Measure Overview
Use in CMS Programs
- Finalized through rulemaking for inclusion in Merit-based Incentive Payment System (MIPS) in 2016.
- Implemented in MIPS starting with Performance Year (PY) 2017.
Description
Percentage of patients aged 18 years and older undergoing isolated coronary artery bypass graft (CABG) surgery who require a return to the operating room (OR) for mediastinal bleeding with or without tamponade, unplanned coronary artery intervention (native vessel, graft or both), valve dysfunction, aortic reintervention or other cardiac reason during the current hospitalization.
Measure Specification
Patients undergoing isolated CABG surgery who require a return to the OR for mediastinal bleeding with or without tamponade, unplanned coronary artery intervention (native vessel, graft or both), valve dysfunction, aortic reintervention or other cardiac reason during the current hospitalization.
N/A
N/A
All patients undergoing isolated CABG surgery.
None
N/A
Measure Information
Endorsement History
- This measure was initially endorsed in 2007
- The measure retained endorsement during maintenance in 2018
- Endorsement was removed in 2025
Link to endorsement measure record: Risk-Adjusted Surgical Re-exploration
Measure Performance in Program
Measure Score by Performance Year
Impact Summary: This measure supports the Merit‑based Incentive Payment System (MIPS) by assessing the occurrence of surgical re‑exploration during hospitalization among patients undergoing isolated coronary artery bypass graft surgery, an outcome associated with serious postoperative complications and patient safety.
Due to low reporting on this measure, no benchmark data are currently available in the publicly reported MIPS Quality Benchmarks files Battelle reviewed for this assessment. As a result, Battelle cannot evaluate performance trends and the potential impact of improvement on patient outcomes at this time. The absence of benchmark data limits the ability to assess the importance or impact of this measure within MIPS. This measure is in the Surgical Care MIPS Value Pathway (MVP), which should increase adoption and reporting in the future.
For this measure, Battelle reviewed the following publicly available datasets at Benchmarks - QPP:
- 2026 MIPS Quality Benchmarks.csv
- 2025 MIPS Quality Benchmarks.csv
- 2024 MIPS Quality Benchmarks.csv
2023 MIPS Quality Benchmarks.csv
There are no benchmark values for “Measure_ID”=168 in these files, and therefore no data are available to assess. For these years, there has been an insufficient volume of data submitted to establish a performance period benchmark.
Meaningfulness
Importance
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
Data Stream Burden Reduction
Data Stream Burden Reduction
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Alignment with the Patient Health Care Journey
Alignment with the Patient Health Care Journey
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Public Comment
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