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
Gender:
Date of Birth:
_____ /_____ /_____
mm
dd
yyyy
Medical Record Number:
□ M □F
_______________________________
Patient Insured Traditional Medicare*:
Medicare Advantage:
Other:
Appointment Date: ____ /_____ /____
(1/1/14 – 12/31/14)
mm
dd
yyyy
□
□
□
ICD-9 (or ICD-10) Diagnosis Code**:
_____________N/A______________
*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.
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, 33536
PLEASE REFER TO THE “CABG” MEASURES GROUP WITH THE CMS 2014 PQRS MEASURES GROUPS
SPECIFICATIONS MANUAL FOR FURTHER INFORMATION.
Patient Name: _________________________
Physician Quality Reporting Measure # 43:
Coronary Artery Bypass Graft (CABG): Use of IMA
in patients with isolated CABG surgery
Percentage of patients aged 18 years and older undergoing
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
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
Page 2 of 6
Check One
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
Check One
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
Successful CMS 2014 Physician Quality Reporting CABG Measures Group submission requires information from 20
unique patients who have had a CABG procedure, the majority of whom must be Medicare Part B FFS.
© 2014 Covisint Corporation
V042314
Patient Name: _________________________
Physician Quality Reporting Measure # 164:
Coronary Artery Bypass Graft (CABG): Prolonged
Intubation
Percentage of patients aged 18 years and older undergoing
isolated CABG surgery who require postoperative
intubation > 24 hours
Page 3 of 6
Check One
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
Percentage of patients aged 18 years and older undergoing
isolated CABG surgery who, within 30 days
postoperatively, develop deep sternal wound infection
involving muscle, bone, and/or mediastinum requiring
operative intervention
Check One
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
Measure Note: A lower calculated performance rate for
this measure indicates better clinical care or control.
Successful CMS 2014 Physician Quality Reporting CABG Measures Group submission requires information from 20
unique patients who have had a CABG procedure, the majority of whom must be Medicare Part B FFS.
© 2014 Covisint Corporation
V042314
Patient Name: _________________________
Physician Quality Reporting Measure # 166 :
Page 4 of 6
Check One
Coronary Artery Bypass Graft (CABG): Stroke
Percentage of patients aged 18 years and older undergoing
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
Measure Note: A lower calculated performance rate for
this measure indicates better clinical care or control.
Physician Quality Reporting Measure # 167 :
Coronary Artery Bypass Graft (CABG):
Postoperative Renal Failure
Percentage of patients aged 18 years and older undergoing
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)
Check One
Developed postoperative renal failure or
required dialysis
No postoperative renal failure / dialysis
not required
Not Eligible – patient has pre-existing
renal failure
Measure Note: A lower calculated performance rate for
this measure indicates better clinical care or control.
Successful CMS 2014 Physician Quality Reporting CABG Measures Group submission requires information from 20
unique patients who have had a CABG procedure, the majority of whom must be Medicare Part B FFS.
© 2014 Covisint Corporation
V042314
Patient Name: _________________________
Physician Quality Reporting Measure # 168:
Coronary Artery Bypass Graft (CABG): Surgical
Re-exploration
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 without tamponade, graft
occlusion, valve dysfunction, or other cardiac reason
Measure Note: A lower calculated performance rate for
this measure indicates better clinical care or control.
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
Page 5 of 6
Check One
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
Check One
Antiplatelet medication at discharge
Antiplatelet medication contraindicated
No Antiplatelet medication at discharge
Successful CMS 2014 Physician Quality Reporting CABG Measures Group submission requires information from 20
unique patients who have had a CABG procedure, the majority of whom must be Medicare Part B FFS.
© 2014 Covisint Corporation
V042314
Patient Name: _________________________
Page 6 of 6
Physician Quality Reporting Measure # 170:
Check One
Coronary Artery Bypass Graft (CABG): BetaBlockers Administered at discharge
Beta-blocker at discharge
Percentage of patients aged 18 years and older undergoing
isolated CABG surgery who were discharged on betablockers
Beta-blocker contraindicated
Physician Quality Reporting Measure # 171:
Check One
Coronary Artery Bypass Graft (CABG): Anti-Lipid
Treatment at Discharge
Anti-lipid treatment at discharge
Percentage of patients aged 18 years and older undergoing
isolated CABG surgery who were discharged on a statin or
other lipid-lowering regimen
No beta-blocker at discharge
Anti-lipid treatment contraindicated
No anti-lipid treatment at discharge
Successful CMS 2014 Physician Quality Reporting CABG Measures Group submission requires information from 20
unique patients who have had a CABG procedure, the majority of whom must be Medicare Part B FFS.
© 2014 Covisint Corporation
V042314