pqrs measures for sts qcdr

8/11/2019 Pqrs Measures for Sts Qcdr

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Measure #20 (NQF0270): Perioperative Care: Timing of Prophylactic Parenteral Antibiotic-Ordering Physician

2014 PQRS OPTIONS FOR INDIVIDUAL MEASURES:CLAIMS, REGISTRY

DESCRIPTION: Percentage of surgical patientsaged 18 years and older undergoing procedures with the indications for prophylacticparenteral antibiotics, who have an order for prophylactic parenteral antibiotic to be given within one hour(iffluoroquinolone or vancomycin, two hours), prior to the surgical incision (or start of procedure when no incisionisrequired)

INSTRUCTIONS: This measure is to be reported each time a procedure is performed during the reporting period for patients whoundergo surgical procedures with the indications for prophylactic parenteral antibiotics. Thereis no diagnosisassociated with this measure. It is anticipated thatclinicians who perform the listed surgical procedures asspecified in the denominator coding will submit this measure.

Measure Reporting viaClaims:CPT codes and patient demographics are used to identify patients who are included in the measure's denominator. Quality-data codes are used to report the numerator of the measure. If multiplesurgical procedures were performedon the same date of service and submitted on the same claimform, it is not necessary for the same cliniciantosubmit the quality-data code with each procedure. However, if multiple NPis are reporting this measure on thesame claim, each NPI should report the quality-data code(G-code).

When reporting the measure via claims, submit the listed CPT codes, and the appropriate quality-data code. Allmeasure-specific coding should be reported on the claim(s) representing the eligible encounter.

Measure Reporting viaRegistry:CPT codes and patient demographics are used to identify patients who are included in the measure's denominator.

The listed numerator options are used to report the numeratorof the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codesmaybe submitted for those registries that utilize claims data.

DENOMINATOR: All surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics

Denominator Instructions:CPT CategoryI procedure codes billed by surgeons performing surgeryonthe same patient, submitted with modifier 62 (indicating two surgeons, ie, dual procedures) willbeincluded in the denominator population. Both surgeons participating in the PQRS willbe fullyaccountable for the clinical action described in the measure.

Denominator Criteria (EligibleCases):Patients aged


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SURGICAL PROCEDURE CPT CODE 15834, 15835, 15836, 15837, 19260, 19271, 19272,

19300, 19301, 19302, 19303, 19304, 19305, 19306, 19307, 19316, 19318, 19324, 19325, 19328, 19330,

19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380Le FortFractures 21346, 21347, 21348, 21422, 21423, 21432, 21433,

21435, 21436MandibularFracture 21454, 21461, 21462, 21465, 21470 Spine 22325, 22586, 22612, 22630, 22800, 22802, 22804,

63030, 63042HipReconstruction 27125, 27130, 27132, 27134, 27137, 27138 Trauma(Fractures) 27235, 27236, 27244, 27245, 27269, 27758, 27759,

27766, 27769, 27792, 27814KneeReconstruction 27440, 27441, 27442, 27443, 27445, 27446, 27447Laryngectomy 31360, 31365, 31367, 31368, 31370, 31375, 31380,

31382, 31390, 31395, 31400, 31420 Vascular 27880, 27881, 27882, 27884, 27886, 27888, 33877,

33880, 33881, 33883, 33886, 33889, 33891, 34800, 34802, 34803, 34804, 34805, 34812, 34820, 34825, 34830, 34831, 34832, 34833, 34834, 34900, 35011, 35013, 35081, 35082, 35091, 35092, 35102, 35103, 35131, 35141, 35142, 35151, 35152, 35206, 35266, 35301, 35363, 35371, 35372, 35460, 35512, 35521, 35522, 35523, 35525, 35533, 35537, 35538, 35539, 35540, 35556, 35558, 35565, 35566, 35570, 35571, 35572, 35583, 35585, 35587, 35601, 35606, 35612, 35616, 35621, 35623, 35626, 35631, 35632, 35633, 35634, 35636, 35637, 35638, 35642, 35645, 35646, 35647, 35650, 35654, 35656, 35661, 35663, 35665, 35666, 35671, 36830, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37617

Spleen and LymphNodes 38100, 38101, 38115, 38120, 38571, 38572, 38700, 38720, 38724, 38740, 38745, 38747, 38760, 38765, 38770, 38780

Glossectomy 41130, 41135, 41140, 41145, 41150, 41153, 41155Esophagus 43020, 43030, 43045, 43100, 43101, 43107, 43108,

43112, 43113, 43116, 43117, 43118, 43121, 43122, 43123, 43124, 43130, 43135, 43279, 43280, 43281, 43282, 43300, 43305, 43310, 43312, 43313, 43314, 43320, 43325, 43327, 43328, 43330, 43331' 43332, 43333, 43334, 43335, 43336, 43337, 43340, 43341,

43350, 43351, 43352, 43360, 43361, 43400, 43401,

43405, 43410, 43415, 43420, 43425, 43496 Stomach 43500, 43501, 43502, 43510, 43520, 43605, 43610,

43611, 43620, 43621, 43622, 43631, 43632, 43633, 43634, 43640, 43641, 43644, 43645, 43651, 43652, 43653, 43800, 43810, 43820, 43825, 43830, 43832, 43840, 43843, 43845, 43846, 43847, 43848, 43850, 43855, 43860, 43865, 43870, 43880


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SURGICAL PROCEDURE CPT CODESmallIntestine 44005, 44010, 44020, 44021, 44050, 44055, 44100,

44120, 44125, 44126, 44127, 44130, 44132, 44133, 44135, 44136

Colon 44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44155, 44156, 44157, 44158, 44160, 44180, 44186, 44187, 44188, 44202, 44204, 44205, 44206, 44207, 44208, 44210, 44211, 44212, 44227, 44300, 44310, 44312, 44314, 44316, 44320, 44322, 44340, 44345, 44346, 44602, 44603, 44604, 44605, 44615, 44620, 44625, 44626, 44640, 44650, 44660, 44661, 44680, 44700

Rectum 45000, 45020, 45110, 45111, 45112, 45113, 45114, 45116, 45119, 45120, 45121, 45123, 45126, 45130, 45135, 45136, 45150, 45160, 45171, 45172, 45395, 45397, 45400, 45402, 45540, 45541, 45550, 45560, 45562, 45563, 45800, 45805, 45820, 45825

Liver 47100, 47120, 47122, 47125, 47130, 47135, 47136, 47140, 47141, 47142, 47350, 47360 Biliary 47400, 47420, 47425, 47460, 47480, 47560, 47561,

47562, 47563, 47564, 47570, 47600, 47605, 47610, 47612, 47620, 47630, 47700, 47701, 47711, 47712, 47715, 47720, 47721, 47740, 47741, 47760, 47765, 47780, 47785, 47800, 47801, 47802, 47900

Pancreas 48000, 48001, 48020, 48100, 48102, 48105, 48120, 48140, 48145, 48146, 48148, 48150, 48152, 48153, 48154, 48155, 48500, 48510, 48520, 48540, 48545, 48547, 48548, 48554, 48556

Abdomen, Peritoneum, &Omentum 27080, 27158, 27202, 27280, 27282, 49000, 49002, 49010, 49020, 49040, 49060, 49203, 49204, 49205, 49215, 49220, 49250, 49320, 49321, 49322, 49323, 49505, 49507, 49568

RenalTransplant 50320, 50340, 50360, 50365, 50370, 50380 GynecologicSurgery 57267, 58150, 58152, 58180, 58200, 58210, 58240,

58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58951, 58953, 58954, 58956

AcousticNeuroma 61520, 61526, 61530, 61591, 61595, 61596, 61598, 61606, 61616, 61618, 61619, 69720, 69955, 69960, 69970

CochlearImplants 69930Neurological Surgery 22524, 22551, 22554, 22558, 22600, 22612, 22630,

61154, 61312, 61313, 61315, 61510, 61512, 61518,

61548, 61697, 61700, 61750, 61751, 61867, 62223, 62230, 63015, 63020, 63030, 63042, 63045, 63047, 63056, 63075, 63081, 63267, 63276

CardiothoracicSurgery 33120, 33130, 33140, 33141, 33202, 33250, 33251, 33256, 33261, 33305, 33315, 33321, 33322, 33332, 33335, 33365, 33366, 33400, 33401, 33403, 33404, 33405, 33406, 33410, 33411, 33413, 33416, 33422,


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SURGI CAL PROCEDURE CPT CODE 33425, 33426, 33427, 33430, 33460, 33463, 33464,

33465, 33475, 33496, 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522,

33523, 33530, 33533, 33534, 33535, 33536, 33542, 33545, 33548, 33572, 35211, 35241, 35271 Cardi othoraci c( Pacemaker ) 33203, 33206, 33207, 33208, 33212, 33213, 33214,

33215, 33216, 33217, 33218, 33220, 33222, 33223, 33224, 33225, 33226, 33233, 33234, 33235, 33236, 33237, 33238, 33240, 33241, 33243, 33244, 33249, 33254, 33255

Geni tour i nary Surgery 50020, 50234, 50236, 50548, 50727, 50728, 50760, 50770, 50780, 50782, 50783, 50785, 50800, 50810, 50815, 50820, 50947, 50948, 50951, 50953, 50955, 50957, 50961, 50970, 50972, 50974, 50976, 50980, 51550, 51555, 51565, 51570, 51575, 51580, 51585, 51590, 51595, 51596, 51597, 51800, 51820, 51900,

51920, 51925, 51960, 52007, 52204, 52214, 52224, 52234, 52235, 52240, 52250, 52260, 52265, 52281, 52300, 52301, 52310, 52315, 52325, 52327, 52330, 52332, 52341, 52342, 52343, 52344, 52345, 52346, 52352, 52354, 52400, 52402, 52450, 52601, 52630, 52640, 52647, 52648, 52649, 53445, 53850, 53852, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54700, 55705, 55801, 55810, 55812, 55815, 55821, 55831, 55840, 55842, 55845, 55866

General Thoraci cSurgery 0236T, 21627, 21632, 21740, 21750, 21805, 21825, 31760, 31766, 31770, 31775, 31786, 31805, 32096, 32097, 32098, 32100, 32110, 32120, 32124, 32140, 32141, 32150, 32215, 32220, 32225, 32310, 32320, 32440, 32442, 32445, 32480, 32482, 32484, 32486, 32488, 32491, 32505, 32506, 32507, 32800, 32810, 32815, 32900, 32905, 32906, 32940, 33020, 33025, 33030, 33031, 33050, 33300, 33310, 33320, 33361, 33362, 33363, 33364, 34051, 35021, 35216, 35246, 35276, 35311, 35526, 37616, 38381, 38746, 39000, 39010, 39200, 39220, 39545, 39561, 64746

Foot &Ankl e 27702, 27703, 27704, 28192, 28193, 28293, 28415, 28420, 28445, 28465, 28485, 28505, 28525, 28531, 28555, 28585, 28615, 28645, 28675, 28705, 28715, 28725, 28730, 28735, 28737

Medi ast i num and Di aphraqm 39501, 39540, 39541, 39545, 39560, 39561 Bari atr i c 43770, 43771, 43772, 43773, 43774, 43775, 43843,

43845, 43846, 43847, 43848, 43886, 43887, 43888Meckel ' s Di vert i cul um and AJ J endi x

44800, 44820, 44850, 44900, 44950, 44955, 44960, 44970

General Surgery 23470, 23472, 23473, 23474, 23616, 24363, 24370, 24371, 60200, 60210, 60212, 60220, 60225, 60240, 60252, 60254, 60260, 60270, 60271, 60280, 60281,


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purposes of this measure. GB632 should be reported when antibiotics from this table werenot Ampicillin/sulbactam Aztreonam Cefazolin Cefmetazole Cefotetan Cefoxitin

Cefuroxime Ciprofloxacin Clindamycin Ertapenem Erythromycin

base Fluoroquinolone Gatifloxacin

Gentamicin Levofloxacin Metronidazole Moxiftoxacin Neomycin Vancomycin

SURGICAL PROCEDURE CPTCODE 60500, 60502, 60505, 60520, 60521, 60522, 60540,

60545, 60600, 60605, 60650

NUMERATOR: Surgical patients who have an order for prophylactic parenteral antibiotic to be given within one hour(iffluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision isrequired)

Numerator Instructions:There must be documentation of order (written order, verbal order, or standingorder/protocol) specifying lhat prophylactic parenteral antibiotic is to be given within one hour(iffluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure whennoincision is required)OR documentation that prophylactic parenteral antibiotic has been given within onehour (if fluoroquinolone or vancomycin, two hours) prior to thesurgical incision (or start of procedure whenno incision isrequired).

NUMERATOR NOTE: In the event surgeryis delayed, as long as the patientis redosed {ifclinically

appropriate)the numerator coding should be applied. Numerator Quality-DataCoding Options for ReportingSatisfactorily:Table 1A: The antimicrobial drugs fisted below are considered prophylactic parenteral antibioticsfor the

ordered.

Documentation of Order for ProphylacticParenteral Antibiotic (writtenorder , verbal order , orstandingorder/protocol)G8629: Documentation of order for prophylactic parenteral antibiotics to be given within one hour(iffluoroquinolone or vancomycin, two hours) prior tosurgical incision (or start of procedure when no incision is required)OR Documentation that Prophylactic Parenteral Antibiotichas been Givenwithin One Hour Prior totheSurgical Incision (or start of procedure when no incision is required)G8630: Documentation that administration of prophylactic parenteral antibiotics wasinitiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure when noincision is required), as ordered

Order for Prophylactic Parenteral Antibiotic not Given for DocumentedReasonsG8631: Clinician documented that patient was not an eligible candidate for ordering prophylactic parenteral antibiotics to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior tothe surgicalincision (or start of procedure when no incision is required)

Order for Administration of Prophylactic Parenteral Antibiotic not Given, Reason notGiven


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G8632: Prophylactic parenteral antibiotics were not ordered to be given or given within one hour(iffluoroquinolone or vancomycin, two hours) prior to thesurgical incision (or start of procedure when noincision is required), reasonnot given

RATIONALE: The appropriate timing of administration of prophylactic parenteral antibiotics has been demonstrated toreduce theincidence of surgical wound infections. Specifying the time of administration in the orderis critical as availableevidence suggests that the drug should be received within one hour before incision for maximum antimicrobialeffect.

CLINICAL RECOMMENDATION STATEMENTS: Overall, administration of the first dose ofantimicrobial beginning within 60 minutes before surgical incision isrecommended. Administration of vancomycin and fluoroquinolones should begin within 120 minutes beforesurgicalincision because of the prolonged infusion times required for these drugs. (ASHP, 2013)

Infusion of the first antimicrobial dose should begin within 60 minutes before incision. However, when afluoroquinolone or vancomycinis indicated, the infusion should begin within 120 minutes beforeincision to preventantibiotic-associated reactions. Althoughresearch has demonstrated thatadministration of the antimicrobial at the

time ofanesthesia induction is safeand results in adequateserum and tissue druglevels at the timeof incision, therewas no consensus that theinfusion must be completedbefor e incision. (SIPGWW, 2004)11


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Measure #21 (NQF 0268):Perioperative Care: Selection of Prophylactic Antibiotic- First OR SecondGeneration Cephalosporin

2014 PQRS OPTIONS FORINDIVIDUAL MEASURES:CLAIMS, REGISTRY

DESCRIPTION: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first ORsecond generation cephalosporin prophylactic antibiotic, who had an order for afirst OR second generationcephalosporin for antimicrobialprophylaxis

INSTRUCTIONS: This measure is to be reported each time a procedure is performed during the reporting period for patients whoundergo surgical procedures with the indications for a first or second generation cephalosporin prophylactic antibiotic.There is no diagnosis associated with this measure. It is anticipated thatclinicians who perform the listedsurgicalproceduresas specified in the denominator coding will submit this measure.

Measure Reporting viaClaims:

CPT codes and patient demographics are used to identify patients who are included in the measure's denominator.Quality-data codes are used to report the numerator of the measure. If multiple surgical procedures were performedon the same date of service and submitted on the same claimform, it is not necessary for the same clinician tosubmit the quality-data code with each procedure. However, ifmultiple NPis are reporting this measure on the sameclaim, each NPI should report the quality-data code.

When reporting the measure via claims, submit the listed CPT codes, and the appropriate quality-data code.Allmeasure-specific coding should be reported on the claim(s) representing the eligible encounter.

Measure Reporting viaRegistry:CPT codes and patient demographics are used to identify patients who are included in the measure's denominator.The listed numerator options are used to report the numerator of the measure.

The quality-data codes listed do not need to be submitted for registry-based submissions; however,these codes maybe submitted for those registries that utilizeclaims data.

DENOMINATOR: Allsurgical patients aged 18 years and older undergoing procedures with the indications fora first OR second generation cephalosporin prophylactic antibiotic

Denominator Instructions:CPT Category I procedure codes billed by surgeons performing surgeryonthe same patient, submitted with modifier 62 (indicating two surgeons, ie,dual procedures) willbeincluded in the denominator population. Both surgeons participating in PQRS will be fully accountable for theclinical action described in the measure.

Denominator Criteria (EligibleCases):Patients aged"' 18 years on date of encounter

AND Patient encounter during the reporting period(CPT): Listed below aresurgical procedures withindications for first or second generation cephalosporin prophylactic antibiotic

SURGICAL PROCEDURE CPTCODE Integumentary 15732, 15734, 15736, 15738, 15830, 15832, 15833, 15834,

15835, 15836,15837,19260,19271,19272, 19300,19301,


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SURGICALPROCEDURE CPT CODE 19302, 19303, 19304, 19305, 19306, 19307, 19316, 19318,19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355,19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370,19371, 19380

Spine 22325, 22586, 22612, 22630, 22800, 22802, 22804, 63030, 63042

Hip Reconstruction 27125, 27130, 27132, 27134, 27137, 27138 Trauma(Fractures) 27235, 27236, 27244, 27245, 27269, 27758, 27759, 27766,

27769, 27792, 27814KneeReconstruction 27440, 27441, 27442, 27443, 27445, 27446, 27447 Vascular 27880, 27881, 27882, 27884, 27886, 27888, 33877, 33880,

33881, 33883, 33886, 33889, 33891, 34800, 34802, 34803, 34804, 34805, 34812, 34820, 34825, 34830, 34831, 34832, 34833, 34834, 34900, 35011, 35013, 35081, 35082, 35091, 35092, 35102, 35103, 35131, 35141, 35142, 35151, 35152, 35206, 35266, 35301, 35363, 35371, 35372, 35460, 35512, 35521, 35522, 35523, 35525, 35533, 35537, 35538, 35539, 35540, 35556, 35558, 35565, 35566, 35570, 35571, 35572, 35583, 35585, 35587, 35601, 35606, 35612, 35616, 35621, 35623, 35626, 35631, 35632, 35633, 35634, 35636, 35637, 35638, 35642, 35645, 35646, 35647, 35650, 35654, 35656, 35661, 35663, 35665, 35666, 35671, 36830, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37617

Spleen and LymphNodes 38100, 38101, 38115, 38120, 38571, 38572, 38700, 38720, 38724, 38740, 38745, 38747, 38760, 38765, 38770, 38780

Esophagus 43020, 43030, 43045, 43100, 43101, 43107, 43108, 43112, 43113, 43116, 43117, 43118, 43121, 43122, 43123, 43124, 43130, 43135, 43279, 43280, 43281, 43282, 43300, 43305, 43310, 43312, 43313, 43314, 43320, 43325, 43327, 43328,43330, 43331, 43332, 43333, 43334, 43335, 43336, 43337, 43340, 43341, 43350, 43351, 43352, 43360, 43361, 43400, 43401, 43405, 43410, 43415, 43420, 43425, 43496

Stomach 43500, 43501, 43502, 43510, 43520, 43605, 43610, 43611, 43620, 43621, 43622, 43631, 43632, 43633, 43634, 43640, 43641, 43644, 43645, 43651, 43652, 43653, 43800, 43810, 43820, 43825, 43830, 43832, 43840, 43843, 43845, 43846, 43847, 43848, 43850, 43855, 43860, 43865, 43870, 43880

SmallIntestine 44005, 44010, 44020, 44021, 44050, 44055, 44100, 44120,44125, 44126, 44127, 44130, 44132, 44133, 44135, 44136

Colon 44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44155, 44156, 44157, 44158, 44160, 44180, 44186,

44187, 44188, 44202, 44204, 44205, 44206, 44207, 44208, 44210, 44211, 44212, 44227, 44300, 44310, 44312, 44314, 44316, 44320, 44322, 44340, 44345, 44346, 44602, 44603, 44604, 44605, 44615, 44620, 44625, 44626, 44640, 44650, 44660, 44661, 44680, 44700

Rectum 45000, 45020, 45110, 45111, 45112, 45113, 45114, 45116, 45119, 45120, 45121, 45123, 45126, 45130, 45135, 45136, 45150, 45160, 45171, 45172, 45395, 45397, 45400, 45402,


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SURGICAL PROCEDURE CPT CODE 47350, 47370, 47371, 47380, 47381

GynecologicSurgery 57267, 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290,

58291, 58292, 58293, 58294, 58951, 58953, 58954, 58956GeneralSurgery 23470, 23472, 23473, 23474, 23616, 24363, 24370, 24371, 60200, 60210, 60212, 60220, 60225, 60240, 60252, 60254, 60260, 60270, 60271, 60280, 60281, 60500, 60502, 60505, 60520, 60521, 60522, 60540, 60545, 60600, 60605, 60650

NUMERATOR: Surgical patients who had an order for a first OR second generation cephalosporin for antimicrobialprophylaxis

NumeratorInstructions: There must be documentation of an order (written order, verbal order, or standingorder/protocol) for a first OR second generation cephalosporin for antimicrobial prophylaxis ORdocumentation that a first OR second generation cephalosporin wasgiven.

NUMERATOR NOTE: In the event surgeryis delayed, as long as the patientis redosed (if clinicallyappropriate) the numerator coding should be applied.

Numerator Quality-Data Coding Options for ReportingSatisfactorily:Documentation of Order for First or Second Generation Cephalosporin for AntimicrobialProphylaxis(written order,verbal order, or standingorder/protocol)G9197: Documentation of an order for first OR second generation cephalosporin for antimicrobial prophylaxis

Note:G9197is provided for antibioticordered or antibioticgiven. Report G9197if a first or second generation cephalosporin was given for antimicrobial prophylaxis.

Order for First or Second Generation Cephalosporin not Ordered forMedical ReasonsG9196: Documentation ofmedical reason(s) for not ordering a first OR second generation cephalosporinfor

antimicrobial prophylaxis Order for First or Second Generation Cephalosporin not Ordered, Reason not GivenG9198: Order for a first OR second generation cephalosporin for antimicrobial prophylaxis wasnotdocumented, reason notgiven

RATIONALE: Current published evidence supports the use of either cefazolin, a first generation cephalosporin, or cefuroxime, a second generation cephalosporin, for many surgical procedures, in the absence of 0-lactam allergy. An alternativeantimicrobial regimen may be appropriate depending on the antimicrobial susceptibility patternin an individualinstitution (potentially a medical reason for excluding patients treated at that institution from this measure).

CLINICAL RECOMMENDATION STATEMENTS: For most procedures, cefazolin is the drug of choice for prophylaxis because it is the most widelystudiedantimicrobial agent, with proven efficacy. It has a desirable duration of action, spectrum of activity against organismscommonly encountered in surgery, reasonable safety, andlow cost. (ASHP,2013)

In operations for which cephalosporins represent appropriate prophylaxis, alternative antimicrobials shouldbeprovided to those with a high likelihood of serious adverse reaction or allergy on the basis of patient history ordiagnostic tests such as skin testing.


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The preferred antimicrobialsfor prophylaxis in patientsundergoing hip or kneearthroplasty are cefazolin andcefuroxime. Vancomycin or clindamycin maybe used in patientswith serious allergy or adverse reactions to P-lactams.

The recommended antimicrobials for cardiothoracic and vascular operations include cefazolin or cefuroxime. Forpatients with serious allergy or adverse reactionto P-lactams, vancomycin isappropriate, and clindamycin maybe anacceptable alternative. (SIPGWW, 2004)


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Measure #43 (NQF 0134): Coronary Artery Bypass Graft(CABG): Use ofInternal Mammary Artery(IMA)in Patientswith Isolated CABGSurgery

2014 PQRS OPTIONSFOR INDIVIDUAL MEASURES:CLAIMS, REGISTRY

DESCRIPTION: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received anIMA graft

INSTRUCTIONS: This measure is to be reported each time an isolated CABG procedure is performed during the reporting period. It isanticipated thatclinicians who provide services for isolated CABGwill submit this measure. This measureis intended to reflect the quality of thesurgical services provided for isolated CABGpatients. Isolated CABG referstoCABG using arterial and/or venous grafts only. Part B claims data will be analyzed to determine "isolated" CABG.This measure does not include patients undergoing repeat CABG surgery.

Measure Reporting viaClaims:CPT codes and patient demographics are used to identify patients who are included in the measure's denominator. CPT Category II codes are used to report the numerator of the measure.

When reporting the measure via claims, submit the listed CPTcodes, and the appropriate CPT Category II code ORthe CPT Category II code with the modifier. The modifiers allowed for this measureare: 1P- medical reasons, 8P-reason not otherwise specified. All measure-specific coding should be reported on the claim(s) representing theeligible encounter.

Measure Reporting viaRegistry:CPT codes and patient demographics are used to identify patients who are included in the measure's denominator. The listed numerator options are used to report the numerator of 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 utilizeclaims data. DENOMINATOR: All patients undergoing isolated CABG

Denominator Criteria (EligibleCases):Patients aged " 18 years on date of encounterAND Patient encounter during the reporting period(CPn: 33510, 33511, 33512, 33513, 33514, 33516, 33517,33518,33519,33521,33522,33523,33533,33534,33535,33536

NUMERATOR: Patients undergoing isolated CABG who received an IMA graft

Numerator Qualitv-Data Coding Options for ReportingSatisfactorily:IMA GraftPerformedCPT114110F: Internal mammary artery graft performed for primary, isolated coronary artery bypass graft procedure

IMA Graft not Performed for MedicalReasonsAppend a modifier (1P) to the CPT Category II code 4110F to report documented circumstances that appropriately exclude patients from the denominator.


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4110Fwith 1P: Documentation of medical reason(s) for not performing an internal mammary arterygraft forprimary, isolated coronary artery bypass graft procedure. Acceptable medical reasonsinclude: subclavian stenosis, previous cardiac or thoracic surgery, previous mediastinalradiation, emergent or salvage procedure, no left anterior descending artery disease.

IMA Graft not Performed, Reason not OtherwiseSpecifiedAppend a reporting modifier (8P) to CPT Category II code 4110F to report circumstances when the action described in the numerator is not performed and the reason isnot otherwise specified. 4110F with 8P: Internal mammary artery graft not performed for primary, isolated coronary arterybypass

graft procedure, reason not otherwise specified

RATIONALE: A major innovation has been the introduction of off-bypass CABG, which has reduced the post-procedure lengthof stay in some centers to between 2 and 3 days. In some centers, this has led to a total 3-month cost for single-vesselcoronary bypass that is not significantly different from the total3-month cost for angioplasty ofsingle-vessel disease.Considering the favorable long-term patency of an internal mammary artery (IMA) graft to the LAD, the costreductions possible with off-bypass CABG may improve the relative cost-effectiveness of coronary bypass compared

with either medical therapy or percutaneous techniques, particularly for symptomatic, proximal LAD disease.

CLINICAL RECOMMENDATION STATEMENTS:Class I In every patient undergoing CABG, the left internal mammary artery (IMA) should be given primary consideratfor revascularization of the left anterior descending (LAD) artery. (Level of Evidence:B)


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Measure #44(NQF0236): Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blockerin Patients with Isolated CABG Surgery

2014 PQRSOPTIONS FOR INDIVIDUAL MEASURES:CLAIMS, REGISTRY

DESCRIPTION: Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blockerwithin 24 hours prior tosurgical incision

INSTRUCTIONS: This measure is to be reported each time an isolated CABG procedure is performed during the reporting period.It is anticipated thateligible professionals who provide services for isolatedCABG will submit this measure. Thetimeframe for this measure includes the entire 24 hour period prior to thesurgical incision time.

Measure Reporting viaClaims:CPT codes and patient demographics are used to identify patients who are included in the measure's denominator. CPT CategoryII codes are used to report the numerator of the measure.

When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT Category II code ORthe CPT Category II code with the modifier. The modifiers allowed for this measure are: 1P-medical reasons, 8P-reason not otherwise specified. All measure-specific coding should be reported on the claim(s) representing theeligible encounter.


The quality-data codes listed do not need to be submitted for registry-based submissions; however,these codes maybe submitted for those registries that utilizeclaims data.

DENOMINATOR: Isolated CABG surgeries for patients aged 18 years and older

Definitions:Isolated CABG- Refers to CABG using arterial and/or venous grafts only. Part8 claims datawill be analyzed to determine "isolated"CABG.

Denominator Criteria (EligibleCases):Patients aged


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Patients who received a beta-blocker within 24 hours prior to surgical incision of isolated CABG surgeries

Definitions:Medical Reason- Eligibleprofessional must document specific reason(s) for not administering beta-

blockers. Numerator Quality-Data Coding Options for ReportingSatisfactorily:Preoperative Beta-blocker AdministrationDocumentedCPT II 4115F: Beta blocker administered within 24 hours prior to surgicalincision

Preoperative Beta-blocker not administered for DocumentedMedical ReasonsAppend a modifier (1P) to the CPT Category II code 4115F to report documented circumstances thatappropriately exclude patients from the denominator. 4115Fwit h 1P: Documentation of medical reason(s) for not administering beta blocker within 24 hoursprior to surgical incision (eg, not indicated, contraindicated, othermedical reason)

Preoperative Beta-blocker not Received, Reason not otherwisespecified

Append a reporting modifier (BP)to CPT Category II code 4115F to report circumstances when the actiondescribed in the numerator is not performed and the reason isnot otherwise specified. 4115Fwit h BP: Beta blocker not administered within 24 hours prior to surgical incision, reason nototherwise specified

RATIONALE: Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery, occurring in 25-40patients (Crystal, 2004, Burgess, 2006). POAF has been associated with increased rates of post-operative morbidityand mortality and consequently, increased costs (Mariscalco, 2008, Crystal, 2004, Bramer, 2010). Prophylacticadministration of beta-blockers have been shown to reduce the risk of POAF and mortality following isolated coronaryartery bypass graft surgery (Connolly, 2003, Mariscalco, 2008, Ferguson, 2002). Khan's meta-analysis of RCTs found that "Preoperative BB initiation resulted in 52% reduction in the incidence of AF as compared to controls,however these results were not statistically significant."EIBardissi (2012) showed a 19.5% increase in preoperative

use of beta-blockers from 2000-2009. Coronary revascularization, comprising coronary artery bypass graft (CABG) surgery and percutaneous coronaryintervention (PCI), is among the most common major medical procedures provided by the US health care system,with more than 1 million procedures performed annually. It is also among the most costly (Medicare inpatientpayments to hospitals for coronary revascularizations exceeded $6.7 billion infiscal year 2006, an amountlargerthan the reimbursement for any other medical or surgical procedure) (Epstein,2011).

CLINICAL RECOMMENDATION STATEMENTS:PreoperativeBeta-blockers Class I

1. Beta-blockers should be administered for at least 24 hours before CABG to all patients withoutcontraindications to reduce the incidence or clinical sequelae of postoperative AF.(Level of Evidence:B),(ACCF/AHA, 2011)

Class IIa 1.Preoperative use of beta-blockers in patients without contraindications, particularly in those with an LV ejectionfraction (LVEF) greater than 30%, can be effective in reducing the risk of in-hospital mortality.(Level of Evidence: B),(ACCF/AHA, 2011)

2.Beta-blockers can be effective in reducing the incidence of perioperativemyocardial ischemia.(Level of Evidence: B),(ACCF/AHA, 2011)


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Measure #45 (NQF 0637): Perioperative Care:Discontinuation of Prophylactic ParenteralAntibiotics (Cardiac Procedures)

2014 PQRS OPTIONS FORINDIVIDUAL MEASURES:CLAIMS, REGISTRY

DESCRIPTION: Percentage of cardiacsurgical patients aged 18 years and older undergoing procedures with the indicationsfor prophylactic parenteral antibiotics AND who received a prophylactic parenteral antibiotic, who havean order fordiscontinuation of prophylactic parenteral antibiotics within 48 hours ofsurgical end time

INSTRUCTIONS: This measure is to be reported each time a procedure is performed during the reporting period for patients who undergo cardiac procedures with the indications for prophylactic parenteral antibiotics. Thereis no diagnosisassociated with this measure. It is anticipated thatclinicians who perform the listedsurgical procedures asspecified inthe denominator coding will submit this measure.

Measure Reporting viaClaims:CPT codes and patient demographics are used to identify patients who are included in the measure's denominator.CPT Category II codes and/or quality-data codes are used to report the numerator of the measure. Ifmultiple surgicalprocedures were performed on the same date of service and submitted on the same claimform, it is not necessarytosubmit the CPT Category II code(s)or quality-data code(s) with each procedure.

When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT CategoryII codeAND/OR quality-data code OR the CPT CategoryII code with the modifier AND quality-data code. The modifiersallowed for this measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific codingshould be reported on the claim(s) representing the eligible encounter.

Measure Reporting viaRegistry:CPT codes and patient demographics are used to identify patients who are included in the measure's denominator.

The listed numerator options are used to report the numerator of the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codesmaybe submitted for those registries thatutilize claims data.

DENOMINATOR: All cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics AND who received a prophylacticparenteral antibiotic

DenominatorInstructions: CPT Category I procedure codes billed by surgeons performing surgery on the same patient,

submittedwith modifier 62 (indicating two surgeons, ie,dual procedures) will be included in thedenominator population. Both surgeons participating in PQRS will be fully accountable for the

clinical action described in the measure. For the purpose of this measure of antibiotic discontinuation, patients may be counted as having"received a prophylactic parenteral antibiotic" if the antibiotic was received within4 hours prior to thesurgical incision (or start of procedure when no incision is required) or intraoperatively.

Denominator Criteria (EligibleCases):Patients aged " 18 years on date of encounterAND


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Patient encounter during the reporting period(CPT): Listed below are cardiac surgical proceduresforwhich prophylactic parenteral antibioticsare indicated

SURGICAL PROCEDURE CPTCODE

CardiothoracicSurgery 33120,33130,33140,33141,33250,33251,33256, 33261,33305,33315,33332,33335,33365,33366, 33400,33401,33403,33404,33405,33406,33410, 33411,33413,33416,33422,33425,33426,33427, 33430,33460,33463,33464,33465,33475,33496, 33510,33511,33512,33513,33514,33516,33517, 33518,33519,33521,33522,33523,33530,33533, 33534,33535,33536,33542,33545,33548,33572

NUMERATOR: Cardiac surgical patients who have an order for discontinuation of prophylactic parenteral antibiotics within 48 hoursof surgical end time

NumeratorInstructions: There must be documentation of order (written order, verbal order, or standingorder/protocol) specifying that the prophylactic parenteral antibiotic is to be discontinued within 48 hoursofsurgical end time OR specifying a course of antibiotic administration limited to that 48-hour period (eg,"to begiven every 8 hours for three doses" or for "one time" IV dose orders) OR documentation that prophylacticparenteralantibioticdiscontinued within 48 hours of surgical end time.

NUMERATOR NOTE: The correct combinatton of numerator code(s) must be reported on the claim forminorder to properly report this measure. The "correct combination" of codes may require the submissionofmultiple numerator codes.

Numerator Quality-Data Coding Options for ReportingSatisfactorily:Documentation of Order for Discontinuation of Prophylactic Parenteral Antibiotics (writtenorder,verbalorder , or standing order/protocol} within 48 hours of surgical endtime(One CPT II code and one quality-datacode {AlH3F8,C8702]are required on the claim form to submit thisnumerator option) CPTII4043F: Documentation that an order was given to discontinue prophylactic antibiotics within 48 hoursof surgical endtime, cardiac procedures

Note: CPT Category II code 4043F may be provided for documentation that antibiotic discontinuationwithin 48 hours was ordered or that antibiotic discontinuation wasaccomplished.

AND G8702: Documentation that prophylactic antibiotics were given within 4 hours prior tosurgical incisionor intraoperatively

ProphylacticParenteral Antibiotics not Discontinued for MedicalReasons(One CPT II code and one quality-data code iP i/,C8702]are required on the claim form to submit this numeratoroption) Append a modifier (1P) to CPT Category II code 4043F to report documented circumstances that appropriately exclude patients from the denominator. 4043Fwit h 1P: Documentation ofmedical reason(s) for not discontinuing prophylactic antibiotics within 48

hours of surgical end time, cardiac procedures

G8702: Documentation that prophylactic antibiotics were given within 4 hours prior tosurgical incision orintraoperatively


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OR

Ifpatientis not eligible for this measure because patient was not documented to haveprophylacticparenteral antibiotics given within 4 hours prior tosurgical incision,report:

{One quality-data code [G8103] is required on the claim form to submit this numerator option) G8703: Documentation that prophylactic antibiotics were neither given within 4hours prior to surgicalincision nor intraoperatively

ProphylacticParenteral Antibiotics not Discontinued,Reason not OtherwiseSpecified(One CPT II code and quality-data code '" (;3702}are required on the claim form to submit thisnumeratoroption) Append a reporting modifier (BP)to CPT Category II code 4043F to report circumstances when the actiondescribed in the numerator is not performed and thereason is not otherwise specified. 4043Fwit h BP: Order was not given to discontinue prophylactic antibiotics within 48 hours ofsurgical end

time, cardiac procedures, reason not otherwise specified

G8702: Documentation that prophylactic antibiotics were given within 4 hours prior to surgical incision or

intraoperatively

RATIONALE: There is no evidence there is added benefit of prolonged prophylactic antibiotic use. Prolonged use may increase antibiotic resistant organisms.

CLINICAL RECOMMENDATION STATEMENTS: At a minimum,antimicrobial coverage must be provided from the timeofincision to closure of the incision. For mostprocedures, the duration of antimicrobial prophylaxis should be 24 hours or less, with the exception of cardiothorprocedures (up to72 hours' duration) and ophthalmic procedures (duration not clearly established). (ASHP) Thereisevidence indicating that antibiotic prophylaxis of 48 hours duration is effective. There is some evidence that single- dose prophylaxis or 24-hour prophylaxis may be as effective as 48-hour prophylaxis, butadditional studies arenecessary before confirming the effectiveness of prophylaxis lasting less than 48 hours. There is no evidence that

prophylaxis administered for longer than 48 hours is more effective than a 48-hour regimen. Optimal practice:Antibiotic prophylaxis is not continued for more than 48 hours postoperatively. (ClassIIa, Level B) (STS, 2005)


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Measure #164 (NQF0129): Coronary Artery Bypass Graft (CABG):Prolonged Intubation

2014 PQRS OPTIONS FOR INDIVIDUAL MEASURES:REGISTRYONLY

DESCRIPTION: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperativeintubation> 24 hours

INSTRUCTIONS: This measure is to be reported each time an isolated CABG procedure is performed during the reporting period.It isanticipated thatclinicians who provide services for isolated CABG will submit this measure. This measureisintended to reflect the quality of surgical services provided for isolated CABGor isolated reoperation CABG patients.Isolated CABG refers to CABG using arterial and/or venous grafts only.


The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codesmaybe submitted for those registries that utilize claimsdata. There are no allowable performance exclusions for thismeasure.

DENOMINATOR: All patients undergoing isolated CABG surgery

Denominator Criteria (EligibleCases):Patients aged;, 18 years on date of encounterAND Patient encounter during the reporting period(CPT):33510,33511,33512,33513,33514,33516,33517,33518,33519,33521,33522,33523,33533,33534,33535,33536

OR

Patient encounter during the reporting period(CPT): 33510, 33511, 33512, 33513, 33514, 33516, 33517,33518,33519,33521,33522,33523,33533,33534,33535,33536AND Patient encounter during the reporting period(CPT): 33530

NUMERATOR: Patients undergoing isolated CABG who require intubation> 24 hours following exit from theoperating room

Numerator Instructions:A lower calculated performance ratefor this measure indicates better clinical

care or control.

NumeratorOptions:Prolonged postoperative intubation (> 24 hrs) required (G8569)

Prolonged postoperative intubation (> 24 hrs) not required (G8570)


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RATIONALE: Based on the STS coronary artery bypass graft {CABG) study population, the morbidity rate associated withprolonged intubation following CABG is 5.96%. Also, prolonged ventilation (defined as>24 hours) was anindependent predictor for readmission to the ICU following CABG surgery (OR=10.53; Cl: 6.18 to 17.91). Shorter

ventilation times are linked to high quality of care (i.e., reduced in-hospital and operative mortality, as well as betterlong-term outcomes as compared to prolonged ventilation).

CLINICAL RECOMMENDATION STATEMENTS: Extubation greater than(>) 24 hours is considered a "pulmonary complication." Patients who were extubated afthours had a longer duration ofhospital stay and a greater incidence of postoperative complications.


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Measure #165 (NQF0130):Coronary Artery Bypass Graft(CABG): Deep Sternal Wound InfectionRate

2014 PQRS OPTIONS FORINDIVIDUAL MEASURES:REGISTRYONLV

DESCRIPTION: Percentage of patientsaged 18years and older undergoing isolated CABG surgery who, within 30dayspostoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiringoperativeintervention

INSTRUCTIONS: This measure is to be reported each time an isolated CABG procedure is performed during the reporting period.It isanticipated thatclinicians who provide se rvi ces for isolated CABG will submit this measure. This measureis 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.


The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codesmaybe submitted for those registries that utilize claims data. There are no allowable performance exclusions for thismeasure.


Denominator Criteria (EligibleCases):All patients aged


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NumeratorOptions:Development of deep sternal wound infection within 30 days postoperatively(G8571)

No deep sternal wound infection(G8572)

RATIONALE: The rnost serious hospital-acquired infection associatedwith coronary arterybypass graft (CABG) surgery is deepsternal wound or deep surgical siteinfection. The most common bacteria involved are5. aureus includingincreasingly more common methicillin resistantStaph (MRS). For CABG only outcomes 1997-1999 the STS datasetreported 0.63% deep sternal wound infection rate in 503,478 records. A report from an academic hospital reported 1.9% deep surgical site infections (Centers for Disease Control and PreventionNational Nosocomial Infection Surveillance [CDC NNIS] criteria) in 1,980 patients undergoing isolated CABG or CABG+ procedures from1996- 1999. The Northern New England Cardiovascular Disease Study Group reported an incidence rate for mediastiniof 1.25% and noted a marked increase in mortality during the first year post-CABG and a threefold increase during a4-year follow-up period.

CLINICAL RECOMMENDATION STATEMENTS:

Several risk factors for sternal wound infection have been identified that can be optimized with good care practices:prophylactic antibiotics within 1 hour before incision time (odds ratio 5.3) [see antibiotic timing process measure] andavoiding elevated blood glucose levels (odds ratio 10.2). Surveillance for surgical site infections is acritical hospital function to monitor infection control practices and direct improvement activity.


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Measure #166 (NQF 0131): Coronary Artery Bypass Graft(CABG): Stroke


DESCRIPTION: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have apostoperativestroke (i.e., any confirmedneurological 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 reported each time an isolated CABG procedure is performed during the reporting period.It is anticipated thatclinicians who provide services for isolatedCABG will submit this measure. This measureisintended to reflect the quality ofsurgical services provided for isolated CABG or isolated reoperation CABG patients.Isolated CABG refers to CABG using arterial and/orvenous grafts only.


The quality-data codes listed do not need to be submitted for registry-based submissions; however, thesecodes maybe submitted for those registries that utilize claims data. There are no allowable performance exclusions for thismeasure.


Denominator Criteria (EligibleCases):All patientsaged "18 years on date of encounter AND Patient encounter during the reporting period(CPn: 33510, 33511, 33512, 33513, 33514, 33516, 33517,33518,33519,33521,33522,33523,33533,33534,33535,33536

OR

Patient encounter during the reporting period (CPn:33510, 33511, 33512, 33513, 33514, 33516, 33517,33518,33519,33521,33522,33523,33533,33534,33535,33536AND Patient encounter during the reporting period(CPn: 33530

NUMERATOR: Patients who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by adisturbancein blood supply to the brain) that did not resolve within 24 hours

Numerator Instructions:A lower calculated performance rate for this measure indicates better clinicalcare or control.

NumeratorOptions:Stroke following isolated CABG surgery(G8573}

OR


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No stroke following isolated CABG surgery(G8574)

RATIONALE: Stroke is a devastating complication after coronary bypass surgery. The 1999 American College of

Cardiology/American Heart Association (ACC/AHA)guidelines indicate that adverse cerebral outcomes are observedin -6% of patients after bypass surgery equally divided between 2 types: 1) associatedwith major, focal neurological defects, stupor or coma and 2) evidence of deteriorationin intellectualfunction. Type 1 deficitsoccur in -3% of patients and are responsible for 21% mortality.

Reports in the literature on postoperative stroke incidence are difficult tocompare because the conditions included inthe term "stroke" vary. A standardized definition of stoke will providecommon language to compare strokeincidenceand evaluate management strategies for reducing this devastating complication.

Reported rates of postoperative cerebral dysfunction range from 0.4% to 13.8% following coronary operations.Complications for patients undergoing emergent CABG or valve surgery were greater than the complication rateforpatients undergoing elective CABG or valve surgery. As bypass times increased, so did the incidence ofstroke.When bypass time was 90 to 113 minutes, OR =1.59, p=0.022 and when bypass time was> 114 minutes, the OR

=2.59, p< 0.001. Outcomes are better when patient age is younger andwith beating-heart surgery rather thanon- pump surgery.

CLINICAL RECOMMENDATION STATEMENTS: The 1999 ACC/AHA guidelines describe strategies for reducing the risk of postoperative stroke such as anaggressive approach to the management of patients with severely diseased ascending aortas identified byintraoperative echocardiographic imaging, prevention or aggressive management of postoperative atrial fibrillatidelay of bypass surgery in the case of a left ventricular mural thrombus or a recent, preoperative CVA andpreoperative carotid screening. Patients should carefully be screened for cerebrovascular disease to help preventstroke and its associated morbidities.

Use of beta-adrenergic antagonists was associated with a lower incidence of stroke in patients undergoing electiveCABG (OR=0.45; 95% Cl 0.23 to 0.83; p=0.016). Use of antiplatelet agents within 48 hours of surgery is associatedwith a decreased risk of stroke (OR=0.51, p=0.01). Increased use of beating-heart surgery withoutcardiopulmonarybypass may lead to a lower prevalence of stroke following cardiac surgery and thus improve patient outcomes.


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Measure #167 (NQF 0114): Coronary Artery Bypass Graft(CABG): PostoperativeRenal Failure


DESCRIPTION: Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renalfailure) who develop postoperative renal failureor require dialysis

INSTRUCTIONS: This measure is to be reported each time an isolated CABG procedure is performed during the reporting period. isanticipated thatclinicians who provide services for isolated CABGwill submit this measure. This measureisintended to reflect the quality of surgical services provided for isolated CABG or isolated reoperation CABG patients.Isolated CABG refers to CABG using arterial and/or venous grafts only.


The quality-data codes listed do not need to be submitted for registry-based submissions; however,these codes maybe submitted for those registries that utilize claims data. There are no allowable performance exclusions for thismeasure.


Denominator Criteria (EligibleCases):All patientsaged18 years on date of encounter AND Patient encounter during the reporting period (CPn:33510, 33511, 33512, 33513, 33514, 33516, 33517,33518,33519,33521,33522,33523,33533,33534,33535,33536

OR

Patient encounter during the reporting period(CPn: 33510, 33511, 33512, 33513, 33514, 33516, 33517,33518,33519,33521,33522,33523,33533,33534,33535,33536AND Patient encounter during the reporting period(CPn: 33530

WITHOUT Documented history ofrenal failure or baseline serum creatinine4.0mg/dl

NUMERATOR: Patients who develop postoperative renal failure or require dialysis; (Definition of renal failure/dialysisrequirement-patient had acute renal failure or worsening renal function resulting in one of thefollowing: 1) increase of serumcreatinineto 4.0 mg/dol r 3x most recent preoperative creatinine level, or 2)a new requirement for dialysis postoperatively)

Numerator Instructions:A lower calculated performance rate for this measure indicates better clinicalcare or control.


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NumeratorOptions:Developed postoperative renal failure or required dialysis(G8575)

No postoperative renal failure/dialysis not required (G8576}

RATIONALE: In 2000, coronary artery bypass graft (CABG) surgery was performed on more than 350,000 patientsat a cost of close to $20 billion. Some degree of AcuteRenal Dysfunction (ARD) occurs in about 8% of patients following CABG,and dialysis-dependent renal failure occurs in 0.7% to 3.5% of patients receiving CABG. The latter is associated withsubstantial increases inmorbidity, length of stay, and mortality (odds ratios for mortality range from 15 to 27). ARDisassociated with increased morbidity, mortality and length of stay in an ICU following surgery. In addition, AcuteFailure occurs in 1.5% of patients undergoing any type of cardiac surgery. There has been a substantial increaseinpostoperative morbidity, mortality, and cost associated with this relativelycommon complication, regardless ofwhether or not this incidence variesmuch between providers, and there are implications of even a modest decrease in its incidence.

CLINICAL RECOMMENDATION STATEMENTS:

Acute renal failure following CABG is an intermediate outcome measure for mortality since this complication isindependently associated (OR=27) with early mortality following cardiac surgery, even after adjustmentfor co-morbidity and postoperative complications.


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Measure #168 (NQF 0115): Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration


DESCRIPTION: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or withouttamponade, graftocclusion, valve dysfunction, orother cardiac reason

INSTRUCTIONS: This measure is to be reported each time an isolated CABG procedure is performed during the reporting period.isanticipated thatclinicians who provide services for isolatedCABG will submit this measure. This measureisintended to reflect the quality of the surgical services provided for isolated CABG or isolated reoperation CABGpatients. Isolated CABG refers to CABG using arterial and/or venous graftsonly.


The quality-data codes listed do not need to be submitted for registry-based submissions; however, thesecodes maybe submitted for those registries that utilize claimsdata. There are no allowable performance exclusions for thismeasure.


Denominator Criteria (EligibleCases):All patients aged2: 18 years on date of encounter AND Patient encounter during the reporting period(CPT):33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536

OR

Patient encounter during the reporting period(CPT):33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536 AND Patient encounter during the reporting period(CPT): 33530

NUMERATOR: Patients who require a return to the OR during the current hospitalization for mediastinal bleeding wilh or without

tamponade, graft occlusion, valve dysfunction,or other cardiac reason

Numerator Instructions:A lower calculated performance rate for this measure indicates betterclinical careor control.

NumeratorOptions:Re-exploration required due tomediastinal bleeding with or without tamponade, graft occlusion, valvedysfunction, or other cardiac reason(G8577)


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Re-exploration not required due to mediastinal bleeding withor without tamponade, graft occlusion, valvedysfunction, or other cardiac reason (G8578)

RATIONALE:In 2000, coronary artery bypass graft (CABG) surgery was performed on more than 350,000 patients ata cost ofclose to $20 billion. Re-exploration after surgery is a serious complication that impacts length of stay, efficientuse ofresources, and increases risk for additional complications and death. As one of several major complicationsofcardiac surgery, repeat surgery is particularly worrisome for consumers and is an inefficient use of resources.

CLINICAL RECOMMENDATIONSTATEMENTS:Re-exploration after surgery is a serious complication that impacts length of stay, efficient use of resources, andincreases risk for additional complications and death. This measure is currently in use by approximately65% ofproviders in the United States who perform cardiac surgery and report data to the STS National Database.


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Measure #169 (NQF 0116): Coronary Artery Bypass Graft(CABG): Antiplatelet Medications at Discharge

2014 PQRS OPTIONS FOR INDIVIDUALMEASURES:REGISTRYONLY

DESCRIPTION: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who were dischargedonantiplatelet medication

INSTRUCTIONS: This measure is to be reported each time an isolated CABG procedure is performed during the reporting period.It is anticipated thatclinicians who provide services for isolatedCABG will submit this measure. This measureisintended 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.


The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codesmaybe submitted for those registries that utilizeclaims data.


Denominator Criteria (EligibleCases):All patientsaged


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RATIONALE: Use of aspirin soon after coronary artery bypass graft (CABG) is associaled wilh reduced riskof death and ischemic complicalions involving the heart, brain, kidneys, and gastrointestinaltracl. High-risk patienls now representthemajority of patients who undergo bypass surgery, giving rise to rates of 15% or higher for complications affecting

heart, brain, kidneys, and inteslines. Guidelines from the American College of Chest Physicians recommend the administration of aspirinsoon after CABG, specifically 325 mg per day starting six hours after surgery.

CLINICAL RECOMMENDATIONSTATEMENTS: Evidence-based discharge therapies are underutilized in older patients who undeiWentCABG during hospitalization for acutemyocardial infarction.


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Measure #170 (NQF 0117): Coronary Artery Bypass Graft(CABG): Beta-Blockers AdministeredatDischarge


DESCRIPTION: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who were discharged onbeta- blockers

INSTRUCTIONS: This measure is to be reported each time an isolated CABG procedure is performed during the reporting period.It isanticipated thatclinicians who provide services for isolatedCABG will submit this measure. This measureisintended to reflect the quality of the surgical services provided for isolated CABG or isolated reoperation CABGpatients. Isolated CABG refers to CABG using arterial and/or venous grafts only.


The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codesmaybe submitted for those registries that utilizeclaims data.


Denominator Criteria (EligibleCases):All patientsaged ;, 18 years on date of encounter AND

Patient encounter during the reporting period (CPn:33510, 33511, 33512, 33513, 33514,33516, 33517,33518,33519,33521,33522,33523,33533,33534,33535,33536

OR

Patient encounter during the reporting period (CPn:33510, 33511, 33512, 33513, 33514, 33516, 33517,33518,33519,33521,33522,33523,33533,33534,33535,33536AND Patient encounter during the reporting period(CPn: 33530 AND Patient not deceased priorto discharge

NUMERATOR:

Patients who were discharged on beta-blockers NumeratorOptions:Beta-blocker at discharge(G8582)

OR Beta-blocker contraindicated(G8583)

OR No beta-blocker at discharge (G8584)


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RATIONALE: Upwards of70% of patients who undergo revascularization procedures have had a myocardial infarction(MI).Cumulative evidence and randomized trials indicate that patients with a previous Mllive longer if they are on betablockers. For many years, patients were taken off beta-blocker medications in preparation for surgery. Evidencefrom

the STS National Database demonstrated that beta blocker use is safe and effective in many CABGpatientspreviously thought to be at high risk for adverse events of betablocker therapy (women, elderly, diabetes, congestiveheart failure). In addition, the use of post-operative b-blockers is now known to protect patients both at oneyear andlong term (greater than5 years) from death following cardiac surgery. This effect is associated with a 46%riskreduction in death at one year and 35% risk reduction in mortality during long-term follow-up (Chan et al., 2012).

CLINICAL RECOMMENDATION STATEMENTS: Beta blockade reduces atrial fibrillation complications following CABG. At four to fiveyears, survival wasapproximately 13% worse in patients who developed postoperative atrial fibrillation (p< 0.001).


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Measure#171 (NQF 0118): Coronary Artery Bypass Graft(CABG): Anti-Lipid Treatment at Discharge

2014 PQRS OPTIONSFOR INDIVIDUAL MEASURES:REGISTRYONLY

DESCRIPTION: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who were discharged on astatin or other lipid-lowering regimen

INSTRUCTIONS: This measure is to be reported each time an isolated CABG procedure is performed during the reporting period.It isanticipated thatclinicians who provide services for isolatedCABG will submit this measure. This measureisintended to reflect the quality of the surgical services provided for isolated CABG or isolated reoperation CABGpatients. Isolated CABG refers to CABG using arterial and/orvenous grafts only.


The quality-data codes listed do not need to be submitted for registry-based submissions;however, these codes maybe submitted for those registries that utilize claims data.


Denominator Criteria (EligibleCases):All patients aged;, 18 years on date of encounter AND Patient encounter during the reporting period(CPn: 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536

OR

Patient encounter during the reporting period(CPn: 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536 AND Patient encounter during the reporting period(CPn: 33530 AND Patient not deceased prior todischarge

NUMERATOR: Patients who were discharged on a statin or other lipid-lowering regimen

NumeratorOptions:Anti-lipid treatment at discharge(G8585)

Anti-lipid treatment contraindicated (G8586)No anti-lipid treatment at discharge(G8587)


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RATIONALE: Atherosclerosis is a chronic disease. Events such as acutemyocardial infarction (AMI) and coronary artery bypassgraft (CABG) surgery identify patients with the disease, but acute therapy is not sufficient for optimal long-termoutcomes. In post-bypass patients, atherosclerosis continues to progress in the native circulation and develops atan

accelerated rate in saphenous vein bypass grafts. Management of the chronic disease is critically importantinpatients with atherosclerosis, such as those undergoing CABG.

The advantages of adherence to the American College of Cardiology/American Heart Association "Get with theGuidelines" program are discussed in a recent article, which also demonstrates both variationin quality andopportunity for improvement (38% compliance with guidelines before program implementation, 98.4% compliancethereafter ). The article also discusses educational and process measures used by a majormedical center to achievecompliance.

CLINICAL RECOMMENDATION STATEMENTS: Compliance rates for patients receiving personalized follow-up for lipid management over two years were significantlybetter than in the control group. Lipid lowering in coronary heart disease has been demonstrated distinctivelythroughthree trials (CLAS, post-CABG, and CARE) to delay the progression of atherosclerosis and/or reduce deaths,and

non- fatal Ml following bypass surgery. Aggressive (low-densitylipoprotein [LDL]) cholesterol-lowering treatment(target< 85 mg/dl)was correlated to a slower rate of diseaseprogression (31%) after 4-5 years in comparison tothecontrol group, which was comprised of patients receiving moderate lipid- lowering treatment (target< 130 to 140 mg/dl).

pqrs measures for sts qcdr

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