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Fall 2007


Coding Corner: Are You Reporting Pre-Operative Antibiotic Prophylaxis Under the Physician Quality Reporting Initiative (PQRI)?

Sharon Hughes
MBA, RHIA, CCS

AT A GLANCE

The Tax Relief and Health Care Act of 2006 (TRHCA) Section 101 authorized,in Title I, the Physician Quality Reporting Initiative. This voluntary quality reporting program began on July 1st and ends on December 31, 2007. Unlike its predecessor, the Physician Voluntary Reporting Program (PVRP), the PQRI will pay physicians a bonus if they report the applicable quality measure(s) on at least 80% of the claims for eligible services performed during the second half of 2007. The only PQRI measure applicable to anesthesia care is #30, the timely preoperative administration of antibiotic prophylaxis.

Although groups seeking the bonus already have more than three months’ experience with the program, questions about the mechanics are still surfacing. A set of Frequently Asked Questions (FAQs)and answers furnished by members of the MGMA Anesthesia Administration Assembly (AAA) and by American Society of Anesthesiologists (ASA) staff recently appeared on the AAA list serv. These FAQs, as amended in October, appear below.

Without additional legislation and funding it is not clear whether the PQRI will continue into 2008. Although Congress has failed to pass Medicare legislation thus far, it still has more than two months to do so. The Centers for Medicare and Medicaid Services (CMS) expects to be administering the PQRI or a similar program next year.

PQRI FAQS

The following answers to the Frequently Asked Questions were produced by MGMA and ASA staff in consultation with the Centers for Medicare and Medicaid Services (CMS) and are intended as an educational resource and reference guide only. They should not be considered legally binding or definitive statements of law. Differing answers may be warranted, based on varying facts and/or circumstances.

PQRI comments related to Perioperative Prophylactic Antibiotics:

Measure #20: is intended for the ordering physician and pertains to the surgeon.

Measure #30: is intended for the administering physician – typically an eligible professional providing anesthesia services – giving the prophylactic antibiotic at the correct time.

Eligible professionals include anesthesiologists, CRNAs and Anesthesiologist Assistants (AAs).

Question 1: Can both the Anesthesiologist and CRNA or AA receive credit if PQRI Measure #30 (antibiotic prophylactic timing) is submitted?

Answer 1: Any eligible professional with privileges to perform the clinical action described in Measure #30 can report CPT® II codes on the Medicare FFS claim. Therefore, both the anesthesiologist and the CRNA or AA may report Measure #30 (antibiotic prophylactic timing) if the actions described in the measure specification were performed for a given case. There is no medical direction issue or need to allocate the measure to one or the other of the clinicians.

Question 2: Can an Anesthesiologist and CRNA or AA report and get credit for delivery of prophylactic antibiotics if they are “hung” in the pre-op area and there is documentation that that they have been given pre-op as specified in PQRI Measure #30?

Answer 2: Yes, the anesthesiologist and CRNA or AA can report Measure #30 to indicate the prophylactic antibiotics were “hung” pre-operatively as long as there is a documented order and documentation of the timing of prophylactic antibiotic administration in the anesthesia record.

Question 2a: What about with a patient who comes down from the floor on antibiotics, so none are given prophylactically, how is this reported?

Answer 2a: In the scenario described above, there is no order for prophylactic antibiotics and the dosing schedule of the therapeutic antibiotics is unrelated to the procedure start or incision; therefore, Measure #30 would not apply to anesthesiology.

Question 3: PQRI Measure #30 “Timing of prophylactic antibiotics-administering physician” contains only two available numerators; 4048F-Given in timely manner and 4048F-8P-Not given in a timely manner. Modifier 1P is not listed with Measure #30. Can this modifier be used even if it is not listed on the measure for when a patient comes down from the floor already on an antibiotic?

Answer 3: No, there are no allowable performance exclusions for PQRI Measure #30 identified by the measure developer. Reportable numerator codes include 4048F or 4048F-8P as instructed in the measure specification.

Question 4: In a case with a deep abscess or wound infection, the surgeon states, “I do not want the prophylactic antibiotics to be given until after I obtain cultures from the wound” (i.e., after the incision has been made and the abscess has been located). May I report on PQRI Measure #30 using 4047F-8P and 4048F8P?

Answer 4: Since there was no order for prophylactic antibiotics to be administered prior to the surgical incision (or start of procedure when surgical incision is not required), Measure #30 does not apply. 4047F-8P is not a reportable code for measure #30.

Question 5: Is the reporting of PQRI Measure #30 “Timing of Prophylactic Antibiotic-Administering Physician” only for surgical site prophylaxis or will SBE (Subacute Bacterial Endocarditis) Prophylaxis, when indicated, be included as well?

Answer 5: No, SBE prophylaxis is not included. The clinical recommendation statements and rationale refer to surgical wound infections which do not include SBE. See guidelines referenced for this measure in Measure #30 worksheet

Question 6: When reporting PQRI Measure #30 should we use the same diagnosis used when reporting the surgical procedure?

Answer 6: Yes, codes should be submitted via the CMS 1500 as part of your routine claims processing.

Question 7: How should one report PQRI codes on the claim form when Medicare is the secondary insurance? If the measure is applied to the primary insurance claim will it result in denials? Has CMS worked this out with other insurance carriers?

Answer 7: As referenced in FAQ #8467 on the CMS website: “Providers should not include the PQRI codes on claims submitted to primary payers (when Medicare is secondary) unless notified or approved to do so by that payer. Providers should, however, place the PQRI codes on the claim when submitting that claim to Medicare for secondary payment. When Medicare is primary there is an automatic cross-over of claims to payers who enter into agreements with CMS. Some payers may also elect to receive claims where Medicare is the secondary payer.”

Question 8: Should one report both the 4047F and 4048F for PQRI Measure #30 or does 4048F indicate an order was given?

Answer 8: Measure #30 requires you to submit both 4047F for the order and 4048F (with or without the 8P as indicated) for the administration of the prophylactic antibiotic. The denominator coding for Measure #30 includes 4047F (Documentation of order for prophylactic antibiotics) and the numerator coding includes 4048F with or without the 8P modifier (Documentation should note that prophylactic antibiotic was given within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required).

Question 9: If 4047F has to be checked off by the anesthesiologist, must there be documentation that the surgeon ordered the prophylactic antibiotic for PQRI Measure #30?

Answer 9: Yes. For the purpose of reporting for PQRI, standing orders (clinical pathways and protocols) may be included; however, what is submitted on the claim should match the documented actions in the patient’s chart. Each physician or other eligible professional would need to refer to internal policies and standards from other governing bodies to determine whether the use of standing orders is permitted.

Question 10: How should reporting of the perioperative care measures be documented in the medical record? Should they be taken from the pre-operative nurse notes? Do they need to be noted in the anesthesiologist’s pre-operative evaluation and plan? Do they need to be on the anesthesia record?

Answer 10: Medical record documentation is required for all clinical actions described in a measure. Each eligible professional will need to determine the appropriate forms (paper or electronic) that require documentation (i.e. nurse’s notes, anesthesia record, etc.). The anesthesia provider should document the time the prophylactic antibiotic was initiated verifying the timing was appropriate for reporting the measure.

Question 10a: In the event that a pre-op or hospital RN administers the medication in the presence of an Anesthesiologist or CRNA, who should report the measure?

Answer 10a: Only eligible professionals can report PQRI Measure #30. However, if an Anesthesiologist or CRNA or AA is responsible for the administration of the prophylactic antibiotic, including observation of the pre-operative nurse administering the medication, they may report Measure #30. Note: The measure must be reported on the same claim as the procedure with which it is associated.

Question 11: Regarding PQRI Measure #30, does the time of administration of the antibiotic and the time of incision (or start of procedure if no incision) need to be documented together on the anesthesia record or other document?

Answer 11: Each physician or other eligible professional would need to refer to internal medical record documentation policy. For Measure #30, the timing, dosage, and route of administration of the prophylactic antibiotic must be documented in the medical record at the time of administration. Appropriate documentation may be more easily accessible for anesthesia providers if it were documented in one place, i.e. the anesthesia record. The incision time should be noted either in the anesthesia record or the operative record of the patient’s chart.

Question 11a: Does the type of antibiotic used, the time and signature have to be on the record?

Answer 11a: Yes, please refer to internal policies and standards from other governing bodies (i.e. JCAHO), which require this documentation.

Question 12: If a case is scheduled as an orthopedic “closed procedure/possible open procedure” how should this be handled for PQRI reporting purposes? The antibiotics may not be ordered until after the closed procedure is not successful and the open procedure is planned.

Answer 12: Note that prophylactic antibiotics may be given for planned open or closed procedures: “or start of procedure when no incision is required”. In this scenario, the antibiotics would be ordered to be given within 60 minutes of the incision and the relevant PQRI codes may be reported. It does not matter that the closed (non-eligible measure) intervenes between induction and incision.

Question 13: What should occur when a surgeon fails to write an antibiotic order, for a procedure or does not give the verbal order until the incision has been made? In this situation there would be no time to prepare and administer the prophylactic antibiotic “on time” because of this “late” order.

Answer 13: Late ordering of prophylactic antibiotic will result in performance failure for Measure #20. The surgeon responsible for the “late” order could report 4047F-8P (antibiotics were not ordered within one hour….) providing the surgical procedure performed was part of the denominator inclusion codes for the measure. The eligible professional providing anesthesia services would not be accountable to report Measure #30 since there was no documentation of the order for prophylactic antibiotics prior to the incision.

Question 14: The patient is an inpatient and has been receiving regular scheduled doses of one or more therapeutic antibiotics. When the patient arrives in the operating room, the previous dose of antibiotics may not have been given within the “one hour prior to the incision” timeframe. How should the anesthesia provider report Measure #30?

Answer 14: In this scenario, the patient is receiving therapeutic, not prophylactic, antibiotics and the dosage schedule is unrelated to surgical incision or procedure start. Measure #30 is inapplicable unless an additional dose or additional antibiotic agent is ordered to be administered in the specified timeframe for wound prophylaxis. For more information please visit www.communiquenews.com.

For additional information please visit www.cms.hhs.gov.