2017 MIPS Measure #344: Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)

Valid Data Submission Method(s) Measure Type High Priority Measure? NQS Domain Specialty Measure Sets
Registry Outcome Yes Effective Clinical Care Interventional Radiology, Vascular Surgery

Measure Description

Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2

Instruction

This measure is to be reported each time a CAS is performed during the performance period. It is anticipated that eligible clinicians who provide services of CAS, as described in the measure, based on the services provided and the measure-specific denominator coding will report this measure. 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.

Denominator

Patients aged 18 and older who are asymptomatic undergoing CAS

Denominator Criteria (Eligible Cases):
Patients aged 18 and older
AND
Patient procedure during performance period (CPT): 37215
AND NOT
DENOMINATOR EXCLUSIONS:
Symptomatic carotid stenosis: Ipsilateral carotid territory TIA or stroke less than 120 days prior to procedure: 9006F
OR
Other carotid stenosis: Ipsilateral TIA or stroke 120 days or greater prior to procedure or any prior contralateral carotid territory or vertebrobasilar TIA or stroke: 9007F

Numerator

Patients discharged to home no later than post-operative day 2 following CAS

Definition:
Home – For purposes of reporting this measure, home is the point of origin prior to hospital admission prior to procedure. For example, if the patient comes from a skilled facility and returns to the skilled facility, this would meet criteria for discharged to home.

Numerator Options:
Performance Met: Documentation of patient discharged to home no later than post-operative day 2 following CAS (G9255)
OR
Performance Not Met: Documentation of patient discharged to home later than
post-operative day 2 following CAS (G9254)

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