2026 #356 MIPS Measure Unplanned Hospital Readmission within 30 Days of Principal Procedure

2026 COLLECTION TYPE:

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)

‌MEASURE TYPE:

Outcome – High Priority

• INVERSE MEASURE: LOWER SCORE – BETTER

‌DESCRIPTION:

Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.

‌INSTRUCTIONS:‌

Reporting Frequency:

This measure is to be submitted each time a denominator eligible procedure as defined in the denominator criteria is performed.

‌Intent and Clinician Applicability:

This measure is intended to reflect the quality of services provided for patients who undergo an operative procedure. 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 Strata and Performance Rates:

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate.

‌Implementation Considerations:

For the purposes of MIPS implementation, this procedure measure is submitted each time a procedure is performed for the performance period. There is no diagnosis associated with this measure.

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.

This is an inverse measure which means 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.

‌Telehealth:

NOT TELEHEALTH ELIGIBLE: This measure is not appropriate for nor applicable to the telehealth setting. This measure is procedure based and therefore doesn’t allow for the denominator criteria to be conducted via telehealth. It would be appropriate to remove these patients from the denominator eligible patient population. Telehealth eligibility is at the measure level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.

‌Measure Submission:

The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this collection type for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. The coding provided to identify the measure criteria: Denominator or Numerator, may be an example of coding that could be used to identify patients that meet the intent of this clinical topic. When implementing this measure, please refer to the ‘Reference Coding’ section to determine if other codes or code languages that meet the intent of the criteria may also be used within the medical record to identify and/or assess patients. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

‌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, 49186, 49187, 49188, 49189, 49190, 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

‌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 – see Implementation Considerations.

‌Numerator Options:

Performance Not Met: No unplanned hospital readmission within 30 days of principal procedure (G9309)

OR

Performance Met: Unplanned hospital readmission within 30 days of principal procedure (G9310)

RATIONALE:

This is an adverse surgical outcome, which is often a preventable cause of harm, thus it is important to measure and report. It is feasible to collect the data and produce reliable and valid results about the quality of care. It is useful and understandable to stakeholders. This measure was developed in a collaborative effort by the American College of Surgeons and the American Board of Surgery. This measure addresses the National Quality Strategy Priorities, and was identified by an expert panel of physician providers to be a critical outcome for this procedure. This measure addresses a high-impact condition as it is one of the most common procedures performed in the U.S. The measure aligns well with the intended use. The care settings include Acute Care Facilities/Hospitals. Data are being collected in a clinical registry that has been in existence for over 10 years, with over 5500 current, active users. Thus, we are requesting consideration of this measure in the MIPS CQM reporting option. The level of analysis is the clinician/individual. All populations are included, except children. The measure allows measurement across the person-centered episode of care out to 30 days after the procedure whether an inpatient, outpatient, or readmitted. The measure addresses disparities in care. The risk adjustment is performed with a parsimonious dataset and aims to allow efficient data collection resources and data reporting. The measure has been harmonized when possible.