, 62000, 62005, 62010, 62100, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, 63047, 63050, 63051, 63055, 63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63700, 63707, 63709, 64702, 64704, 64708, 64713, 64722, 64755, 64760, 64804, 64809, 64818, 64856, 64862, 69511, 69530, 69601, 69602, 69603, 69604, 69610, 69631, 69632, 69633, 69635, 69636, 69637, 69642, 69644, 69645, 69646, 69705, 69706, 69801, 0184T, 0202T, 0236T, 0238T, 0505T, 0553T, 0684T, 0600T, 0601T, 0620T, 0655T, 0656T, 0657T, 0660T, 0661T, 0664T*, 0665T*, 0666T*, 0667T*, 0673T

WITHOUT

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

AND NOT

DENOMINATOR EXCLUSION: Emergency surgery: G9752

Numerator

Documentation of empirical, personalized risk assessment based on the patient’s risk factors with a validated risk calculator using multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient and/or family

Numerator Instructions:
The number of adult patients (age 18 and over) having had non-emergency surgery as defined by CPT codes during the performance period who had their personalized risk of procedure-specific, 30-day postoperative complications assessed and documented by their surgeon prior to surgery using a clinical data-based, patient-specific risk-calculator* and who had a documented personal discussion with their surgeon about these risks.

The procedure-specific, patient-specific, data-based risk calculator should be based on a validated, risk- adjusted statistical model predicting 30-day postoperative complications (detailed below) for the procedure that the patient is to undergo. Risk calculations should be based on preoperative patient-specific clinical data, and should include the following groups of variables: patient demographic characteristics (e.g., age, gender); relevant lifestyle and clinical risk factors (e.g., smoking status, American Society of Anesthesiologists class, body mass index); patient comorbidities (e.g., diabetes; neurologic event/disease; disseminated cancer); and procedure type.

Postoperative complications should include 30-day risk-adjusted mortality, 30-day risk-adjusted overall morbidity (superficial surgical site infection, deep incisional surgical site infection, wound dehiscence, pneumonia, deep venous thrombosis; pneumonia; renal failure; urinary tract infection; prolonged ventilator dependence; bleeding complications; sepsis; and pulmonary embolism), serious complications (cardiac arrest; myocardial infarction, pneumonia; progressive renal insufficiency; acute renal failure; pulmonary embolism; deep venous thrombosis; return to the operating room deep incisional surgical site infection; organ space surgical site infection; systemic sepsis; unplanned intubation; urinary tract infection; and wound dehiscence), surgical site infection, and average length of stay.

Risk calculators based on multi-institutional, validated clinical data are acceptable for this measure. ACS NSQIP offers a risk calculator, which can be used for operations in many surgical subspecialties (ACS NSQIP Surgical Risk Calculator – http://riskcalculator.facs.org/RiskCalculator/). Other risk calculators are available and acceptable for this measure, including but not limited to the risk calculator from the Society of Thoracic Surgeons.

Numerator Options:

Performance Met:

Documentation of patient-specific risk assessment with a risk calculator based on multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient or family (G9316)

Performance Not Met: