ORGANIZATIONS BEHIND
MEASUREMENT SETS
NQF
AHRQ
CMS
JCAHO
NCQA
AMA - PCPI
AQA
AHA
SCIP
IHI
ACC
STS
Premier-CMS
COAP
MEASUREMENT SETS
AQA – AQA Measures
AQA – Cardiac Surgery
AQA – Cardiology
CMS – HQA
CMS – PVRP
NQF – Cardiac Surgery
Premier-CMS – HQI
SCIP
PERFORMANCE MEASURES
CROSSWALK BY TOPIC
Patient Safety
CABG / Cardiac Surgery
PCI (angioplasty)
ACS / AMI
PERFORMANCE MEASURE
CODING
HIPAA Standard Codes
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– PERFORMANCE MEASURE SETS –
Ambulatory Care Quality Alliance (AQA)
Cardiac Surgery Performance Measures
in Ambulatory Care
AQA Cardiac Surgery
Starter Set of 15 Measures [Word .Doc]
Adapted from NQF National Voluntary Consensus Standards for Cardiac Surgery [PDF]
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Performance Measure
Clinical Topic |
Measure |
Description |
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| 1. |
Participation in a Systematic Database for Cardiac Surgery |
STS |
| Numerator – Does the facility participate in a multicenter, data collection and feedback program that provides benchmarking relative to peers and uses process and outcome measures? (Yes/No) |
| Denominator – Not Applicable |
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| 2. |
Timing of Antibiotic Administration for Cardiac Surgery Patients |
CMS |
| Numerator – Cardiac surgery patients who received prophylactic antibiotics within one hour of surgical incision (two hours if vancomycin) |
| Denominator – Surgical patients with CABG ICD-9-CM procedure codes: |
| a. | CABG (ICD-9 codes: 36.10, 36.11, 36.12, 36.13, 36.15, 36.16, 36.19, 36.20) |
| b. | Other cardiac surgery, (ICD-9 codes: 35.0x, 35.1x, 35.2x, 35.3x, 35.4x, 35.5x, 35.6x, 35.7x, 35.8x, 35.91-35.95, 35.98, 35.99) |
| Exclusions: |
| 1. | Principal or admission diagnosis suggestive of pre-operative infectious disease |
| • | Infectious diseases 001.0-139.8 |
| • | Meningitis 320.0-326 |
| • | Ear infection 380.0-380.23; 382.0-382.20 |
| • | Endocarditis 421.0-422.99 |
| • | Respiratory 460-466.19; 472-476.1; 480-487.8; 490-491.9; 510-511.9; 513-513.1 |
| • | Digestive 540-542; 575.0 |
| • | Renal 590-590.9; 595.0 |
| • | Prostate 601.0-601.9 |
| • | Gynecologic 614-614.9; 616-616.4 |
| • | Skin 680-686.9 |
| • | Musculo-skeletal 711.9-711.99; 730.0-730.99 |
| • | Fever of unknown origin 780.6 |
| • | Septic shock 785.59 |
| • | Bacteremia 790.7 |
| • | Viremia 790.8 | |
| 2. | Receiving antibiotics at the time of admission |
| 3. | Medical records do not include antibiotic start date/time or incision date/time |
| 4. | Receiving antibiotics more than 24 hours prior to surgery |
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| 3. |
Selection of Antibiotic Administration for Cardiac Surgery Patients |
CMS |
| Numerator – Cardiac surgery patients who received prophylactic antibiotics recommended for the specific operation: cefazolin, cefuroxime, cefamandole, or vancomycin* |
| * | Special consideration: For cardiac and vascular surgery, if patient is allergic to b-lactam, then
vancomycin or clindamycin is an acceptable substitute |
| Denominator – Surgical patients with CABG ICD-9-CM procedure codes: 36.10-36.17, 36.19; and other cardiac surgery: ICD-9 35.0-35.95, 35.98, 35.99 |
| Exclusions: |
| 1. | Principal or admission diagnosis suggestive of pre-operative infectious disease |
| • | Infectious diseases 001.0-139.8 |
| • | Meningitis 320.0-326 |
| • | Ear infection 380.0-380.23; 382.0-382.20 |
| • | Endocarditis 421.0-422.99 |
| • | Respiratory 460-466.19; 472-476.1; 480-487.8; 490-491.9; 510-511.9; 513-513.1 |
| • | Digestive 540-542; 575.0 |
| • | Renal 590-590.9; 595.0 |
| • | Prostate 601.0-601.9 |
| • | Gynecologic 614-614.9; 616-616.4 |
| • | Skin 680-686.9 |
| • | Musculo-skeletal 711.9-711.99; 730.0-730.99 |
| • | Fever of unknown origin 780.6 |
| • | Septic shock 785.59 |
| • | Bacteremia 790.7 |
| • | Viremia 790.8 | |
| 2. | Receiving antibiotics at the time of admission |
| 3. | Medical records do not include antibiotic start date/time or incision date/time |
| 4. | Receiving antibiotics more than 24 hours prior to surgery |
| 5. | No antibiotics received before or during surgery, or within 24 hours after surgery end time (i.e., patient did not receive any prophylactic antibiotics) |
| 6. | No antibiotics received during the hospitalization |
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| 4. |
Pre-operative Beta Blockade |
STS |
| Numerator – Number of patients coming to isolated CABG with documented pre-operative (24 hours) beta
blockade |
| Denominator – All patients undergoing CABG surgery |
| Exclusions: Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
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| 5. |
Use of Internal Mammary Artery (IMA) |
CMS/
QIO |
| Numerator – Patients who received an IMA graft (ICD-9 procedure codes 36.15 and 36.16) |
| Denominator – Surgical patients undergoing isolated CABG (ICD-9-CM procedure codes: 36.10 - 36.19) who were
discharged, transferred, or expired |
| Exclusions: |
| • | Other heart procedures (IDC-9 procedure codes 37.32, 37.34, 37.35, 36.2, 35.0-35.99) |
| • | Repeat CABG (ICD-9 status code V45.81) |
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| 6. |
Duration of Prophylaxis for Cardiac Surgery Patients |
CMS |
| Numerator –Cardiac surgery patients whose prophylactic antibiotics were discontinued within 24 to 48 hours after surgery end time |
| Denominator – Surgical patients with CABG ICD-9-CM procedure codes: 36.10-36.17, 36.19; and other cardiac surgery: ICD-9 35.0-35.95, 35.98, 35.99 |
| Exclusions: |
| 1. | Principal or admission diagnosis suggestive of pre-operative infectious disease |
| • | Infectious diseases 001.0-139.8 |
| • | Meningitis 320.0-326 |
| • | Ear infection 380.0-380.23; 382.0-382.20 |
| • | Endocarditis 421.0-422.99 |
| • | Respiratory 460-466.19; 472-476.1; 480-487.8; 490-491.9; 510-511.9; 513-513.1 |
| • | Digestive 540-542; 575.0 |
| • | Renal 590-590.9; 595.0 |
| • | Prostate 601.0-601.9 |
| • | Gynecologic 614-614.9; 616-616.4 |
| • | Skin 680-686.9 |
| • | Musculo-skeletal 711.9-711.99; 730.0-730.99 |
| • | Fever of unknown origin 780.6 |
| • | Septic shock 785.59 |
| • | Bacteremia 790.7 |
| • | Viremia 790.8 | |
| 2. | Receiving antibiotics at the time of admission |
| 3. | Medical records do not include antibiotic start date/time or incision date/time |
| 4. | Receiving antibiotics >24 hours prior to surgery |
| 5. | No antibiotics received before or during surgery, or within 24 hours after surgery end time (i.e., patient did not receive any prophylactic antibiotics) |
| 6. | Diagnosed with and treated for infections within two days after surgery date |
| 7. | No antibiotics received during the hospitalization |
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| 7. |
Prolonged Intubation (ventilation) |
STS |
| Numerator – Number of patients who undergo isolated CABG who require intubation >24 hours |
| Denominator – All patients undergoing isolated CABG |
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| Inclusions: |
| Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
| • | Number of patients undergoing isolated CABG without pre-existing intubation / tracheostomy |
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| Exclusions: |
| • | Patients intubated prior to isolated CABG; patients with tracheostomy prior to isolated CABG |
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| Risk adjustment: |
| • | Multivariate logistic regression and hierarchical modeling available for STS. |
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| 8. |
Deep Sternal Wound Infection Rate |
STS |
| Numerator – Number of patients who developed deep sternal wound infections within 30 days post-operative |
| Definition of deep sternal wound infection: |
| Patient with a deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention. Must have all of the following conditions: |
| • | Wound opened with excision of tissue (I&D) or re-exploration of mediastinum |
| • | Positive culture |
| • | Treatment with antibiotics |
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| Denominator – All patients undergoing isolated CABG |
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| Inclusions: |
| Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
| • | All patients undergoing isolated CABG surgery who developed a deep sternal wound infection within 30 days post-operative |
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| Exclusions: |
| • | Patients undergoing isolated CABG surgery with superficial wound site infections and no involvement of deeper tissue post-operative |
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| Risk adjustment: |
| • | Multivariate logistic regression and hierarchical modeling available for STS. |
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| 9. |
Stroke/Cerebrovascular Accident |
STS |
| Numerator – Number of patients who undergo isolated CABG with post-operative neurologic deficit persisting >72 hours |
| Denominator – All patients undergoing isolated CABG |
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| Inclusions: |
| Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
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| Exclusions: |
| • | Patients with pre-existing neurologic deficits |
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| Risk adjustment: |
| • | Multivariate logistic regression and hierarchical modeling available for STS. |
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| 10. |
Post-operative Renal Insufficiency |
STS |
| Numerator – Number of patients undergoing isolated CABG who develop post-operative renal failure/dialysis requirement |
| Definition of renal failure/dialysis requirement: |
| Patients with acute or worsening renal failure
resulting in one or more of the following: |
| • | Increase in serum creatinine to >2.0 and two times most recent pre-operative creatinine level |
| • | New requirement for dialysis post-operatively |
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| Denominator – All patients undergoing isolated CABG |
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| Inclusions: |
| Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
| • | Number of patients undergoing isolated CABG without pre-existing renal failure |
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| Exclusions: |
| • | Patients with documented history of renal failure, baseline serum creatinine >2.0; prior renal transplants are not considered pre-operative renal failure unless since transplantation their Cr has been or is >2.0 |
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| Risk adjustment: |
| • | Multivariate logistic regression and hierarchical modeling available for STS. |
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| 11. |
Surgical Re-exploration |
STS |
| Numerator – Number of patients undergoing isolated CABG who require return to the operating room for bleeding/tamponade, graft occlusion, or other cardiac reason |
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| Denominator – All patients undergoing isolated CABG |
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| Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
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| Risk adjustment: |
| • | Multivariate logistic regression and hierarchical modeling available for STS. |
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| 12. |
Anti-platelet Medication at Discharge |
STS |
| Numerator – Number of patients who were discharged on aspirin/safety-coated aspirin or clopidogrel after isolated CABG |
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| Denominator – All patients undergoing isolated CABG |
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| Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
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| 13. |
Beta Blockade at Discharge |
STS |
| Numerator – Number of isolated CABG patients discharged on beta blockers |
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| Denominator – All patients undergoing isolated CABG |
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| Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
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| 14. |
Anti-lipid Treatment at Discharge |
STS |
| Numerator – Number of isolated CABG patients discharged on a statin or other pharmacologic lipid-lowering regimen |
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| Denominator – All patients undergoing isolated CABG |
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| Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
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| 15. |
Risk-Adjusted 30-day Operative Mortality for CABG |
STS |
| Numerator: Number of patients undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation |
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| Denominator – All patients undergoing isolated CABG |
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| Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
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| Risk adjustment: |
| • | Multivariate logistic regression and hierarchical modeling available for STS. |
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| The following 6 NQF cardiac surgery measures are not AQA measures |
| 16. |
Risk-Adjusted Inpatient Operative Mortality for CABG |
CCORP |
| Numerator – Number of patients from participating hospitals who had an isolated CABG surgery and died in hospital |
| Denominator – Number of patients from participating hospitals who had isolated CABG surgery |
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| Exclusions: |
| Deaths are not counted after discharge even if the patient dies soon after the operation. If a patient is transferred post-operatively to a rehabilitation or transitional care facility and dies before going home, this death is not counted. |
| Procedures performed during the same surgery: |
| • | valve procedures |
| • | operations on structures adjacent to heart valves |
| • | ventriculectomy |
| • | repair of atrial and ventricular septa |
| • | excision of aneurysm of heart |
| • | head and neck, intracranial endarterectomy |
| • | other open heart surgeries, such as aortic arch repair, pulmonary endarterectomy |
| • | endarterectomy of aorta |
| • | thoracic endarterectomy |
| • | heart transplantation |
| • | repair of certain congenital cardiac anomalies |
| • | implantation of cardiomyostimulation system |
| • | any aortic aneurysm repair |
| • | aorta-subclavian-carotid bypass |
| • | aorta-renal bypass |
| • | aorta-iliac-femoral bypass |
| • | caval-pulmonary artery anastomosis extracranial-intracranial (EC-IC) vascular bypass |
| • | coronary artery fistula |
| • | resection of a portion of the lung does not include simple biopsy of lung nodule in which surrounding lung is not resected or biopsy of a thoracic lymph node |
| • | incisional (ventral) hernia repair |
| • | lumpectomy or mastectomy for breast cancer |
| • | maze procedures, surgical or catheter |
| • | total or partial excision of thymus |
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| Inclusions: |
| The CABG cases with the following procedures performed concurrently will be considered isolated CABG: |
| • | transmyocardial laser revascularization (TMR) |
| • | pericardiectomy and excision of lesions of heart |
| • | repair/restoration of the heart or pericardium |
| • | coronary endarterectomy |
| • | pacemakers |
| • | internal cardiac defibrillators |
| • | fem-fem cardiopulmonary bypass |
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| Risk adjustment: |
| • | Multivariate logistic regression. Adjusted for differences in the case mix across hospitals and accounted for the pre-operative condition of each patient, using California CABG Outcome Reporting Program risk model, which is available from CCORP at http://www.oshpd.cahwnet.gov/HQAD/
Outcomes/CCORP/index.htm. |
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| 17. |
Risk-Adjusted 30-day Operative Mortality for Aortic Valve Replacement (AVR) |
STS |
| Numerator: Number of patients undergoing isolated AVR who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation |
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| Denominator – All patients undergoing isolated AVR surgery |
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| Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
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| Exclusions: |
| • | Patients receiving CABG or other valve or cardiac surgery during this admission |
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| Risk adjustment: |
| • | Multivariate logistic regression and hierarchical modeling available for STS. |
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| 18. |
Risk-Adjusted 30-day Operative Mortality for Mitral Valve Replacement (MVR) |
STS |
| Numerator: Number of patients undergoing isolated MVR who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation |
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| Denominator – All patients undergoing isolated MVR surgery |
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| Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
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| Exclusions: |
| • | Patients receiving CABG or other valve or cardiac surgery during this admission |
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| Risk adjustment: |
| • | Multivariate logistic regression and hierarchical modeling available for STS. |
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| 19. |
Risk-Adjusted 30-day Operative Mortality for AVR + CABG |
STS |
| Numerator: Number of patients undergoing combined AVR and CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation |
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| Denominator – All patients undergoing combined AVR + CABG surgery |
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| Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
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| Exclusions: |
| • | Patients receiving CABG or other valve or cardiac surgery during this admission |
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| Risk adjustment: |
| • | Multivariate logistic regression and hierarchical modeling available for STS. |
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| 20. |
Risk-Adjusted 30-day Operative Mortality for MVR + CABG |
STS |
| Numerator: Number of patients undergoing combined MVR and CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, unless the cause of death is clearly unrelated to the operation |
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| Denominator – All patients undergoing combined MVR + CABG surgery |
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| Age qualification: For patients <20 years, the data are accepted into the database, but are not included in the national analysis and report |
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| Exclusions: |
| • | Patients receiving CABG or other valve or cardiac surgery during this admission |
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| Risk adjustment: |
| • | Multivariate logistic regression and hierarchical modeling available for STS. |
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| 21. |
Surgical Volume |
CMS |
| Surgical Volume to include: |
| a. | Isolated Coronary Artery Bypass Graft (CABG) Surgery |
| b. | Valve Surgery |
| c. | CABG + Valve Surgery |
| Numerator |
| a. | Number of patients undergoing isolated CABG surgery, (ICD-9 codes: 36.10, 36.11, 36.12, 36.13, 36.15, 36.16, 36.19) |
| b. | Number of patients undergoing Valvuloplasty surgery, (ICD-9 codes: 35.10, 35.11, 35.12, 35.13, 35.14) or |
| Number of patients undergoing valve replacement surgery, (ICD-9 codes: 36.20, 36.21, 36.22, 36.23, 36.24, 36.25, 36.26, 36.27, 36.28) |
| c. | Number of patients undergoing valve+CABG surgery, ICD-9 codes: 36.10-36.16, 36.19 and 35.10-35.14, 35.20-35.28) |
| Denominator – Not Applicable |
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