# 2016 Anesthesia PQRS



## missyah20 (Dec 16, 2015)

Good Evening All,

I was just wondering if anyone out there can help me decipher the new format CMS is using in their PQRS descriptions.  In particular I am looking at Measure #424 which is pretty much a replacement for current measure #193.  

The wording in the measure just has me confused at to what codes are reported.  For example if the pt meets the measure requirements do I report both 4255F and 4559F?

Do I still report a Measure Code if MAC is the mode of anesthesia?  They have code G9654 by MAC?

Thanks in advance for any help given.  I will more than likely need to send a question to qualitynet help desk but thought maybe someone had already figured this out.

Thanks again!


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## dwaldman (Dec 17, 2015)

Yes, it seems if  you use registry reporting you would use  4559F & 4255F, but I haven't had chance to review any articles describing how this revised measure is reported. It seems they did away with G9363 or G9362, lower the temperature threshold from 96.8 (36) to 95.9 (35.5), and removed the claims reporting option. I thought they felt this measure was topped out and were removing it.
_________________________________________

DENOMINATOR: All patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer 

AND Anesthesia of 60 minutes duration or longer: 4255F 

AND NOT Monitored Anesthesia Care (MAC): G9654 

Performance Met: At least 1 body temperature measurement equal to or greater than 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time (4559F) 
______________________________________________


Measure #424 (NQF 2671): Perioperative Temperature Management ? National Quality Strategy
Domain: Patient Safety 

2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES:  REGISTRY ONLY 
DESCRIPTION: Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time 

INSTRUCTIONS:  This measure is to be reported each time any procedure including surgical, therapeutic or diagnostic is performed under general or neuraxial anesthesia during the reporting period. There is no diagnosis associated with this measure. It is anticipated that clinicians who provide the listed anesthesia services as specified in the denominator coding will submit this measure.  

Measure Reporting via Registry: CPT codes, HCPCS codes, quality-data codes and patient demographics are used to identify patients who are included in the measure?s denominator. The listed numerator options are used to report the numerator of the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. 

DENOMINATOR: All patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer 
Denominator Instructions: The anesthesia time used for this measure should be the time recorded in the anesthesia record. 
Denominator Criteria (Eligible Cases): All patients, regardless of age AND Patient encounter during the reporting period (CPT): 00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01961, 01962, 01963, 01965, 01966 

AND Anesthesia of 60 minutes duration or longer: 4255F AND NOT Monitored Anesthesia Care (MAC): G9654 

NUMERATOR: Patients for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time 
Numerator Options: Performance Met: At least 1 body temperature measurement equal to or greater than 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time (4559F) 
OR 
Medical Performance Exclusion: Documentation of one of the following medical reason(s) for not achieving at least 1 body temperature measurement equal to or greater than 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time (e.g., Emergency cases, Intentional hypothermia, etc.) (4559F with 1P) 
OR 
Performance Not Met: At least 1 body temperature measurement equal to or greater than 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time (4559F with 8P) 

RATIONALE: A drop in core temperature during surgery, known as p
perioperative hypothermia, can result in numerous adverse effects, which can include adverse myocardial outcomes, subcutaneous vasoconstriction, increased incidence of surgical site infection, and impaired healing of wounds. The desired outcome, reduction in adverse surgical effects due to perioperative hypothermia, is affected by maintenance of normothermia during surgery. Unintended perioperative hypothermia occurs in up to 20% of surgical patients. An observational cohort study in a pediatric setting found that more than 50% of children experienced intraoperative hypothermia. Pediatric patients undergoing major surgery were at greater risk of intraoperative hypothermia. 

CLINICAL RECOMMENDATION STATEMENTS: Preadmission/Preoperative Recommendations 
Assessment: Assess for risk factors for perioperative hypothermia (Class I, Level C); Measure patient temperature on admission (Class I, Level C); Determine patient?s thermal comfort level (Class I, Level C); Assess for signs and symptoms of hypothermia (Class I, Level C); Document and communicate all risk factor assessment findings to all members of the anesthesia/surgical team (Class I, Level A) 
Version 10.0 CPT only copyright 2015 American Medical Association. All rights reserved. 11/17/2015  Page 3 of 7 
Interventions: Implement passive thermal care measures (Class I, Level B); Maintain ambient room temperature at or above 24 degrees Celsius (Class I, Level C); Institute active warming for patients who are hypothermic (Class IIb, Level B); Consider preoperative warming to reduce the risk of intra/postoperative hypothermia (Class IIb, Level B) 
Intraoperative Recommendations Assessment: Identify patient?s risk factors for unplanned preoperative hypothermia (Class I, Level C); Frequent intraoperative temperature monitoring should be considered in all cases (Class I, Level C); Assess for signs and symptoms of hypothermia (Class IIb, Level C); Determine patient?s thermal comfort level (Class IIb, Level C); Document and communicate all risk factor assessment findings to all members of the anesthesia/surgical team (Class I, Level A) 
Interventions: Limit skin exposure to lower ambient environmental temperatures (Class I, Level C); Initiate passive warming measures (Class I, Level C); Maintain ambient room temperature from 20-25 degrees Celsius based on AORN and architectural recommendations (Class I, Level C); Patients undergoing a procedure with an anticipated anesthesia time greater than 30 minutes (Class I, Level C) and/or who are hypothermic preoperatively (Class I, Level A), and/or patients at risk for hypothermia (Class I, Level C) or at increased risk for suffering its complications (Class I, Level C) ? Forced air warming should be implemented (Class I, Level A); There is evidence to suggest that alternative active warming measures may maintain normothermia when used alone or in combination with forced air warming (Class IIb, Level B). These warming measures include: Warmed IV fluids (Class IIa, Level B), Warmed irrigation fluids (Class IIb, Level B), Circulating water garments (Class IIb, Level B), Circulating water mattresses (Class IIb, Level B), Radiant heat (Class IIb, Level B), Gel pad surface warming (Class IIa, Level B), Resistive heating (Class IIa, Level B) (ASPAN, 2010) 
Maintenance of body temperature in a normothermic range is recommended for most procedures other than during periods in which mild hypothermia is intended to provide organ protection (e.g., during high aortic cross-clamping) (Class I Recommendation, Level of Evidence B) (ACC/AHA, 2007) 
COPYRIGHT: The Measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. 
The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. 
Commercial uses of the Measures require a license agreement between the user and the American Medical Association (AMA), [on behalf of the Physician Consortium for Performance Improvement? (PCPI?)] or American Society of Anesthesiologists (ASA). Neither the AMA, ASA, PCPI, nor its members shall be responsible for any use of the Measures. 
The AMA?s, PCPI?s and National Committee for Quality Assurance?s significant past efforts and contributions to the development and updating of the Measures is acknowledged. ASA is solely responsible for the review and enhancement (?Maintenance?) of the Measures as of May 15, 2014. ASA encourages use of the Measures by other health care professionals, where appropriate. 
THE MEASURES AND SPECIFICATIONS ARE PROVIDED ?AS IS? WITHOUT WARRANTY OF ANY KIND. 
? 2014 American Medical Association and American Society of Anesthesiologists. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use. 
Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, ASA, the PCPI and its 
Version 10.0 CPT only copyright 2015 American Medical Association. All rights reserved. 11/17/2015  Page 4 of 7 
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT?) or other coding contained in the specifications. 
CPT? contained in the Measures specifications is copyright 2004-2015 American Medical Association. LOINC? copyright 2004-2015 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT?) copyright 2004-2015 College of American Pathologists. All Rights Reserved.


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## missyah20 (Dec 17, 2015)

Thanks for replying . . . that is kind of the way it looked to me as well.  I also thought they were just going to retire this measure as intra-op warming is basically a standard of practice.


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## jkyles@decisionhealth.com (Dec 31, 2015)

*Patient Warming*

Since this is registry only measure in 2016, the registry should do the measures selection for you. I've heard nothing but good things about AQI and assume they'll be approved for 2016, but I don't know what other registries will be reporting anesthesia measures next year. 

Anesthesia providers who are still claims-based won't use this measure next year. Maybe good news?


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## Alice Claar (Jan 11, 2016)

*Claims based*

What do you do if you have been doing claims based reporting?  Are we now forced to go through a registry?

Thanks!


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## avon4117 (Jan 11, 2016)

did anyone meet the requirements for 2014? I did so much reporting claim based and we were still penalize


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## themaid174@gmail.com (Jan 14, 2016)

I am still a bit confused... The way I understand it is, if everything is correct (met) you would code 4255F/G9654 and 4559F (all three) is that correct?  If its not met you would use all three codes except you would add the 1P or 8P to 4559F, is that correct?  Now what if the procedure is less then 60 minutes? no code?  If it is over 60 but MAC what do we code?  Thanks to anyone that can answer in understandable terms.


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## dwaldman (Jan 15, 2016)

themaid174@gmail.com 
I don't believe you would code all three codes for the measure to met. I believe  you would report two codes (4255F/4559F or just 4559F alone:  4255F to state it was general or neuraxial anesthesia of 60 minutes or greater and then 4559F to state the 35.5 Celsius or greater was documented. I don't believe monitored anesthesia cases would count towards this measure. Since you provide them the time in minutes, they can identify if the cases was less than 60 minutes and the QS modifier would denote it was MAC or the G9654 for cases of MAC that are 60 minutes or greater would denote to them that this is not part of the measure performance denominator. This is my interpretation of the information they provide in the measure and maybe others have different insight into this. They describe reporting 4559F but they don't specifically describe that you have to report 4255F. 



4255F  
Duration of general or neuraxial anesthesia 60 minutes or longer, as documented in the anesthesia record (CRIT) (Peri2)  

 4559F  
At least 1 body temperature measurement equal to or greater than 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time (Peri2)  

G9654  
Monitored anesthesia care (MAC)


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## themaid174@gmail.com (Jan 15, 2016)

Thank you dwaldman, I am curious to see if anyone else has a thought on this. So the way I understand it (the way you understand it) Performance met 4559F , not met 4559F 1P or 8P.  We report nothing on the cases under 60 minutes. If it is MAC and over 60 minutes, the way I see that on the measure flow chart is 4255F (over 60) plus G9654 (MAC). Anyone else?


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## dwaldman (Jan 19, 2016)

4255F describes general or neuraxial anesthesia. I don't believe it would be used in conjunction to denote over 60 minutes. G9654 does not have a specific time frame associated with this HCPCS code I believe it could represent over 60 minutes of MAC.

4255F  
Duration of general or neuraxial anesthesia 60 minutes or longer, as documented in the anesthesia record (CRIT) (Peri2)  

 G9654 
 Monitored anesthesia care (MAC)


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## mihill (Jan 22, 2016)

So do any of these measures apply for claims based reporting only?

Thank you!!  Very confused on this topic!


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## jkyles@decisionhealth.com (Feb 6, 2016)

mihill said:


> So do any of these measures apply for claims based reporting only?
> 
> Thank you!!  Very confused on this topic!



Everyone should look at their providers' claims data and compare it to the 2016 measures denominators to make sure they are reporting all applicable measures. And don't forget cross-cutting measures. I think some people got tripped up last year because they billed for hospital visits on post-op block checks but didn't report a cross-cutting measure. That's an automatic fail for PQRS. 

In 2016 #76 (CVC) is the last of the claims-based measures traditionally associated with anesthesia, so if your providers are running lines, they should certainly be reporting that one. 

By the way, I've spoken with CMS and they told me that no one is required to move to registry, but in 2016 you MUST do PQRS reporting to avoid the PQRS and the VBM penalties in 2018.


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## awhittaker (Apr 29, 2016)

*Contributor*

I bill for a CRNA who only sees patients in an ASC setting. According to the American Association of Nurse Anesthetist, there are only 7 PQRS measures that would be possibly reportable for anesthesia in this setting. Measures 44, 76, 404, 424, 426, 427, and 430. Out of these seven, only one is eligible to be reported via claims, #76, but this is related to Prevention of CVP catheter infections, which clearly doesn't apply to patients in an ASC setting.   Patients do not come into the ASC the day before for pre-op anesthesia evaluation and clearance, they are seen on the day of surgery, so this leaves 404 - Smoking Abstinence out, because the patient needs to be seen the day before to qualify as a reportable measure.  Same with 427 - Post Anesthetic transfer to ICU, not applicable to an ASC setting   All the remaining 4 measures are reportable by a Registry only.  So CMS may say no one is being forced to go from claims reporting to registry reporting, but I beg to differ! It would appear that my provider is going to forced to pay the added expense to report with a registry to avoid the negative adjustments in the future.  Hardly seems fair.


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