| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Outcome | Yes | Patient Safety | Electrophysiology Cardiac Specialist |
Measure Description
Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is reported as four rates stratified by age and gender: Reporting Age Criteria 1: Females 18-64years of age Reporting Age Criteria 2: Males 18-64 years of age Reporting Age Criteria 3: Females 65 years of age and older Reporting Age Criteria 4: Males 65 years of age and older
Instruction
This measure is to be reported a minimum of once per performance period for patients with atrial fibrillation ablation performed during the performance period. This measure may be reported by 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, 2017, 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 reporting year. 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 reporting.
This measure will be calculated with 5 performance rates:
- Females 18-64 years of age
- Males 18-64 years of age
- Females 65 years of age and older
- Males 65 years of age and older
- Overall percentage of patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days
Eligible clinicians should continue to report the measure as specified, with no additional steps needed to account for multiple performance rates.
Denominator
All patients aged 18 years and older with atrial fibrillation ablation performed during the reporting period
Denominator Criteria (Eligible Cases):
REPORTING CRITERIA 1: Females 18-64 years old
REPORTING CRITERIA 2: Males 18-64 years old
REPORTING CRITERIA 3: Females 65 years of age and older
REPORTING CRITERIA 4: Males 65 years of age and older
AND
Diagnosis for atrial fibrillation (ICD-10-CM): I48.0, I48.1, I48.2, I48.91
AND
Diagnosis for atrial fibrillation ablation (ICD-10-PCS): 02563ZZ, 02573ZZ, 02583ZZ, 025S3ZZ, 025T3ZZ, 02560ZZ, 02564ZZ, 02570ZZ, 02574ZZ, 02580ZZ, 02584ZZ, 025S4ZZ, 025T4ZZ
AND
Ablation procedures that have been performed by November 30 of current reporting year
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. Reporting 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)