2016 Measures Group (MG) Flow General Surgery
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4 2016 Measures Group (MG) Flow General Surgery Please refer to the specific section of the 2016 PQRS Measures Groups Specifications Manual to identify specific coding and instructions to report the General Surgery Measures Group Patient Sample Criteria (denominator), individual measures, and numerator options information for use in reporting this Measures Group. 1. Start with G9237 Intent G-code if Utilized 2. Check Patient Age: a. If the Age is greater than or equal to 18 years of age at Date of Service equals No, do not include in Eligible Population/Denominator. Stop Processing. b. If the Age is greater than or equal to 18 years of age at Date of Service equals Yes, proceed to check Procedure Performed. 3. Check Procedure Performed: a. If Procedure Codes as Listed in the MG Patient Sample Criteria equals No, do not include in Eligible Population. Stop Processing. b. If Procedure Codes as Listed in the MG Patient Sample Criteria equals Yes, continue to Procedure Date of Service 1/1/2016 thru 12/01/ Check Procedure Performed Date: a. If Procedure Date of Service 1/1/2016 thru 12/01/2016 equals No, do not include in Eligible Population. Stop Processing. b. If Procedure Date of Service 1/01/2016 thru 12/01/2016 equals Yes, include in the Eligible Population/Denominator. 5. Denominator Population a. Include in Eligible Population/Denominator all eligible patients who meet the Patient Sample Criteria (denominator) for the Measures Group. For each measure within the measures group each numerator option is represented by a letter which is used in the Scenarios for Reporting and Performance Algorithms at the end of this document. 6. Start Numerator Options for Measures within the Measures Group 7. Composite Quality Data Code (QDC) G9235 has been created for registries that utilize claims data. This QDC may be reported in lieu of individual QDCs when all quality clinical actions for all applicable measures within the group have been performed for this patient. 8. Measure 130 a. Numerator option Performance Met has an arrow pointing to G9235 Composite Quality Data Code (QDC) or Equivalent. Performance Met is represented by letter a i. b. Numerator option Performance Exclusion is represented by letter b i. c. Numerator option Performance Not Met is represented by letter c i.
5 d. Numerator option Not Reported is represented by letter d i. 9. Measure 226 a. Numerator option Performance Met has an arrow pointing to G9235 Composite Quality Data Code (QDC) or Equivalent. Performance Met is represented by letter a ii. b. Numerator option Performance Exclusion is represented by letter b ii. c. Numerator option Performance Not Met is represented by letter c ii. d. Numerator option Not Reported is represented by letter d ii. 10. Measure 354 a. Measure #354 is an inverse measure. A lower calculated performance rate for this measure indicates better clinical control and care. b. Measure #354 is only reported when the patient has a procedure performed specific to gastric bypass surgery or colectomy. When measure #354 is Not Applicable it is represented by letter e iii in the Scenarios for Reporting Algorithms. c. Numerator option Performance Met is represented by letter a iii. d. Numerator option Performance Not Met has an arrow pointing to G9235 Composite Quality Data Code (QDC) or Equivalent. Performance Not Met is represented by letter c iii. e. Numerator option Not Reported is represented by letter d iii. 11. Measure 355 a. Measure #355 is an inverse measure. A lower calculated performance rate for this measure indicates better clinical control and care. b. Numerator option Performance Met is represented by letter ai v. c. Numerator option Performance Not Met has an arrow pointing to G9235 Composite Quality Data Code (QDC) or Equivalent. Performance Not Met is represented by letter c iv. d. Numerator option Not Reported is represented by letter d iv. 12. Measure 356 a. Measure #356 is an inverse measure. A lower calculated performance rate for this measure indicates better clinical control and care. b. Numerator option Performance Met is represented by letter a v. c. Numerator option Performance Not Met has an arrow pointing to G9235 Composite Quality Data Code (QDC) or Equivalent. Performance Not Met is represented by letter c v. d. Numerator option Not Reported is represented by letter d v.
6 13. Measure 357 a. Measure #357 is an inverse measure. A lower calculated performance rate for this measure indicates better clinical control and care. b. Numerator option Performance Met is represented by letter a vi. c. Numerator option Performance Not Met has an arrow pointing to G9235 Composite Quality Data Code (QDC) or Equivalent. Performance Not Met is represented by letter c vi. d. Numerator option Not Reported is represented by letter d vi. 14. Measure 358 a. Measure #358 is not required when the patient has a specific AV Fistula procedure performed. When measure #358 is Not Applicable it is represented by letter e vii in the Scenarios for Reporting Algorithms. b. Numerator option Performance Met has an arrow pointing to G9235 Composite Quality Data Code (QDC) or Equivalent. Performance Met is represented by letter a vii. c. Numerator option Performance Not Met is represented by letter c vii. d. Numerator option Not Reported is represented by letter d vii. 15. Scenarios for Reporting and Performance Algorithms 16. Patient X Procedure Specific to Colectomy a. Patient X Met Measure 130 (represented by a i ) b. Patient X Exclusion Reported for Measure 226 (represented by b ii ) c. Patient X Met Measure 354 (represented by a iii ) d. Patient X Met Measure 355 (represented by a iv ) e. Patient X Not Met but Reported Measure 356 (represented by c v ) f. Patient X Not Met but Reported Measure 357 (represented by c vi ) g. Patient X Not Met but Reported Measure 358 (represented by c vii ) 17. Patient Y Procedure Not Specific to Gastric Bypass or Colectomy, Had AV Fistula Procedure a. Patient Y Not Met but Reported Measure 130 (represented by c i ) b. Patient Y Not Met but Reported Measure 226 (represented by c ii ) c. Patient Y Not Applicable for Measure 354 (represented by e iii ) d. Patient Y Not Met but Reported Measure 355 (represented by c iv ) e. Patient Y Met Measure 356 (represented by a v ) f. Patient Y Not Met but Reported Measure 357 (represented by c vi )
7 g. Patient Y Not Applicable for Measure 358 (represented by e vii ) 18. Patient Z Procedure Specific to Gastric Bypass a. Patient Z did Not Report Measure 130 (represented by d i ) b. Patient Z Met Measure 226 (represented by a ii ) c. Patient Z Not Met but Reported Measure 354 (represented by c iii ) d. Patient Z did Not Report Measure 355 (represented by d iv ) e. Patient Z Met Measure 356 (represented by a v ) f. Patient Z Met Measure 357 (represented by a vi ) g. Patient Z Met Measure 358 (represented by a vii ) 19. Reporting Algorithm a. Reporting of all applicable measures contained in the measures group, per eligible patient, equals one b. Patient X Reporting equals 1 Plus Patient Y Reporting equals 1 Plus Patient Z Reporting equals 0 for a total of 2 of the Required 20 Patient Sample Reported 20. Performance Algorithms 21. Measure 130 a. Performance Met equals 1 divided by Reported QDC for 2 eligible patients minus 0 Performance Exclusions equals 50% Performance 22. Measure 226 a. Performance Met equals 1 divided by Reported QDC for 3 eligible patients minus 1 Performance Exclusion equals 50% Performance 23. Measure 354 a. Performance Met equals 1 divided by Reported QDC for 2 eligible patients equals 50% Performance 24. Measure 355 a. Performance Met equals 1 divided by Reported QDC for 2 eligible patients equals 50% Performance 25. Measure 356 a. Performance Met equals 2 divided by Reported QDC for 3 eligible patients equals 66.67% Performance 26. Measure 357 a. Performance Met equals 1 divided by Reported QDC for 3 eligible patients equals 33.33% Performance
8 27. Measure 358 a. Performance Met equals 1 divided by Reported QDC for 2 eligible patients equals 50% Performance
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