MIPS Clinical Quality Measures (CQMS)
MEASURE TYPE: Outcome – High Priority
Description
Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2).
Instructions
This measure is to be submitted each time an endovascular repair AAA is performed during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who provide services of AAA repair, as described in the measure, based on the services provided and the measure-specific denominator coding will submit this measure. This measure may be submitted by 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
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 endovascular repairs of non-ruptured, infrarenal abdominal aortic aneurysms
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for non-rupture, infrarenal abdominal aortic aneurysms (ICD-10-CM): I71.40, I71.43
AND
Patient procedure during the performance period (CPT): 34701, 34703, 34705
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10
AND NOT
Denominator Exclusion:
For women: Aortic aneurysm 5.5 – 5.9 cm maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9003F
OR
Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9004F
OR
For men: Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9004F
Numerator
Patients discharged to home no later than post-operative day #2 following EVAR of AAA
Definition:
Home – For purposes of submitting this measure, “home” is the point of origin prior to hospital admission prior to procedure of AAA. For example, if the patient comes from a skilled facility and returns to the skilled facility post AAA repair, this would meet criteria for discharged to home.
Numerator Options:
Performance Met: Patient discharged to home no later than post-operative day #2 following EVAR (G8826)
OR
Performance Not Met: Patient not discharged to home by post-operative day #2 following EVAR (G8833)
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