December 14, 2009
Beginning on January 1, 2010, anesthesiologists, nurse anesthetists and anesthesiologists assistants will have a new measure to report under the Physician Quality Reporting Initiative: perioperative temperature management. This addition to the PQRI brings the number of anesthesia measures to a total of three.
- #30, Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics
- #76, Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol
- #193, Perioperative Temperature Management
The new temperature management measure applies to anesthesia cases involving:
patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer, except patients undergoing cardiopulmonary bypass, for whom either active warming was used intraoperatively for the purpose of maintaining normothermia, OR at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.
This measure is to be reported each time a surgical or therapeutic procedure not involving cardiopulmonary bypass is performed under general or neuraxial anesthesia during the reporting period. The “reporting period,” next year, may be either 12 months (01/01/2010 - 12/31/2010) or 6 months (07/01/2009 - 12/31/2010). If both the physician and the CRNA/AA in a care team case are responsible for ensuring the timely administration of prophylactic antibiotics, both may report the PQRI measure.
How to Report Measure #193
First, recall the basics of PQRI reporting. Each anesthesia measure is a ratio consisting of the specific quality intervention or clinical action identified by a Quality Data Code (QDC) (the numerator) and a CPT™ procedure code showing that the anesthesia service performed was an “eligible case” (the denominator). QDCs appear as CPT Category II codes. Successful reporting of a given measure requires the clinician to submit the appropriate QDC in 80 percent of all eligible cases.
Modifiers (1P, 2P, 8P) allow the anesthesiologist to indicate that the clinical action was not performed in an otherwise-eligible case and still count the case toward achieving the 80 percent threshold.
- Modifier 1P denotes a case in which the physician did not perform the clinical action for medical reasons.
- Modifier 2P applies when the reason for not performing the clinical action is patient-based, e.g., the patient declined.
- Modifier 8P signals that there is no documentation in the medical record that the physician performed the action at all or that there was a particular reason for omitting the action.
In the 2010 PQRI Implementation Guide , CMS suggests that Modifier 8P should be used sparingly, not as a default. Although the conventional wisdom is that the PRQI incentivizes pure reporting, not performance improvement, CMS warns that physicians “can use the 8P modifier to receive credit for satisfactory reporting but will not receive credit for performance.” There are as yet no special incentives for performance. CMS goes on to say that physicians “should use the 8P reporting modifier judiciously for applicable measures they have selected to report. The 8P modifier may not be used indiscriminately in an attempt to meet satisfactory reporting criteria without regard toward meeting the practice’s quality improvement goals.” There is no penalty for “indiscriminate” use but that may change in the future.
Included in the numerator for Measure #193 are those patients for whom either:
- Active warming was used intraoperatively for the purpose of maintaining normothermia, OR
- At least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.
“Active warming” is limited to over-the-body active warming (e.g., forced air, warm-water garments, and resistive heating blankets). Measure #193 should only be reported for cases lasting at least 60 minutes.
The QDCs to use for Measure #193, and the circumstances in which they apply, are set forth in Table 1. Unless the procedure takes fewer than 60 minutes, in which case the applicable QDC is 4256F, the numerator for perioperative temperature management will consist of two QDCs. Each QDC is reported as a separate line item on the claim (if the claim is submitted electronically, QDCs are entered on the SV1 “Professional Service” segment of the 2400 “Service Line” loop). The individual physician’s National Provider Identifier (NPI) also goes on the line item and the group’s NPI is submitted at the claim level.
Click here to download a pdf of Table 1
An anesthesiologist performing, hypothetically, 500 transurethral prostatectomies (00914) and 500 total hip arthroplasties (01214) and no other anesthesia services could meet the 80 percent threshold by submitting the combination of QDC codes shown in Table 2.
Click here to download a pdf of Table 2
In the example above, the anesthesiologist reported the appropriate QDCs in 80 percent of her transurethral prostatectomies (160/200) and in 84 percent of her total hip arthroplasties (670/800) – even though anesthesia time in half of the prostatectomies was under 60 minutes and no active warming was performed (or no body temperature recording was 36°C or greater) in 54 percent (430/800) of the eligible arthroplasties.
Note that the anesthesiologist here reported a QDC in at least 80 percent of each of the two procedures that she performed. If she had reported 4256F in just 70 of her 200 prostatectomies and thus achieved a reporting rate of 75 (150/200) percent, she would not have reported Measure #193 in 80 percent of all her eligible cases. She would not, therefore, qualify for the PQRI bonus in 2010, which will again be 2 percent of all allowed Medicare charges.
Measure #30, Antibiotic Prophylaxis – Updated Specifications
The title for Measure #30 has been changed, from “Timing of Prophylactic Antibiotic – Administering Physician” to “Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics.” The measure description has been updated accordingly, and it now reads:
Percentage of surgical patients aged 18 years and older who receive an anesthetic when undergoing procedures with the indications for prophylactic parenteral antibiotics for whom administration of the prophylactic parenteral antibiotic ordered has been initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required).
Table 3 lays out the numerator and denominator codes for Measure #30. QDC 4048F applies when prophylactic antibiotics have been administered within 1 hour/2 hours pre-incision, as appropriate; or when antibiotics are not indicated, or when they have been ordered but not administered. QDC 4047F applies when there is no documented order for antibiotic prophylaxis.
Click here to download a pdf of Table 3
The specifications for Measure #30 make it clear that QDC 4047-8P also covers the situation where the anesthesia service is among the denominator CPT codes but prophylactic antibiotics are not medically appropriate for procedure-based rather than patient-based reasons: “The anesthesia services included in the denominator are associated with some surgical procedures for which prophylactic parenteral antibiotics may not be indicated. As a result, clinicians should report 4047F-8P for those instances in which anesthesia services are provided but not associated with surgical procedures for which prophylactic antibiotics are indicated.” (The detailed specifications for all 179 measures in the 2010 PQRI are available at http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage .)
Also updated are the instructions for reporting the administration of prophylactic parenteral antibiotics that are not on the official list: “The antimicrobial drugs listed below [see specifications for Measure #30] are considered prophylactic parenteral antibiotics for the purposes of this measure. 4048F-8P should be reported when antibiotics from this table were not ordered.”
Finally, the 2010 specifications explain that the word “’ordered’ includes instances in which the prophylactic parenteral antibiotic is ordered by the clinician performing the surgical procedure OR is ordered by the clinician providing the anesthesia services.”
Measure #76: Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol – Updated Specifications
The only change in the specifications for Measure #76 is a word transposition. The applicable numerator QDCs and denominator CPT codes appear in Table 4.
Click here to download a pdf of Table 4
How Many Measures Must an Anesthesiologist (or CRNA or AA) Report?
The PQRI system requires a clinician to report 3 or more measures, unless only 1 or 2 measures apply to his or her practice. For most anesthesiologists, that has meant reporting only Measure #30 and/or Measure #76. Now that the specialty has 3 measures, must anesthesiologists successfully report all 3 to be eligible for their PQRI bonus?
The answer is no. If an anesthesiologist chooses to report just the CVC insertion protocol measure, #76, he does not have to report either the antibiotic prophylaxis measure or the normothermia measure. He is free to do so, however. If the anesthesiologist submits claims with PQRI codes for Measure #76 and either Measure #30 or Measure #193, then he will need to report 2 or all 3 measures in at least 80 percent of his eligible cases for each.
IMPORTANT: if you report more than a nominal number of cases for any one measure, you are declaring that measure applicable to your practice. Be very careful to continue reporting any measure that you include on any claims submitted to Medicare in the first half of 2010 or you may forfeit the entire bonus you would have earned otherwise.
The reason for all of these complex and seemingly magical rules is the Measure Applicability Validation (MAV) process to which any clinician who reports fewer than 3 measures may be subject. The MAV process allows CMS to check whether there really are only 1 or 2 applicable measures. First CMS will apply a “clinical relation test” by looking at the “Clinically Related Cluster” it has defined to include the measure reported by the clinician. If are other measures in that cluster, failure to report one or more of them will cost the physician the bonus unless he passes the second step, the “Minimum Threshold Test.”
The minimum threshold differs depending on whether the physician is using the full 12-month reporting period or whether he has opted for the 6-month period from July 1st through December 31st, 2010. If he is using the 12-month timeframe, he only fails the second test if he submits 15 or more claims for eligible cases without reporting the relevant PQRI measure. For 6-month reporting, the minimum threshold is 8 cases. It is unlikely that a practicing anesthesiologist will provide fewer than 15 (or 8) anesthetics in 2010, so the best course would be to make sure to report both of the measures in at least one of the two anesthesia clusters that CMS has introduced for 2010:
Anesthesia Care Cluster 1: Measure #30 and Measure #76
Anesthesia Care Cluster 2: Measure #193 and Measure #30
Thus the anesthesiologist does not have to report the new normothermia measure simply because she is reporting the antibiotic prophylaxis measure, and vice versa. She will have to report the CRBSI prevention measure in that case, however. That measure (#76) is not subject to the MAV process at all and the anesthesiologist may qualify for the bonus without reporting any other measure.
The labyrinth described above should not be an obstacle to successful PQRI reporting for this specialty. During the 2008 reporting period, anesthesia providers reported 1,500,224 QDCs for Measure #30, of which 1,347,079 were valid (89.79% success rate). The bulk of errors arose from incorrect codes. We hope that the detailed coding information provided in this paper will help ensure that you receive your bonus for 2010.
With best wishes,
President and CEO