2017 MIPS Measure #445: Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)

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

Measure Description

Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure

Instruction

This measure is to be reported a minimum of once per performance period for patients undergoing isolated CABG 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.

Denominator

All patients undergoing isolated CABG

Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of enc unter
AND
Patient procedure during the performance period (CPT): 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
OR
Patient procedure during the performance period (CPT): 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
AND
Patient procedure during the performance period (CPT): 33530

Numerator

Number of patients undergoing isolated CABG who die, including both all deaths occurring during the
hospitalization in which the operation was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure

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: Patient died including all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure (G9812)
OR
Performance Not Met: Patient did not die within 30 days of the procedure or during the index hospitalization (G9813)

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