| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Process | No | Effective Clinical Care |
Measure Description
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received an IMA graft
Instruction
This measure is to be reported each time an isolated CABG procedure is performed during the performance period. It is anticipated that eligible clinicians who provide services for isolated CABG will submit this measure. This measure is intended to reflect the quality of the surgical services provided for isolated CABG patients. Isolated CABG refers to CABG using arterial and/or venous grafts only.
Denominator
All patients undergoing isolated CABG
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient procedure during the performance period (CPT): 33510, 33511, 33512, 3514,
33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
Numerator
Patients undergoing isolated CABG who received an IMA graft
Numerator Options:
Performance Met: Internal mammary artery graft performed for primary, isolated coronary artery bypass graft procedure (CABG) (4110F)
OR
Denominator Exception: Documentation of medical reason(s)
for not performing an internal mammary artery graft for primary, isolated coronary artery bypass
graft procedure. Acceptable medical reasons include: subclavian stenosis, previous cardiac or
thoracic surgery, previous mediastinal radiation, emergent or salvage procedure, no bypassable left
anterior descending artery disease (4110F with 1P)
OR
Performance Not Met: Internal mammary artery graft not performed for primary, isolated coronary artery bypass graft procedure, reason not otherwise specified (4110F with 8P)