2018 MIPS Measure #423: Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy

Measure Type High Priority Measure? NQS Domain
Process No Effective Clinical Care
Data Submission Method(s)
Claims, Registry

Measure Description

Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery

Instructions

This measure is to be submitted each time carotid endarterectomy is performed during the perfromance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Measure Submission:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

Denominator

Patients over age 18 undergoing carotid endarterectomy

Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter 

AND

Patient procedure during the performance period (CPT): 35301

Numerator

Patients undergoing carotid endarterectomy who received anti-platelet agents within 48 hours prior to the initiation of surgery AND are prescribed this medication at hospital discharge following surgery

Numerator Instructions: There must be documentation in the patient’s medical record of an order (written order, verbal order, or standing order/protocol) for anti-platelet agents OR documentation that anti-platelet agents was given within 48 hours prior to surgery AND patient has prescription for this medication hospital discharge following surgery.

Numerator Options:

Performance Met:

Documentation of an order for anti-platelet agents (G9609)

OR

Denominator Exception:

Documentation of medical reason(s) in the patient’s record for not ordering anti-platelet agents (G9610)

OR

Performance Not Met:

Order for anti-platelet agents was not documented in the patient’s record, reason not given (G9611)

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