2017 MIPS Measure #259: Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2)

Valid Data Submission Method(s) Measure Type High Priority Measure? NQS Domain Specialty Measure Sets
Registry Outcome Yes Patient Safety Interventional Radiology, Vascular Surgery

Measure Description

Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2)

Instruction

This measure is to be reported each time an endovascular repair AAA is performed during the performance period. It is anticipated that eligible clinicians who provide services of AAA repair, as described in the measure, based on the services provided and the measure-specific denominator coding will report this measure. 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.

Denominator

All endovascular repairs of non-ruptured, infrarenal abdominal aortic aneurysms

Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient procedure during the performance period (CPT): 34800, 34802, 34803, 34804, 34805
AND NOT
DENOMINATOR EXCLUSIONS:
For women:
Aortic aneurysm 5.5 – 5.9 cm maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9003F
OR
Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9004F
OR
For men:
Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9004F

Numerator

Patients discharged to home no later than post-operative day #2 following EVAR of AAA

Definition:
Home – For purposes of reporting this measure, home is the point of origin prior to hospital admission prior to procedure of AAA. For example, if the patient comes from a skilled facility and returns to the skilled facility post AAA repair, this would meet criteria for discharged to home.

Numerator Options:
Performance Met: Patient discharged to home no later than post-operative day #2 following EVAR (G8826)
OR
Performance Not Met: Patient not discharged to home by post-operative day #2 following EVAR (G8833)

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