2017 MIPS Measure #348: HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate

Measure Description

Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD

Instruction

This measure is to be reported a minimum of once per performance period for patients with a first time implantation of an ICD during the performance period. 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.

NOTE: Include only patients that have had first time implantation through November 30 for evaluation of complications for 30 days and September 30 for evaluation of complications for 90 days post procedure within the performance period. This will allow the evaluation of ICD implant complications within the reporting year.

There are 2 performance rates to be calculated for this measure:

1. Complications or mortality at 30 days
   OR
2. Complications at 90 days

Denominator

THERE ARE TWO REPORTING CRITERIA FOR THIS MEASURE:

1) Patients who are 18 years and older with a diagnosis of HF with a current or prior LVEF < 40% seen inthe outpatient setting with two denominator eligible visits

OR

2) Patients who are 18 years and older with a diagnosis of HF with a current or prior LVEF < 40% anddischarged from hospital

DENOMINATOR (REPORTING CRITERIA 1): 
Patients with a first time implantation of an ICD

Denominator Instructions: Include patients with procedures that are performed ≥ 31 days prior to the end of the performance period. Denominator patients can be identified using the following
ICD-10 codes.

Denominator Criteria (Eligible Cases):
Patient aged ≥ 65 years on date of encounter
AND
Implantation of ICD (ICD-10-PCS): 02H40JZ, 02H43JZ, 02H43KZ, 02H43MZ, 02H44JZ, 02H60JZ, 02H60KZ, 02H63JZ, 02H63KZ, 02H64JZ, 02H64KZ, 02H70KZ, 02H73KZ, 02H74KZ, 02HK0JZ, 02HK0KZ, 02HK3JZ, 02HK3KZ, 02HK4JZ, 02HK4KZ, 02HL0JZ, 02HL0KZ, 02HL3JZ, 02HL3KZ, 02HL4JZ, 02HL4KZ, 0JH607Z, 0JH608Z, 0JH609Z, 0JH637Z, 0JH638Z, 0JH639Z, 0JH807Z, 0JH808Z, 0JH809Z, 0JH837Z, 0JH838Z, 0JH839Z
AND/OR
Patient encounter during performance period (CPT): 33216, 33217, 33218, 33220, 33223, 33240, 33249
AND NOT
DENOMINATOR EXCLUSIONS:
Removal of ICD (ICD-10-PCS): 0JPT0PZ, 0JPT3PZ
AND/OR
Removal of ICD (CPT): 33241, 33262, 33263, 33264

–OR–

DENOMINATOR (REPORTING CRITERIA 2):
Patients with a first time implantation of an ICD

Denominator Instructions: Include patients with procedures that are performed ≥ 91 days prior to the end of
the performance period. Denominator patients can be identified using the following ICD-10 codes.

Denominator Criteria (Eligible Cases):
Patient aged ≥ 65 years on date of encounter
AND
Implantation of ICD (ICD-10-PCS): 02H40JZ, 02H43JZ, 02H43KZ, 02H43MZ, 02H44JZ, 02H60JZ, 02H60KZ, 02H63JZ, 02H63KZ, 02H64JZ, 02H64KZ, 02H70KZ, 02H73KZ, 02H74KZ, 02HK0JZ, 02HK0KZ, 02HK3JZ, 02HK3KZ, 02HK4JZ, 02HK4KZ, 02HL0JZ, 02HL0KZ, 02HL3JZ, 02HL3KZ, 02HL4JZ, 02HL4KZ, 0JH607Z, 0JH608Z, 0JH609Z, 0JH637Z, 0JH638Z, 0JH639Z, 0JH807Z, 0JH808Z, 0JH809Z, 0JH837Z, 0JH838Z, 0JH839Z
AND/OR
Patient encounter during performance period (CPT): 33216, 33217, 33218, 33220, 33223, 33240, 33241,
33249, 33262, 33263, 33264
AND NOT
DENOMINATOR EXCLUSIONS:
Removal of ICD (ICD-10-PCS): 0JPT0PZ, 0JPT3PZ
AND/OR
Removal of ICD (CPT): 33241, 33262, 33263, 33264

Numerator

THERE ARE TWO REPORTING CRITERIA FOR THIS MEASURE:

1) Patients who are 18 years and older with a diagnosis of HF with a current or prior LVEF < 40% seen inthe outpatient setting with two denominator eligible visits

OR

2) Patients who are 18 years and older with a diagnosis of HF with a current or prior LVEF < 40% anddischarged from hospital

NUMERATOR (REPORTING CRITERIA 1):
Number of patients with one or more of the following complications or mortality within 30 days (depending on the
complication) following ICD implantation

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.

Definition:
Complications measured for 30 days:

1. Death
2. Pneumothorax or hemothorax plus a chest tube
3. Hematoma plus a blood transfusion or evacuation
4. Cardiac tamponade or pericardiocentesis

Numerator Options:
Performance Met: Documentation of patient with one or more complications or mortality within 30 days (G9267)
OR
Performance Not Met: Documentation of patient without one or more complications and without mortality within 30 days (G9269)

–OR–

NUMERATOR (REPORTING CRITERIA 2):
Number of patients with one or more of the following complications within 90 days (depending on the complication) following ICD implantation

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.

Definition:
Complications measured for 90 days:

1. Mechanical complications requiring a system revision
2. Device related infection
3. Additional ICD implantation

Numerator Options:
Performance Met: Documentation of patient with one or more complications within 90 days (G9268)
OR
Performance Not Met: Documentation of patient without one or more complications within 90 days (G9270)