2023 # 445 Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)

CMS Measure ID: #445

Collection Type: CQM

Reporting Frequency: Once per patient per year

Outcome: Yes

High Priority: Yes

NQS Domain: Effective Clinical Care

Measure Age: > 2 years

Instructions

This measure is to be submitted a minimum of once per performance period for patients undergoing isolated CABG during the performance period. 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.

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

Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure

2022 Benchmarks (from 2020 CMS data)

Registry

Topped out: No
Capped at 7: No

Minimum: 3.86 – 100
Decile 3: 3.29 – 3.85
Decile 4: 2.64 – 3.28
Decile 5: 2.18 – 2.63
Decile 6: 1.7 – 2.17
Decile 7: 1.28 – 1.69
Decile 8: 0.01 – 1.27
Decile 10: 0 – 0

Denominator

All patients undergoing isolated CABG

Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years 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

Number of patients undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the 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:

Patient died including all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure (G9812)

OR

Performance Not Met:

Patient did not die within 30 days of the procedure or during the index hospitalization (G9813)


Tags

CQM-2023