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 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
346 1540 Outcome Yes Effective Clinical Care Registry

Measure Description

Percent of asymptomatic patients undergoing CEA who are stroke free or discharged alive following surgery

Instructions

This measure is to be submitted each time a CEA is performed during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who provide services of CEA, as described in the measure, based on the services provided and the measure-specific denominator coding will submit this measure. This measure may be submitted by MIPS eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: No data 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 as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data.

Numerator

Patients who are stroke free or discharged alive following CEA

Numerator Quality-Data Coding Options

Performance Met:

Documentation of patient survival and absence of stroke following CEA (G9261)

Denominator Exception:

Documentation of patient stroke following CEA (G9258)

Performance Not Met:

Documentation of patient death following CEA (G9260)

Denominator

Patients aged 18 and older who are asymptomatic undergoing CEA

Physical Therapy Denominator Criteria (Eligible Cases):
Patients aged 18 and older

AND

Patient procedure during performance period (CPT): 35301

AND NOT
DENOMINATOR EXCLUSIONS:
Symptomatic carotid stenosis: Ipsilateral carotid territory TIA or stroke less than 120 days prior to procedure:
9006F

OR

Other carotid stenosis: Ipsilateral TIA or stroke 120 days or greater prior to procedure or any prior contralateral carotid territory or vertebrobasilar TIA or stroke: 9007F

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