MEASURE DESCRIPTION:
Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.
NQS DOMAIN/MEANINGFUL MEASURE AREA:
Patient Safety/Healthcare Associated Infections
MEASURE TYPE:
Process
HIGH PRIORITY STATUS:
Yes
INSTRUCTIONS:
This measure is to be submitted each time a CVC insertion is performed during the performance period. There is no diagnosis associated with this measure. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who perform CVC insertion will submit this measure.
MEASURE SUBMISSION TYPE:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
DENOMINATOR:
All patients, regardless of age, who undergo CVC insertion
-
Denominator Criteria (Eligible Cases):
Patient procedure during the performance period (CPT):
36555, 36556, 36557, 36558, 36560, 36561, 36563, 36565, 36566, 36568, 36569, 36570, 36571, 36572, 36573, 36578, 36580, 36581, 36582, 36583, 36584, 36585, 93503, 93593, 93594, 93595, 93596, 93597
WITHOUTTelehealth Modifier: GQ, GT, 95, POS 02
NUMERATOR:
Patients for whom central venous catheter (CVC) was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed
Numerator Definitions:
Maximal Sterile Barrier Technique – includes all of the following elements: Cap AND mask AND sterile gown AND sterile gloves AND sterile full body drape.
Sterile Ultrasound Techniques – require sterile gel and sterile probe covers.
Hand Hygiene – Washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR).
-
Numerator Options:
Performance Met: All elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed (6030F)
OR
Performance Not Met: All elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques not followed, reason not otherwise specified (6030F with 8P)
OR
Denominator Exception: Documentation of medical reason(s) for not following all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques during CVC insertion (including increased risk of harm to patient if adherence to aseptic technique would cause delay in CVC insertion) (6030F with 1P)
RELEVANT FIELDS:
- Date of service
- Date of birth
- ASA CPT code
- CBP performed
- Hypothermia status
RATIONALE:
Catheter-related bloodstream infection is a costly complication of central venous catheter insertion, but may be avoided with routine use of aseptic technique during catheter insertion. This measure is constructed to require that all of the listed elements of aseptic technique are followed and documented. Hospital-acquired bloodstream infections are a common complication that leads to increased costs and mortality. It is estimated that approximately 51% of hospital-acquired bloodstream infections occur in an intensive care unit (ICU), with the presence of a central venous catheter being the largest risk factor for the development of a bloodstream infection in the hospital. Catheter-related bloodstream infections (CRBSIs) commonly occur when the catheter becomes contaminated by microbes on the skin during insertion. The use of maximal sterile barriers, including sterile gloves, long-sleeved sterile gown, mask, cap, and full-sized sterile drape, during insertion of the catheter has been shown to cost effectively reduce CRBSI rates compared to the use of less stringent precautions.
REPORTING CODES: