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 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
076 0000 Process Yes Patient Safety Claims

Measure Description

Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

Instructions

This measure is to be submitted each time a CVC insertion is performed during the performance period. There is no diagnosis associated with this measure. It is anticipated that eligible clinicians who perform CVC insertion will submit this measure.

NOTE: No notes related

Measure Submission

The listed denominator criteria is used to identify the intended patient population. The numerator quality-data codes included in this specification are used to submit the quality actions allowed by the measure. All measure-specific coding should be submitted on the claim(s) representing the eligible encounter.

Numerator

Patients for whom central venous catheter (CVC) was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

Definition

Maximal Sterile Barrier Technique – includes all of the following elements: Cap AND mask AND sterile gown AND sterile gloves AND sterile full body drape.
Sterile Ultrasound Techniques – require sterile gel and sterile probe covers.

Numerator Quality-Data Coding Options

Denominator Exclusion: G6030 with 1P:
All Elements of Maximal Sterile Barrier Technique not Followed for Medical Reasons:

Documentation of medical reason(s) for not following all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques during CVC insertion (including increased risk of harm to patient if adherence to aseptic technique would cause delay in CVC insertion)

Performance Met: CPT II 6030F:
All Elements of Maximal Sterile Barrier Technique Followed

All elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

Performance Not Met: 6030F with 8P:
All Elements of Maximal Sterile Barrier Technique not Followed, Reason not Otherwise Specified

Append a reporting modifier (8P) to CPT Category II code 6030F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

All elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques not followed, reason not otherwise specified

Append a modifier (1P) to CPT Category II code 6030F to report documented circumstances that appropriately exclude patients from the denominator

Denominator

All patients, regardless of age, who undergo CVC insertion

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

Option 1 – Denominator Criteria (Eligible Cases):

Patient procedure during the performance period (CPT): 36555, 36556, 36557, 36558, 36560, 36561, 36563, 36565, 36566, 36568, 36569, 36570, 36571, 36578, 36580, 36581, 36582, 36583, 36584, 36585, 93503

 

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