2024 MIPS Measure #392: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation

2024 COLLECTION TYPE:

MIPS Clinical Quality Measures (CQMS)

‌MEASURE TYPE: Outcome – High Priority

Description

Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This measure is submitted as four rates stratified by age and gender:

• Submission Age Criteria 1: Females 18-64 years of age
• Submission Age Criteria 2: Males 18-64 years of age
• Submission Age Criteria 3: Females 65 years of age and older
• Submission Age Criteria 4: Males 65 years of age and older

Instructions

This measure is to be submitted a minimum of once per performance period for patients with atrial fibrillation ablation performed 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.

NOTE: Include only patients that have had atrial fibrillation ablation performed by November 30, 2024 for evaluation of cardiac tamponade and/or pericardiocentesis occurring within 30 days within the performance period. This will allow the evaluation of cardiac tamponade and/or pericardiocentesis complications within the performance period. A minimum of 30 cases is recommended by the measure owner to ensure a volume of data that accurately reflects provider performance; however, this minimum number is not required for purposes of QPP submission.

This measure will be calculated with 5 performance rates:

1. Females 18-64 years of age
2. Males 18-64 years of age
3. Females 65 years of age and older
4. Males 65 years of age and older
5. Overall percentage of patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days

‌MIPS eligible clinicians should continue to submit the measure as specified, with no additional steps needed to account for multiple performance rates. For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 5 is used for performance.

Measure Submission Type

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. 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 by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

Denominator

All patients aged 18 years and older with atrial fibrillation ablation performed during the reporting period

Denominator Criteria (Eligible Cases):

Submission Criteria 1:

1. Submission Criteria 1: Females 18-64 years of age
2. Submission Criteria 2: Males 18-64 years of age
3. Submission Criteria 3: Females 65 years of age and older
4. Submission Criteria 4: Males 65 years of age and older

AND

Diagnosis code for atrial fibrillation (ICD-10-CM): I48.0, I48.11, I48.19, I48.20, I48.21, I48.91

AND

Procedure code for atrial fibrillation ablation (ICD-10-PCS): 02583ZZ, 02584ZZ

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10

AND/OR

Ablation procedures that have been performed by November 30 of current performance period (CPT): 93656

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10

‌Numerator

The number of patients from the denominator with cardiac tamponade and/or pericardiocentesis occurring within 30 days following atrial fibrillation ablation

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: Patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days (G9408)

OR

‌Performance Not Met: Patients without cardiac tamponade and/or pericardiocentesis occurring within 30 days (G9409)