2017 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

Instruction

This measure is to be reported 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 reported by eligible clinicians who perform the quality actions describedin the measure based on the services provided and the measure-specific denominator coding.

Denominator

THERE ARE TWO REPORTING CRITERIA FOR THISMEASURE:
1)Patients who undergo pediatric and/or congenital heart surgery that experience death duringhospitalization

OR

2)Patients who undergo pediatric and/or congenital heart surgery that experience death 30 dayspost procedure

DENOMINATOR (REPORTING 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, 33494, 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, 33646, 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–

DENOMINATOR (REPORTING 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, 33494, 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, 33646, 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 REPORTING CRITERIA FOR THISMEASURE:
1)Patients who undergo pediatric and/or congenital heart surgery that experience death duringhospitalization

OR

2)Patients who undergo pediatric and/or congenital heart surgery that experience death 30 dayspost procedure

NUMERATOR (REPORTING CRITERIA 1):
All deaths occurring during the hospitalization in which the procedure was performed 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. 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: Death occurring during hospitalization (G9814)
OR
Performance Not Met: Death did not occur during hospitalization (G9815)

–OR–

NUMERATOR (REPORTING 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. 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: Death occurring 30 days post procedure (G9816)
OR
Performance Not Met: Death did not occur 30 days post procedure (G9817)