| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Outcome | Yes | Patient Safety | General Surgery |
Measure Description
Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period
Instruction
This measure is to be reported each time a procedure for an unplanned reoperation within the 30 day postoperative period 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 an operative procedure
Denominator Criteria (Eligible Cases):
All patients aged 18 years and older
AND
Patient procedure during the performance period (CPT): 11004, 11005, 11006, 11450 11451, 11462, 11463, 11470, 11471, 11770, 11771, 11772, 15920, 15931, 15933, 15940, 15950 19101, 19110, 19112, 19120, 19125, 19300, 19301, 19302, 19303, 19304, 19305, 19306, 19307, 20100, 20101, 20102, 20200, 20205, 21552, 21554, 21555, 21556, 21931, 21932, 21933, 22900, 22901, 22902, 22903, 22904, 22905, 23071, 23073, 23075, 24071, 24073, 24075, 25071, 27043, 27047, 27327, 27337, 36561, 36563, 36566, 36590, 36818, 36819, 36820, 36821, 36825, 36830, 38100, 38115, 38120, 38308, 38500, 38525, 38530, 38550, 38555, 38740, 38745, 38760, 38765, 39540, 39541, 43122, 43279, 43280, 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, 43770, 43771, 43772, 43773, 43774, 43775, 43800, 43810, 43820, 43825, 43830, 43831, 43832, 43840, 43843, 43845, 43846, 43847, 43848, 43850, 43855, 43860, 43865, 43870, 43880, 43886, 43887, 43888, 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, 45005, 45020, 45100, 45108, 45110, 45111, 45112, 45113, 45114, 45116, 45119, 45120, 45121, 45123, 45126, 45130, 45135, 45136, 45150, 45160, 45171, 45172, 45505, 45540, 45541, 45550, 45562, 45563, 45800, 45805, 45900, 45905, 46040, 46045, 46060, 46080, 46250, 46255, 46257, 46258, 46260, 46261, 46262, 46270, 46275, 46280, 46285, 46288, 47010, 47015, 47100, 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, 49321, 49322, 49323, 49324, 49325, 49402, 49421, 49422, 49425, 49426, 49429, 49436, 49505, 49507, 49520, 49521, 49525, 49540, 49550, 49553, 49555, 49557, 49560, 49561, 49565, 49566, 49570, 49572, 49585, 49587, 49590, 49650, 49651, 49652, 49653, 49654, 49655, 49656, 49657, 49900, 50205, 50500, 50740, 55520, 55540, 57305, 57307, 60200, 60210, 60212, 60220, 60225, 60240, 60252, 60254, 60260, 60270, 60271, 60500, 60502, 60520, 60540, 60545, 60650
Numerator
Unplanned return to the operating room for a surgical procedure, for any reason, within 30 days of the principal operative 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 NOTE: This measure intent is to capture patients who go back to the operating room within 30 days for a follow-up procedure based on complications of the principal (denominator eligible) operative procedure. Examples: Breast biopsies (19101) with return for re-excisions or insertion of port-a-cath for chemotherapy would not be considered an unplanned return to the operating room for a surgical procedure. If this patient had an open, incisional biopsy of breast tissue (19101) and subsequently had an appendectomy performed this would not be considered an unplanned return to the operating room for a surgical procedure.
The return to the OR may occur at any hospital or surgical facility.
Numerator Options:
Performance Met: Unplanned return to the operating room for a surgical procedure, for complications of the principal operative procedure, within 30 days of the principal operative procedure (G9308)
OR
Performance Not Met: No return to the operating room for a surgical procedure for complications of the principal operative procedure within 30 days of the principal operative procedure (G9307)