| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Outcome | Yes | Patient Safety | Electrophysiology Cardiac Specialist |
Measure Description
Infection rate following CIED device implantation, replacement, or revision
Instruction
This measure is to be reported a minimum of once per performance period for patients with a CIED device implantation, replacement, or revision performed from January 1, 2017 through June 30, 2017 of 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 CIED implantation, replacement, or revision performed by June 30. This timeframe allows for evaluation of infection requiring within 180 days within the performance period. This will allow the evaluation of infection status post CIED implantation, replacement, or revision within the reporting year.
Infection rates for new implants shall be calculated and reported separately from device replacements and revisions.
Additional reporting stratification categories may be useful; however, these stratifications are not required for purposes of QPP reporting:
- Device class (e.g., pacemaker, ICD) and type (e.g., single chamber, dual chamber);
- Advanced renal disease (CKD stages 4 and 5, ESRD);
- Diabetes;
- CIED infection requiring device removal within 180 days prior to index CIED procedures; and
- CIED-related surgical procedure within 180 days prior to current CIED procedure.
Denominator
THERE ARE TWO REPORTING CRITERIA FOR THIS MEASURE:
1.Patients, regardless of age, with a new CIED
OR
2.Patients, regardless of age, with a replaced or revised CIED
DENOMINATOR (REPORTING CRITERIA 1):
All patients with a new CIED from January 1, 2017 through June 30, 2017 of the reporting period
Definition:
CIEDs encompassed for this measure are the following devices:
- Pacemaker devices (single or dual chamber);
- Implantable cardioverter-defibrillators (ICDs, single or dual chamber);
- Cardiac resynchronization devices (pacemaker or ICD); and
- Implantable loop recorders (ILRs)
Denominator Criteria (Eligible Cases) 1:
All patients, regardless of age
AND
Codes for CIED implantation, replacement, or revision (ICD-10-CM, ICD-10-PCS procedure codes): 02H40JZ, 02H40KZ, 02H40MZ, 02H43JZ, 02H43KZ, 02H43MZ, 02H44JZ, 02H44KZ, 02H44MZ, 02H60JZ, 02H60KZ, 02H60MZ, 02H63JZ, 02H63KZ, 02H63MZ, 02H64JZ, 02H64KZ, 02H64MZ, 02H70JZ, 02H70KZ, 02H70MZ, 02H73JZ, 02H73KZ, 02H73MZ, 02H74JZ, 02H74KZ, 02H74MZ, 02HK0JZ, 02HK0KZ, 02HK0MZ, 02HK3JZ, 02HK3KZ, 02HK3MZ, 02HK4JZ, 02HK4KZ, 02HK4MZ, 02HL0JZ, 02HL0KZ, 02HL0MZ, 02HL3JZ, 02HL3KZ, 02HL3MZ, 02HL4JZ, 02HL4KZ, 02HL4MZ, 02HN0JZ, 02HN0KZ, 02HN0MZ, 02HN3JZ, 02HN3KZ, 02HN3MZ, 02HN4JZ, 02HN4KZ, 02HN4MZ, 02PA0MZ, 02PA3MZ, 02PA4MZ, 02PAXMZ, 02WA0MZ, 02WA3MZ, 02WA4MZ, 0JH604Z, 0JH605Z, 0JH606Z, 0JH607Z, 0JH608Z, 0JH609Z, 0JH60PZ, 0JH634Z, 0JH635Z, 0JH636Z, 0JH637Z, 0JH638Z, 0JH639Z, 0JH63PZ, 0JH804Z, 0JH805Z, 0JH806Z, 0JH807Z, 0JH808Z, 0JH809Z, 0JH80PZ, 0JH834Z, 0JH835Z, 0JH836Z, 0JH837Z, 0JH838Z, 0JH839Z, 0JH83PZ, 0JPT0PZ, 0JPT3PZ, 0JWT0PZ, 0JWT3PZ, R50.81, R50.9
AND/OR
Patient encounter during performance period (CPT): 33202, 33203, 33206, 33207, 33208, 33212, 33213, 33214, 33215, 33216, 33217, 33218, 33220, 33221, 33222, 33223, 33224, 33225, 33226, 33227, 33228, 33229, 33240, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, 33282, 93260, 93261
AND
New CIED
AND NOT
DENOMINATOR EXCLUSION:
Patients undergoing heart transplantation (ICD-10-PCS procedure codes): 02YA0Z2
–OR–
DENOMINATOR (REPORTING CRITERIA 2):
All patients with replacement or revision of a CIED from January 1, 2017 through June 30, 2017 of the reporting period
Definition:
CIEDs encompassed for this measure are the following devices:
- Pacemaker devices (single or dual chamber);
- Implantable cardioverter-defibrillators (ICDs, single or dual chamber);
- Cardiac resynchronization devices (pacemaker or ICD); and
- Implantable loop recorders (ILRs)
Denominator Criteria (Eligible Cases) 2:
All patients, regardless of age
AND
Codes for CIED implantation, replacement, or revision (ICD-10-CM, ICD-10-PCS procedure codes): 02H40JZ, 02H40KZ, 02H40MZ, 02H43JZ, 02H43KZ, 02H43MZ, 02H44JZ, 02H44KZ, 02H44MZ, 02H60JZ, 02H60KZ, 02H60MZ, 02H63JZ, 02H63KZ, 02H63MZ, 02H64JZ, 02H64KZ, 02H64MZ, 02H70JZ, 02H70KZ, 02H70MZ, 02H73JZ, 02H73KZ, 02H73MZ, 02H74JZ, 02H74KZ, 02H74MZ, 02HK0JZ, 02HK0KZ, 02HK0MZ, 02HK3JZ, 02HK3KZ, 02HK3MZ, 02HK4JZ, 02HK4KZ, 02HK4MZ, 02HL0JZ, 02HL0KZ, 02HL0MZ, 02HL3JZ, 02HL3KZ, 02HL3MZ, 02HL4JZ, 02HL4KZ, 02HL4MZ, 02HN0JZ, 02HN0KZ, 02HN0MZ, 02HN3JZ, 02HN3KZ, 02HN3MZ, 02HN4JZ, 02HN4KZ, 02HN4MZ, 02PA0MZ, 02PA3MZ, 02PA4MZ, 02PAXMZ, 02WA0MZ, 02WA3MZ, 02WA4MZ, 0JH604Z, 0JH605Z, 0JH606Z, 0JH607Z, 0JH608Z, 0JH609Z, 0JH60PZ, 0JH634Z, 0JH635Z, 0JH636Z, 0JH637Z, 0JH638Z, 0JH639Z, 0JH63PZ, 0JH804Z, 0JH805Z, 0JH806Z, 0JH807Z, 0JH808Z, 0JH809Z, 0JH80PZ, 0JH834Z, 0JH835Z, 0JH836Z, 0JH837Z, 0JH838Z, 0JH839Z, 0JH83PZ, 0JPT0PZ, 0JPT3PZ, 0JWT0PZ, 0JWT3PZ, R50.81, R50.9
AND/OR
Patient encounter during performance period (CPT): 33202, 33203, 33206, 33207, 33208, 33212, 33213, 33214, 33215, 33216, 33217, 33218, 33220, 33221, 33222, 33223, 33224, 33225, 33226, 33227, 33228, 33229, 33240, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, 33282, 93260, 93261
AND
Replaced or revised CIED
AND NOT
DENOMINATOR EXCLUSION:
Patients undergoing heart transplantation (ICD-10-PCS procedure codes): 02YA0Z2
Numerator
THERE ARE TWO REPORTING CRITERIA FOR THIS MEASURE:
1.Patients, regardless of age, with a new CIED
OR
2.Patients, regardless of age, with a replaced or revised CIED
NUMERATOR (REPORTING CRITERIA 1):
The number of patients from the denominator admitted with an infection requiring device removal or surgical revision within 180 days following CIED implantation, replacement, or revision
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 Options:
Performance Met: Patient admitted within 180 days, status post CIED implantation, replacement, or revision with an infection requiring device removal or surgical revision (G9410)
OR
Performance Not Met: Patient not admitted within 180 days, status post CIED implantation, replacement, or revision with an infection requiring device removal or surgical revision (G9411)
–OR–
NUMERATOR (REPORTING CRITERIA 2):
The number of patients from the denominator admitted with an infection requiring device removal or surgical revision within 180 days following CIED implantation, replacement, or revision.
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 Options:
Performance Met: Patient admitted within 180 days, status post CIED implantation, replacement, or revision with an infection requiring device removal or surgical revision (G9412)
OR
Performance Not Met: Patient not admitted within 180 days, status post CIED implantation, replacement, or revision with an infection requiring device removal or surgical revision (G9413)