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 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
166 0131 Outcome Yes Effective Clincial Care Registry

Measure Description

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours

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 are 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 undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours

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:

Stroke following isolated CABG surgery (G8573)

Denominator Exception:

No data related

Performance Not Met:

No stroke following isolated CABG surgery (G8574)

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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