| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Claims, Registry | Outcome | Yes | Patient Safety |
Measure Description
Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure
Instruction
This measure is to be reported a minimum of each time an endovascular lower extremity revisualization procedure is performed during the performance period. There is no diagnosis associated with this measure. This measure maybe reported by eligible clinicians who perform the quality actions described in the measure based on the services providedand the measure-specific denominator coding.
NOTE: Include only patients undergoing an endovascular lower extremity revascularization procedure through December 29 of the performance period. This will allow the evaluation of at least 48 hours of the procedure withinthe reporting year.
Denominator
Patients undergoing endovascular lower extremity revascularization
Denominator Criteria (Eligible Cases):
All patients, regardless of age
AND
Patient procedure during the performance period (CPT): 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231
AND NOT
DENOMINATOR EXCLUSION:
Documentation of planned hybrid or staged procedure: G9640
Numerator
Number of patients undergoing major amputation or open surgical bypass within 48 hours of the indexendovascular lower extremity revascularization procedure
Definition:
Major Amputation – An amputation at the level of the ankle or above
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 is trends closer to 0%, as quality increases. For inverse measures a rate of 100% means all of thedenominator eligible patients did not receive the appropriate care or were not in proper control.
Numerator Options:
Performance Met: Major amputation or open surgical bypass required within 48 hours of the index endovascular lower extremity revascularization procedure (G9641)
OR
Performance Not Met: Major amputation or open surgical bypass not required within 48 hours of the index endovascular lower extremity revascularization procedure (G9639)