Measure 358
Patient-Centered Surgical Risk Assessment and Communication
DESCRIPTION:
The percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed and discussed prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.
| MEASURE ID: | 358 |
|---|---|
| Type: | Process |
CMS Derm Specialty Set: | No |
| High priority: | Yes |
| Topped out: | Yes |
| Telehealth Eligible: | No |
| Reporting methods: | Registry/QCDR |
| Maximum points: | 7 |
MEASURE PURPOSE:
This measure encourages physicians to use standardized tools to assess patient risk for postoperative complications and to discuss those findings with patients. The use of risk calculators encourages greater consistency in risk assessment.
Measure 358 FAQs
Q. Is this measure reportable via claims?
A. No.
Q. Are patient encounters conducted via telehealth allowable?
A. No, telehealth encounters are not allowable.
Q. Do I have to report this measure for every adult patient having a non-emergency surgery?
A. Yes, this measure must be reported for every eligible encounter during the performance period.
Q. What is a “risk calculator”?
A. A risk calculator is a procedure-specific, patient-specific, data-based risk calculator should be based on a validated, risk-adjusted statistical model predicting 30-day postoperative complications for the procedure that the patient is to undergo.
Risk calculations should be based on preoperative patient-specific clinical data, and should include the following groups of variables: patient demographic characteristics (e.g., age, gender); relevant lifestyle and clinical risk factors (e.g., smoking status, body mass index); patient comorbidities (e.g., diabetes; neurologic event/disease; disseminated cancer); and procedure type.
Q. What personalized risks of postoperative complications should be assessed?
A. Postoperative complications should include 30-day risk-adjusted mortality, 30-day risk-adjusted overall morbidity (superficial surgical site infection, deep incisional surgical site infection, wound dehiscence, pneumonia, deep venous thrombosis; pneumonia; renal failure; urinary tract infection; prolonged ventilator dependence; bleeding complications; sepsis; and pulmonary embolism), serious complications (cardiac arrest; myocardial infarction, pneumonia; progressive renal insufficiency; acute renal failure; pulmonary embolism; deep venous thrombosis; return to the operating room deep incisional surgical site infection; organ space surgical site infection; systemic sepsis; unplanned intubation; urinary tract infection; and wound dehiscence), surgical site infection, and average length of stay.
Q. Where are the tools located for this measure?
A. The assessment tools specified in the measure are located below:
American College of Surgeons National Surgical Quality Improvement Program Risk Calculator
Society of Thoracic Surgeons Adult Cardiac Surgery Risk Calculator
Q. Can I use other risk assessment tools?
A. Yes, you can use other risk assessment tools, but it must be validated and meet the requirements of a risk calculator defined above. Always document the tool used.
Q. Do I still get credit for the measure if the patient refuses to be assessed?
A. No, you will not receive credit for this measure. There are no exceptions or exclusions in the measure.
Q. What qualifies as communication?
A. Any communication method qualifies, but the method of communication must always be documented.
Calculation
The numerator: The number of patients who received empirical, personalized risk assessment with a validated risk calculator, and findings were communicated to the patient and/or family prior to surgery
The denominator: The total number of adult patients who had non-emergency surgery during the reporting period.
Measure calculation example
Dr. Crocker saw 28 patients who have non-emergency surgery during the reporting period. This is the denominator.
Dr. Crocker used a validated calculator to assess risk and discusses the assessment with the patient and/or their family in 26 of these encounters. This is the numerator.
Quality of patient care = 26/28. Dr. Crocker has a score of 92.9% for this measure. This translates to 2.0 to 2.9 points.
Important note
Because of how this measure is structured, physicians score 3 points even if they report on only one patient. This is applicable only to small practices with 15 providers or fewer. A score of 99.99% earns 4.9 points, while a score of 100% earns 7 points.
Quality measure score benchmark
CMS will award points based on a comparison of your performance rate to CMS benchmarks listed below. Reach the performance rate listed to achieve the corresponding points per measure. Points achieved for the Quality category will account for 30% of the overall MIPS score.
| Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 |
|---|---|---|---|---|---|---|---|
Performance rate |
1.81 - 58.00 |
58.01 - 95.23 |
95.24 - 99.42 |
99.43 - 99.99 |
-- |
-- |
100 |
Points |
1.0 - 1.9 |
2.0 - 2.9 |
3.0 - 3.9 |
4.0 - 4.9 |
-- |
-- |
7 |
