# PQRI Help????



## vballew (Dec 13, 2012)

When billing for PQRI on Anesthesia does the documentation have to be in the anesthesia record or is the hospital having it on file enough?


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## dwaldman (Dec 13, 2012)

For antibiotic adminstered 1 hour prior to surgical incision, this needs to be documented on the anesthesia record. If you are billing for the anesthesia service, a copy of the anesthesia record should be maintain by the practice.

For perioperative temperature management, for a temp of 36 C,  30 minutes prior to the anesthesia end time or documentation of active warming should be documented on the anesthesia record. There might be a situation where you are needing documentation that the temperature was at 36 C or higher, 15 minutes following the anesthesia end time which potentially would be documented on the post anesthesia recovery record which would be part of the hospital forms, could check if this form is carbon copy or if a copy is available for the physician to copy if it is known the other criteria was not met prior to the anesthesia end time. 

For maximal sterile barrier technique for central line placement, this should be part of the procedure note that cap, mask, sterile gloves, sterile gown, large sterile sheet, hand hygiene and 2% chlor prep was used or a form set up that the physician can document these elements were met. 

Although I can not provide direct answer to your question from CMS source document, I would believe it would be best practice to try modify the process to be able maintain documentation for the quality codes you are reporting.


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## dwaldman (Dec 13, 2012)

Measure #30: Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics

DESCRIPTION: 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).




Measure #76: Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol

DESCRIPTION: Percentage of patients, regardless of age, who undergo CVC insertion for whom CVC was inserted with all elements of maximal sterile barrier technique [cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2 percent chlorhexidine for cutaneous antisepsis (or acceptable alternative antiseptics per current guideline)] followed.




Measure #193: Perioperative Temperature Management

DESCRIPTION: Percentage of 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.


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## vballew (Dec 14, 2012)

Thank you very much for your info.


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