# CAP PQRI requirements - If a patient presents



## ggparker14 (May 29, 2012)

If a patient presents to ED and diagnosed with CAP and admitted, but not given antibiotic until third admission day, does this qualify for PQRI 4045F for claim submission?

Thanks for any help.


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## chrao3 (Jun 10, 2012)

*Rao*

When to use:

1. Patient is Medicare
2. Reporting a designated CPT code from the PQRS measures.
3. Reporting a designated ICD-9 code from the PQRS measures.
4. Patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia. 
5. A place-of-service indicator for emergency department is required if using the critical care CPT code to identify the patient for the measure.

Pneumonia ICD-9-CM diagnosis codes
481, 482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39, 482.40, 482.41, 482.42, 482.49, 482.81, 482.82, 482.83, 482.84, 482.89, 482.9 (bacterial pneumonia)
483.0, 483.1, 483.8 (pneumonia due to other specified organism)
485 (bronchopneumonia organism unspecified)
486 (pneumonia organism unspecified)
487.0 (influenza with pneumonia)

Definitions:
Appropriate Empiric Antibiotic – For treatment of community-acquired bacterial pneumonia (CAP) should include any medication from one of the following four drug classes: Fluoroquinolones, Macrolides, Doxycycline, Beta Lactam with Macrolide or Doxycycline (as defined by current ATS/IDSA guidelines).
Prescribed – Includes patients who are currently receiving medication(s) that follow the treatment plan recommended at an encounter during the reporting period, even if the prescription for that medication was ordered prior to the encounter.

CPT codes
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285, 99291 AND Place-of-service indicator: 23 (emergency department) If reporting 99291. 
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350

Quality codes for this measure:
CPT II code descriptors: (Data collection sheet should be used to determine appropriate code.) 
CPT II 4045F: Appropriate empiric antibiotic prescribed 
CPT II 4045F–1P: Documentation of medical reason(s) for not prescribing appropriate empiric antibiotic (eg, not indicated, contraindicated, other medical reason)
CPT II 4045F–2P: Documentation of patient reason(s) for not prescribing appropriate empiric antibiotic (eg, patient declined, economic, social, religious, other patient reason)
CPT II 4045F–3P: Documentation of system reason(s) for not prescribing appropriate empiric antibiotic (eg, resources to perform the services not available, other reason attributable
to health care delivery system)
CPT II 4045F–8P: Appropriate empiric antibiotic not prescribed, reason not otherwise specified

4045F – treatment with any medication from one of the following drug classes: Fluoroquinolones,
Macrolides, Doxycycline,
Adoxa
Levofloxacin
Atridox
Lomefloxacin
Avelox
Maxaquin
Ciprofloxacin
Noroxin
Clarithromycin
Ofloxacin
Dirithromycin
Periostat
Erythromycin
Vibramycin
Floxin, Floxin I.V.
Vibra-Tabs
Gatifloxacin
Vibrox
Azithromycin
Monodox
Biaxin
Moxifloxacin
Cipro, Cipro I.V
Norfloxacin
Doryx
Roxithromycin
Doxyhexal
Rulid, Surlid
Dynabac
Tequin
Levaquin
Zithromax, Zitromax


It will give you clear idea to whether to bill the cpt code 4045 F with modifier 8p. If any please provide your suggestion.


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## Mojo (Jun 14, 2012)

rhblevins61@yahoo.com said:


> If a patient presents to ED and diagnosed with CAP and admitted, but not given antibiotic until third admission day, does this qualify for PQRI 4045F for claim submission?
> 
> Thanks for any help.



Hi Regina:

If the EDP did not order the appropriate empiric antibiotic during the ED visit or documentation of the medical, patient or system reason is absent, the performance measure has not been met and 4045F-8P is assigned.

In your scenario was the antibiotic ordered but missed by nursing?


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