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 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
044 0236 Process No Effective Clinical Care
Registry

Measure Description

Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision

Instructions

This measure is to be submitted each time an isolated CABG procedure is performed during the performance period. It is anticipated that eligible clinicians who provide services for isolated CABG will submit this measure. The timeframe for this measure includes the entire 24 hour period prior to the surgical incision time.

NOTE: No notes related

Measure Submission

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

Numerator

Patients who received a beta-blocker within 24 hours prior to surgical incision of isolated CABG surgeries

Definition

Medical Reason – Eligible clinician must document specific reason(s) for not administering beta- blockers

Numerator Quality-Data Coding Options

Performance Met:

Beta blocker administered within 24 hours prior to surgical incision (4115F)

Denominator Exception:

Documentation of medical reason(s) for not administering beta blocker within 24 hours prior to surgical incision (e.g., not indicated, contraindicated, other medical reason) (4115F with 1P)

Performance Not Met:

Beta blocker not administered within 24 hours prior to surgical incision, reason not otherwise specified (4115F with 8P)

NUMERATOR NOTE: Denominator Exception(s) are determined on the date of the denominator eligible encounter.

Denominator

Isolated CABG surgeries for patients aged 18 years and older

Eligible cases are determined, and must be reported, if either of the following conditions

Definition:
Isolated CABG – Refers to CABG using arterial and/or venous grafts only

DENOMINATOR NOTE: In order to ensure the only surgeries allowed into the denominator for the measure are isolated CABG surgeries, the anesthesiologist CPT code (00562) (which is not specific to isolated CABG), would need to be in conjunction with the CPT indicated for the CABG surgery (33530) and one of the other CABG codes (33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536).

Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter

AND

Patient procedure during the performance period (CPT): 00566, 00567, 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536

OR

Patient procedure during the performance period (CPT): 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536

AND

Patient procedure during the performance period (CPT): 00562, 33530


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