2018 MIPS Measure #446: Operative Mortality Stratified by the Five STS-EACTS Mortality Categories

Measure Description

Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool

Instructions

This measure is to be submitted for all pediatric and/or congenital heart patients each time a surgery is performed during the performance period. 

This measure is intended to reflect the quality of services provided for patients with congenital heart disease. 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. 

Mortality is only counted once – so the denominator is all patients having CHS and the numerator is 1) deaths occurring within the index acute care hospitalization and 2) Deaths occurring after discharge but within 30 days of surgery. 

Measure Submission:

The listed denominator criteria are used to identify the intended patient population. The numerator quality-data codes included in this specification are used to submit the quality actions allowed by the measure. All measure-specific coding should be submitted on the claim(s) representing the eligible encounter. There are two submission criteria for this measure. 1.) Patients who undergo pediatric and/or congenital heart surgery that experience death during hospitalization or 2.) Patients who undergo pediatric and/or congenital heart surgery that experience death after hospital discharge and within 30 days post procedure

Denominator

THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:

Patients who undergo pediatric and/or congenital heart surgery that experience death during the index acute care hospitalization

OR

Patients who undergo pediatric and/or congenital heart surgery that experience death after discharge from the hospital but within 30 days post procedure DENOMINATOR:  

SUBMISSION CRITERIA 1: ALL DEATHS DURING HOSPITALIZATION  

DENOMINATOR (SUBMISSION CRITERIA 1):

Number of index cardiac operations in each level of complexity stratification using the five STS-EACTS Mortality

Levels, a multi-institutional validated complexity stratification tool

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registry-based measures.

Denominator Criteria (Eligible Cases) 1:

Diagnosis for congenital heart disease (ICD-10-CM):

AND

Patient procedure during performance period (CPT): 15732, 15734, 19271, 19272, 21550, 21555, 21552, 21556, 21554, 21557, 21558, 21600, 21615, 21616, 21620, 21627, 21630, 21632, 21685, 21705, 21740, 21742, 21743, 21750, 21899, 31612, 31613, 31614, 31622, 31623, 31624, 31625, 31626, 31627, 31628, 31629, 31630, 31631, 31634, 31635, 31636, 31638, 31640, 31641, 31643, 31645, 31646, 31647, 31648, 31652, 31653, 31786, 32096, 32097, 32100, 32110, 32120, 32124, 32140, 32141, 32150, 32151, 32160, 32200, 32215, 32220, 32225, 32310, 32320, 32400, 32405, 32503, 32504, 32601, 32604, 32606, 32607, 32608, 32609, 32850*, 32851, 32852, 32853, 32854, 32855, 32856, 32900, 33010, 33011, 33015, 33025, 33030, 33031, 33050, 33120, 33130, 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33230, 33231, 33240, 33249, 33250, 33251, 33254, 33255, 33256, 33257, 33258, 33259, 33261, 33265, 33266, 33270, 33271, 33390, 33391, 33404, 33405, 33406, 33410, 33411, 33412, 33413, 33414, 33415, 33416, 33417, 33418, 33419, 33420, 33422, 33425, 33426, 33427, 33430, 33460, 33463, 33464, 33465, 33468, 33470, 33471, 33474, 33475, 33476, 33477, 33478, 33496, 33500, 33501, 33502, 33503, 33504, 33505, 33506, 33507, 33542, 33545, 33548, 33600, 33602, 33606, 33608, 33610, 33611, 33612, 33615, 33617, 33619, 33620, 33621, 33622, 33641, 33645, 33647, 33660, 33665, 33670, 33675, 33676, 33677, 33681, 33684, 33688, 33690, 33692, 33694, 33697, 33702, 33710, 33720, 33722, 33724, 33726, 33730, 33732, 33735, 33736, 33737, 33750, 33755, 33762, 33764, 33766, 33767, 33770, 33771, 33774, 33775, 33776, 33777, 33778, 33779, 33780, 33781, 33782, 33783, 33786, 33788, 33800, 33802, 33803, 33813, 33814, 33820, 33822, 33824, 33840, 33845, 33851, 33852, 33853, 33860, 33863, 33864, 33870, 33875, 33877, 33910, 33915, 33916, 33917, 33920, 33922, 33924, 33925, 33926, 33930*, 33933, 33935, 33940*, 33944, 33945, 33946, 33947, 33948, 33967, 33970, 33971, 33973, 33974, 33975, 33976, 33977, 33978, 33979, 33980, 33981, 33982, 33983, 33987, 33988, 33989, 33990, 33991, 33992, 33993, 33999, 59076, 59897, 71275, 74175, 75557, 75559, 75561, 75563, 75565, 75572, 75573, 75574, 76825, 76826, 76825, 92992, 92993, 93303, 93304, 93315, 93316, 93317, 93355, 93530, 93531, 93532, 93533, 93563, 93564, 93580, 93581, 93582, 93583

AND

STS-EACTS Mortality Level Tool Utilized

–OR–

SUBMISSION CRITERIA 2: DEATHS OCCURING AFTER HOSPITAL DISCHARGE WITHIN 30 DAYS AFTER PROCEDURE

DENOMINATOR (SUBMISSION CRITERIA 2):

Number of index cardiac operations in each level of complexity stratification using the five STS-EACTS Mortality Levels, a multi-institutional validated complexity stratification tool

Denominator Criteria (Eligible Cases) 2:

Diagnosis for congenital heart disease (ICD-10-CM):

AND

Patient procedure during performance period (CPT): 15732, 15734, 19271, 19272, 21550, 21555, 21552, 21556, 21554, 21557, 21558, 21600, 21615, 21616, 21620, 21627, 21630, 21632, 21685, 21705, 21740, 21742, 21743, 21750, 21899, 31612, 31613, 31614, 31622, 31623, 31624, 31625, 31626, 31627, 31628, 31629, 31630, 31631, 31634, 31635, 31636, 31638, 31640, 31641, 31643, 31645, 31646, 31647, 31648, 31652, 31653, 31786, 32096, 32097, 32100, 32110, 32120, 32124, 32140, 32141, 32150, 32151, 32160, 32200, 32215, 32220, 32225, 32310, 32320, 32400, 32405, 32503, 32504, 32601, 32604, 32606, 32607, 32608, 32609, 32850*, 32851, 32852, 32853, 32854, 32855, 32856, 32900, 33010, 33011, 33015, 33025, 33030, 33031, 33050, 33120, 33130, 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33230, 33231, 33240, 33249, 33250, 33251, 33254, 33255, 33256, 33257, 33258, 33259, 33261, 33265, 33266, 33270, 33271, 33403, 33404, 33405, 33406, 33410, 33411, 33412, 33413, 33414, 33415, 33416, 33417, 33418, 33419, 33420, 33422, 33425, 33426, 33427, 33430, 33460, 33463, 33464, 33465, 33468, 33470, 33471, 33474, 33475, 33476, 33477, 33478, 33496, 33500, 33501, 33502, 33503, 33504, 33505, 33506, 33507, 33542, 33545, 33548, 33600, 33602, 33606, 33608, 33610, 33611, 33612, 33615, 33617, 33619, 33620, 33621, 33622, 33641, 33645, 33647, 33660, 33665, 33670, 33675, 33676, 33677, 33681, 33684, 33688, 33690, 33692, 33694, 33697, 33702, 33710, 33720, 33722, 33724, 33726, 33730, 33732, 33735, 33736, 33737, 33750, 33755, 33762, 33764, 33766, 33767, 33770, 33771, 33774, 33775, 33776, 33777, 33778, 33779, 33780, 33781, 33782, 33783, 33786, 33788, 33800, 33802, 33803, 33813, 33814, 33820, 33822, 33824, 33840, 33845, 33851, 33852, 33853, 33860, 33863, 33864, 33870, 33875, 33877, 33910, 33915, 33916, 33917, 33920, 33922, 33924, 33925, 33926, 33930*, 33933, 33935, 33940*, 33944, 33945, 33946, 33947, 33948, 33967, 33970, 33971, 33973, 33974, 33975, 33976, 33977, 33978, 33979, 33980, 33981, 33982, 33983, 33987, 33988, 33989, 33990, 33991, 33992, 33993, 33999, 59076, 59897, 71275, 74175, 75557, 75559, 75561, 75563, 75565, 75572, 75573, 75574, 76825, 76826, 76825, 92992, 92993, 93303, 93304, 93315, 93316, 93317, 93355, 93530, 93531, 93532, 93533, 93563, 93564, 93580, 93581, 93582, 93583

AND

STS-EACTS Mortality Level Tool Utilized

Numerator

THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:

Patients who undergo pediatric and/or congenital heart surgery that experience death during the index acute care hospitalization

OR

Patients who undergo pediatric and/or congenital heart surgery that experience death after discharge from the hospital but within 30 days post procedure 

SUBMISSION CRITERIA 1: ALL DEATHS DURING HOSPITALIZATION  

NUMERATOR (SUBMISSION CRITERIA 1):

All deaths occurring during the index acute care hospitalization in which the procedure was performed (no matter how long post op) in which the procedure was performed stratified by the five STAT Mortality Levels, a multiinstitutional validated complexity stratification tool

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. Submitting 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:

Death occurring during the index acute care hospitalization (G9814)

OR

Performance Not Met:

Death did not occur during the index acute care hospitalization (G9815)

–OR–

SUBMISSION CRITERIA 2: DEATHS OCCURING AFTER HOSPITAL DISCHARGE WITHIN 30 DAYS AFTER PROCEDURE

NUMERATOR (SUBMISSION CRITERIA 2):

Those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool 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. Submitting 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:

Death occurring after discharge from the hospital but within 30 days post procedure (G9816)

OR

Performance Not Met:

Death did not occur after discharge from the hospital within 30 days post procedure (G9817)