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 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
446 0733 Outcome Yes Patient Safety Registry

Measure Description

Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool

Instructions

This measure is to be submitted for all pediatric and/or congenital heart patients each time a surgery is performed during the performance period.

This measure is intended to reflect the quality of services provided for patients with congenital heart disease. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Mortality is only counted once – so the denominator is all patients having CHS and the numerator is 1) deaths occurring within the index acute care hospitalization and 2) Deaths occurring after discharge but within 30 days of surgery.

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.

THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:

  1. Patients who undergo pediatric and/or congenital heart surgery that experience death during the index acute care hospitalization
  2. Patients who undergo pediatric and/or congenital heart surgery that experience death after discharge from the hospital but within 30 days post procedure

Numerator (Submission criteria 1):

Number of patients undergoing isolated CABG who die, including both all deaths occurring during the
hospitalization in which the operation was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure

All deaths occurring during the index acute care hospitalization in which the procedure was performed (no matter how long post op) in which the procedure was performed stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool

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:

Death occurring during the index acute care hospitalization (G9814)

Performance Not Met:

Death did not occur during the index acute care hospitalization (G9815)

Numerator (Submission criteria 2):

Those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool

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:

Death occurring after discharge from the hospital but within 30 days post procedure (G9816)

Performance Not Met:

Death did not occur after discharge from the hospital within 30 days post procedure (G9817)

Denominator (Submission criteria 1):

Number of index cardiac operations in each level of complexity stratification using the five STS-EACTS Mortality Levels, a multi-institutional validated complexity stratification tool

Denominator Criteria (Eligible Cases) 1:
Diagnosis for congenital heart disease (ICD-10-CM):

Clinical Condition Corresponding ICD-10-CM Codes
ASD Q21.1, Q21.2, Q21.8, Q21.9, Q24.9
VSD Q21.0, Q21.8, Q21.9
Atrioventricular Canal Defect Q21.2
Aortopulmonary Window Q21.4
Truncus Arteriosus Q20.0, Q24.8, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Partial Anomalous Pulmonary Venous Connection Q26.3, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Total Anomalous Pulmonary Venous Connection Q26.2, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Cor Tritriatum Q27.2
Pulmonary Venous Stenosis Q26.8
Tetralogy of Fallot Q21.2, Q21.3, Q22.0, Q22.1
Pulmonary Atresia Q21.1, Q22.0, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Tricuspid Valve Disease and Ebstein’s Anomaly Q22.5, Q22.4, Q22.8, Q22.9
Right Ventricular Outflow Tract (RVOT) Obstruction and/or Pulmonary Stenosis Q20.1, Q22.1, Q22.2, Q22.3, Q25.5, Q25.6, Q25.79
Pulmonary Valve Disease Q25.79
Aortic Valve Disease Q23.0, Q23.1, Q23.8, Q25.21, Q25.29, Q25.3
Tracheal Disorder Q32.0, Q32.1, Q32.2
Pectus Excavatum Q67.6, Q67.7
Clinical Condition Corresponding ICD-10-CM Codes
Sinus of Valsalva Fistula/Aneurysm Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Left Ventricular to Aorta Tunnel Q20.8
Mitral Valve Disease Q23.2, Q23.3
Hypoplastic Left Heart Syndrome Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Shone’s Syndrome Q24.8
Single Ventricle Q20.4, Q20.4
Congenitally Correction of the Great Arteries (TGA) Q20.3
Transposition of the Great Arteries Q20.3
Double Outlet Right Ventricle Q20.1
Double Outlet Left Ventricle Q20.2
Coarctation of Aorta and Aortic Arch Hypoplasia Q25.1, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Coronary Artery Anomalies Q24.5
Interrupted Arch Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Patent Ductus Arteriosus Q25.0
Vascular Rings and Slings Q25.47, Q25.48, Q25.49 Q25.79
Aortic Aneurysm Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49

AND
Patient procedure during performance period (CPT): 15732, 15734, 19271, 19272, 21550, 21555, 21552, 21556, 21554, 21557, 21558, 21600, 21615, 21616, 21620, 21627, 21630, 21632, 21685, 21705, 21740, 21742, 21743, 21750, 21899, 31612, 31613, 31614, 31622, 31623, 31624, 31625, 31626, 31627, 31628, 31629, 31630, 31631, 31634, 31635, 31636, 31638, 31640, 31641, 31643, 31645, 31646, 31647, 31648, 31652, 31653, 31786, 32096, 32097, 32100, 32110, 32120, 32124, 32140, 32141, 32150, 32151, 32160, 32200, 32215, 32220, 32225, 32310, 32320, 32400, 32405, 32503, 32504, 32601, 32604, 32606, 32607, 32608, 32609, 32850*, 32851, 32852, 32853, 32854, 32855, 32856, 32900, 33010, 33011, 33015, 33025, 33030, 33031, 33050, 33120, 33130, 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33230, 33231, 33240, 33249, 33250, 33251, 33254, 33255, 33256, 33257, 33258, 33259, 33261, 33265, 33266, 33270, 33271, 33390, 33391, 33404, 33405, 33406, 33410, 33411, 33412, 33413, 33414, 33415, 33416, 33417, 33418, 33419, 33420, 33422, 33425, 33426, 33427, 33430, 33440, 33460, 33463, 33464, 33465, 33468, 33470, 33471, 33474, 33475, 33476, 33477, 33478, 33496, 33500, 33501, 33502, 33503, 33504, 33505, 33506, 33507, 33542, 33545, 33548, 33600, 33602, 33606, 33608, 33610, 33611, 33612, 33615, 33617, 33619, 33620, 33621, 33622, 33641, 33645, 33647, 33660, 33665, 33670, 33675, 33676, 33677, 33681, 33684, 33688, 33690, 33692, 33694, 33697, 33702, 33710, 33720, 33722, 33724, 33726, 33730, 33732, 33735, 33736, 33737, 33750, 33755, 33762, 33764, 33766, 33767, 33770, 33771, 33774, 33775, 33776, 33777, 33778, 33779, 33780, 33781, 33782, 33783, 33786, 33788, 33800, 33802, 33803, 33813, 33814, 33820, 33822, 33824, 33840, 33845, 33851, 33852, 33853, 33860, 33863, 33864, 33870, 33875, 33877, 33886, 33910, 33915, 33916, 33917, 33920, 33922, 33924, 33925, 33926, 33930*, 33933, 33935, 33940*, 33944, 33945, 33946, 33947, 33948, 33967, 33970, 33971, 33973, 33974, 33975, 33976, 33977, 33978, 33979, 33980, 33981, 33982, 33983, 33987, 33988, 33989, 33990, 33991, 33992, 33993, 33999, 59076, 59897, 71275, 74175, 75557, 75559, 75561, 75563, 75565, 75572, 75573, 75574, 76825, 76826, 76825, 92992, 92993, 93303, 93304, 93315, 93316, 93317, 93355, 93530, 93531, 93532, 93533, 93563, 93564, 93580, 93581, 93582, 93583

AND
STS-EACTS Mortality Level Tool Utilized

Denominator (Submission criteria 2):

Number of index cardiac operations in each level of complexity stratification using the five STS-EACTS Mortality Levels, a multi-institutional validated complexity stratification tool

Denominator Criteria (Eligible Cases) 2:
Diagnosis for congenital heart disease (ICD-10-CM):

Clinical Condition Corresponding ICD-10-CM Codes
ASD Q21.1, Q21.2, Q21.8, Q21.9, Q24.9
VSD Q21.0, Q21.8, Q21.9
Atrioventricular Canal Defect Q21.2
Aortopulmonary Window Q21.4
Truncus Arteriosus Q20.0, Q24.8, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Partial Anomalous Pulmonary Venous Connection Q26.3, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Total Anomalous Pulmonary Venous Connection Q26.2, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Cor Tritriatum Q27.2
Pulmonary Venous Stenosis Q26.8
Tetralogy of Fallot Q21.2, Q21.3, Q22.0, Q22.1
Pulmonary Atresia Q21.1, Q22.0, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Tricuspid Valve Disease and Ebstein’s Anomaly Q22.5, Q22.4, Q22.8, Q22.9
Right Ventricular Outflow Tract (RVOT) Obstruction and/or Pulmonary Stenosis Q20.1, Q22.1, Q22.2, Q22.3, Q25.5, Q25.6, Q25.79
Pulmonary Valve Disease Q25.79
Aortic Valve Disease Q23.0, Q23.1, Q23.8, Q25.21, Q25.29, Q25.3
Tracheal Disorder Q32.0, Q32.1, Q32.2
Pectus Excavatum Q67.6, Q67.7
Clinical Condition Corresponding ICD-10-CM Codes
Sinus of Valsalva Fistula/Aneurysm Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Left Ventricular to Aorta Tunnel Q20.8
Mitral Valve Disease Q23.2, Q23.3
Hypoplastic Left Heart Syndrome Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Shone’s Syndrome Q24.8
Single Ventricle Q20.4, Q20.4
Congenitally Correction of the Great Arteries (TGA) Q20.3
Transposition of the Great Arteries Q20.3
Double Outlet Right Ventricle Q20.1
Double Outlet Left Ventricle Q20.2
Coarctation of Aorta and Aortic Arch Hypoplasia Q25.1, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Coronary Artery Anomalies Q24.5
Interrupted Arch Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49
Patent Ductus Arteriosus Q25.0
Vascular Rings and Slings Q25.47, Q25.48, Q25.49 Q25.79
Aortic Aneurysm Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49

AND
Patient procedure during performance period (CPT): 15732, 15734, 19271, 19272, 21550, 21555, 21552, 21556, 21554, 21557, 21558, 21600, 21615, 21616, 21620, 21627, 21630, 21632, 21685, 21705, 21740, 21742, 21743, 21750, 21899, 31612, 31613, 31614, 31622, 31623, 31624, 31625, 31626, 31627, 31628, 31629, 31630, 31631, 31634, 31635, 31636, 31638, 31640, 31641, 31643, 31645, 31646, 31647, 31648, 31652, 31653, 31786, 32096, 32097, 32100, 32110, 32120, 32124, 32140, 32141, 32150, 32151, 32160, 32200, 32215, 32220, 32225, 32310, 32320, 32400, 32405, 32503, 32504, 32601, 32604, 32606, 32607, 32608, 32609, 32850*, 32851, 32852, 32853, 32854, 32855, 32856, 32900, 33010, 33011, 33015, 33025, 33030, 33031, 33050, 33120, 33130, 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33230, 33231, 33240, 33249, 33250, 33251, 33254, 33255, 33256, 33257, 33258, 33259, 33261, 33265, 33266, 33270, 33271, 33403, 33404, 33405, 33406, 33410, 33411, 33412, 33413, 33414, 33415, 33416, 33417, 33418, 33419, 33420, 33422, 33425, 33426, 33427, 33430, 33440, 33460, 33463, 33464, 33465, 33468, 33470, 33471, 33474, 33475, 33476, 33477, 33478, 33496, 33500, 33501, 33502, 33503, 33504, 33505, 33506, 33507, 33542, 33545, 33548, 33600, 33602, 33606, 33608, 33610, 33611, 33612, 33615, 33617, 33619, 33620, 33621, 33622, 33641, 33645, 33647, 33660, 33665, 33670, 33675, 33676, 33677, 33681, 33684, 33688, 33690, 33692, 33694, 33697, 33702, 33710, 33720, 33722, 33724, 33726, 33730, 33732, 33735, 33736, 33737, 33750, 33755, 33762, 33764, 33766, 33767, 33770, 33771, 33774, 33775, 33776, 33777, 33778, 33779, 33780, 33781, 33782, 33783, 33786, 33788, 33800, 33802, 33803, 33813, 33814, 33820, 33822, 33824, 33840, 33845, 33851, 33852, 33853, 33860, 33863, 33864, 33870, 33875, 33877, 33886, 33910, 33915, 33916, 33917, 33920, 33922, 33924, 33925, 33926, 33930*, 33933, 33935, 33940*, 33944, 33945, 33946, 33947, 33948, 33967, 33970, 33971, 33973, 33974, 33975, 33976, 33977, 33978, 33979, 33980, 33981, 33982, 33983, 33987, 33988, 33989, 33990, 33991, 33992, 33993, 33999, 59076, 59897, 71275, 74175, 75557, 75559, 75561, 75563, 75565, 75572, 75573, 75574, 76825, 76826, 76825, 92992, 92993, 93303, 93304, 93315, 93316, 93317, 93355, 93530, 93531, 93532, 93533, 93563, 93564, 93580, 93581, 93582, 93583

AND
STS-EACTS Mortality Level Tool Utilized

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