| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Outcome | Yes | Effective Clinical Care | General Surgery |
Measure Description
Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure
Instruction
This measure is to be reported each time a procedure for an unplanned hospital readmission within 30 days of principal procedure is performed during the performance period ending November 30th . There is no diagnosis associated with 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 years and older undergoing a surgical procedure
Denominator Criteria (Eligible Cases):
All patients aged 18 years and older
AND
Patient procedure during the performance period (CPT): 11004, 11005, 11006, 15920, 15931, 15933, 15940, 15950, 19101, 19301, 19302, 19303, 19304, 19305, 19306, 19307, 20100, 20101, 20102, 22904, 22905, 36566, 36818, 36819, 36820, 36821, 36825, 36830, 38100, 38115, 38120, 38530, 38765, 39540, 39541, 43122, 43279, 43281, 43282, 43325, 43327, 43330, 43332, 43333, 43336, 43337, 43340, 43361, 43500, 43501, 43502, 43510, 43520, 43605, 43610, 43611, 43620, 43621, 43622, 43631, 43632, 43633, 43634, 43640, 43641, 43644, 43645, 43651, 43652, 43653, 43772, 43773, 43774, 43775, 43800, 43810, 43820, 43825, 43830, 43831, 43832, 43840, 43843, 43845, 43846, 43847, 43848, 43850, 43855, 43860, 43865, 43870, 43880, 44005, 44010, 44020, 44021, 44025, 44050, 44055, 44110, 44111, 44120, 44125, 44126, 44127, 44130, 44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44155, 44156, 44157, 44158, 44160, 44180, 44186, 44187, 44188, 44202, 44204, 44205, 44206, 44207, 44208, 44210, 44211, 44212, 44227, 44300, 44310, 44312, 44314, 44316, 44320, 44322, 44340, 44345, 44346, 44602, 44603, 44604, 44605, 44615, 44620, 44625, 44626, 44640, 44650, 44660, 44661, 44680, 44700, 44800, 44820, 44850, 44900, 44950, 44960, 44970, 45000, 45020, 45110, 45111, 45112, 45113, 45114, 45116, 45119, 45120, 45121, 45123, 45126, 45130, 45135, 45136, 45540, 45550, 45562, 45563, 45800, 45805, 47010, 47015, 47100, 47120, 47122, 47125, 47130, 47300, 47350, 47360, 47361, 47362, 47370, 47371, 47380, 47400, 47420, 47425, 47460 ,47480, 47562, 47563, 47564, 47570, 47600, 47605, 47610, 47612, 47620, 47711, 47712, 47715, 47720, 47721, 47740, 47741, 47760, 47765, 47780, 47785, 47800, 47900, 48000, 48001, 48020, 48100, 48105, 48120, 48140, 48145, 48146, 48148, 48150, 48152, 48153, 48154, 48155, 48500, 48510, 48520, 48540, 48545, 48547, 48548, 49000, 49002, 49010, 49020, 49040, 49060, 49062, 49203, 49204, 49205, 49255, 49320, 49322, 49323, 49402, 49425, 49429, 49553, 49557, 49560, 49561, 49565, 49566, 49572, 49585, 49587, 49590, 49652, 49653, 49654, 49655, 49656, 49657, 49900, 50205, 50500, 50740, 57305, 57307, 60200, 60210, 60212, 60220, 60225, 60240, 60252, 60254, 60260, 60270, 60271, 60540, 60545, 60650
Numerator
Inpatient readmission to the same hospital for any reason or an outside hospital (if known to the surgeon), within 30 days of the principal surgical 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: Unplanned hospital readmission within 30 days of principal procedure (G9310)
OR
Performance Not Met: No unplanned hospital readmission within 30 days of principal procedure (G9309)