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 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
165 0130 Outcome Yes Effective Clincial Care Registry

Measure Description

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days post operatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention

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. This measure is intended to reflect the quality of the surgical services provided for isolated CABG or isolated reoperation CABG patients. Isolated CABG refers to CABG using arterial and/or venous grafts only.

NOTE: No additional 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-based submissions; however, these codes may be submitted for those registries that utilize claims data.

Numerator

Patients who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention. Patient must have ALL of the following conditions: 1.) wound opened with excision of tissue (incision and drainage) or re-exploration of mediastinum, 2.) positive culture unless patient is on antibiotics at time of culture or no culture obtained, and 3.) treatment with antibiotics beyond perioperative prophylaxis

Definition

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. Submitting 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 Quality-Data Coding Options

Performance Met:

Development of deep sternal wound infection/mediastinitis within 30 days postoperatively (G8571)

Denominator Exception:

No data related

Performance Not Met:

No deep sternal wound infection/mediastinitis (G8572)

NUMERATOR NOTE: No data related

Denominator

All patients undergoing isolated CABG surgery

Option 1 – Denominator Criteria (Eligible Cases):

All patients aged 18 years and older on date of encounter

AND

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

 

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