2014 Physician Quality Reporting System Data Collection Form: Coronary Artery Bypass Graft (CABG) (for patients aged 18 years and older)

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1 2014 Physician Quality Reporting System Data Collection Form: Coronary Artery Bypass Graft (CABG) (for patients aged 18 years and older) Physician Name: Patient Name: Last First MI Date of Birth: / / mm dd yyyy Gender: M F Medical Record Number: Patient Insured - Traditional Medicare*: Medicare Advantage: Other: *Note: A minimum of 11 patients must be Traditional Medicare Part B **Note: Currently, ICD-10 codes are not required. You may choose to use either the ICD-9 codes listed in each data collection form, or the ICD-10 codes in the document: PQRS2014 Applicable Measure Group Codes. This document also contains a list of ICD-9, encounter, and procedure codes. Not all measures groups require all 3 code types. Appointment Date: / / (1/1/14 12/31/14) mm dd yyyy ICD-9 (or ICD-10) Diagnosis Code**: N/A Encounter Code: N/A Procedure Code: Patient sample criteria for the CABG Measures Group are: patients aged 18 and older who had a CABG procedure: One of the following procedure codes indicating coronary artery bypass graft (CABG): 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, PLEASE REFER TO THE CABG MEASURES GROUP WITH THE CMS 2014 PQRS MEASURES GROUPS SPECIFICATIONS MANUAL FOR FURTHER INFORMATION.

2 Patient Name: Page 2 of 6 Physician Quality Reporting Measure # 43: Coronary Artery Bypass Graft (CABG): Use of IMA in patients with isolated CABG surgery isolated CABG surgery who received an IMA graft Medical reason(s) for not performing an internal mammary artery graft for primary, isolated coronary artery bypass graft procedure. Acceptable medical reasons include: subclavian stenosis, previous cardiac or thoracic surgery, previous mediastinal radiation, emergent or salvage procedure, no left anterior descending artery disease IMA graft performed for primary, isolated coronary artery bypass graft procedure IMA graft not performed for medical reasons Document reason in medical chart IMA graft not performed for primary, isolated coronary artery bypass graft procedure, reason not otherwise specified Physician Quality Reporting Measure # 44: Coronary Artery Bypass Graft (CABG): Preoperative beta-blocker in patients with isolated CABG surgery Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision Medical Reason - Eligible professional must document specific reason(s) for not administering beta-blockers Beta blocker administered within 24 hours prior to surgical incision Documentation of medical reason(s) for not administering beta blocker within 24 hours prior to surgical incision (eg, not indicated, contraindicated, other medical reasons) Document reason in medical chart Beta blocker not administered within 24 hours prior to surgical incision, reason not otherwise specified

3 Patient Name: Page 3 of 6 Physician Quality Reporting Measure # 164: Coronary Artery Bypass Graft (CABG): Prolonged Intubation isolated CABG surgery who require postoperative intubation > 24 hours Prolonged postoperative intubation >24 hours required Prolonged postoperative intubation >24 hours not required Measure Note: For performance, a lower rate indicates better performance. Physician Quality Reporting Measure # 165: Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention Development of deep sternal wound infection within 30 days postoperatively No deep sternal wound infection Patients who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention. Patient must have ALL of the following conditions: 1. wound opened with excision of tissue (incision and drainage) or reexploration of mediastinum; 2. positive culture unless patient is on antibiotics at time of culture or no culture obtained; and 3. treatment with antibiotics beyond perioperative prophylaxis

4 Patient Name: Page 4 of 6 Physician Quality Reporting Measure # 166 : Coronary Artery Bypass Graft (CABG): Stroke 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 Stroke following isolated CABG surgery No Stroke following isolated CABG surgery Physician Quality Reporting Measure # 167 : Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis Patients who develop postoperative renal failure or require dialysis; (Definition of renal failure/dialysis requirement - patient had acute renal failure or worsening renal function resulting in one of the following: 1) increase of serum creatinine to 4.0 mg/dl or 3x most recent preoperative creatinine level, or 2) a new requirement for dialysis postoperatively) Developed postoperative renal failure or required dialysis No postoperative renal failure / dialysis not required Not Eligible patient has pre-existing renal failure

5 Patient Name: Page 5 of 6 Physician Quality Reporting Measure # 168: Coronary Artery Bypass Graft (CABG): Surgical Re-exploration isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason Re-exploration required due to mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason Re-exploration not required due to mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason Physician Quality Reporting Measure # 169: Coronary Artery Bypass Graft (CABG): Antiplatelet medications at discharge Percentage of patients aged 18 years and older undergoing isolated CABG surgery who were discharged on antiplatelet medication Antiplatelet medication at discharge Antiplatelet medication contraindicated No Antiplatelet medication at discharge

6 Patient Name: Page 6 of 6 Physician Quality Reporting Measure # 170: Coronary Artery Bypass Graft (CABG): Beta- Blockers Administered at discharge isolated CABG surgery who were discharged on betablockers Beta-blocker at discharge Beta-blocker contraindicated No beta-blocker at discharge Physician Quality Reporting Measure # 171: Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge isolated CABG surgery who were discharged on a statin or other lipid-lowering regimen Anti-lipid treatment at discharge Anti-lipid treatment contraindicated No anti-lipid treatment at discharge

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