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 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
417 1523 Outcome Yes Patient Safety Registry

Measure Description

Percentage of patients undergoing open repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) who are discharged alive

Instructions

This measure is to be submitted each time a repair of abdominal aortic aneurysms (AAA) is performed during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who provide services of the repair of abdominal aortic aneurysms (AAA), as described in the measure, based on the services provided and the measure-specific 3denominator 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.

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 discharged alive/home following open repair of asymptomatic AAAs in men with < 6 cm diameter and women with < 5.5 cm diameter AAAs

Definition:
Home – For purposes of submitting this measure, home is the point of origin prior to hospital admission prior to procedure of AAA. For example, if the patient comes from a skilled facility and returns to the skilled facility post AAA repair, this would meet criteria for discharged to home.

Instructions

A higher calculated performance rate for this measure indicates better clinical care or control. Therefore the “Performance Met” numerator outcome option for this measure is the representation of the better clinical quality or control. Submitting that numerator outcome option will produce a performance rate that trends closer to 100%, as quality increases.

Numerator Quality-Data Coding Options

Performance Met:

Patient discharge to home no later than post-operative day #7 (G9601)

Performance Not Met:

Patient not discharged to home by post-operative day #7 (G9602)

Denominator (Submission criteria for all rates)

Patients aged 18 and older

AND
Patient procedure during performance period (CPT): 35081, 35102

AND NOT
DENOMINATOR EXCLUSIONS:
For women:
Aortic aneurysm 5.5 – 5.9 cm maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9003F

OR
Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9004F

OR
For men:
Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on axial formatted CT: 9004F

OR
Symptomatic AAAs that required urgent/emergent (non-elective) repair: G9600

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