MIPS/PQRS Anesthesia Measures:  Part I – Perioperative Temperature Management

Published on May 23, 2017

Over the past several years, we have found that certain measures which apply to anesthesia can be confusing and misleading to providers.  To simplify the process, most billing companies develop PQRS forms (similar to superbills) for providers to mark.  The measures most commonly documented/marked in error are:

#424 Perioperative Temperature Management. 

#404 Anesthesiology Smoking Abstinence

#430 Prevention of Post-Operative Nausea and Vomiting

#426 & #427 Post-Anesthetic Transfer of Care to PACU or ICU

Perioperative temperature management is very frequently documented incorrectly on PQRS forms by providers.  However, knowing a few key pieces of information will help you determine the correct way to document these.  There are denominators (common factors) that include or exclude the patient in the population, these include: anesthesia time and anesthesia type, and there are numerators (the condition that is to be met) in this case body temperature at or above 35.5C/95.9F recorded during the 30 minutes before or 15 immediately following anesthesia end time.

Anesthesia Time: It is important to remember that the time used in reporting this measure is the anesthesia time, not the procedure time.

If the anesthesia time is less than 60 minutes the measure does not apply, regardless of anesthesia type.  Stop here, there is nothing more to do.

If the anesthesia time is 60 minutes or more the measure must be reported, regardless of anesthesia type.  If the procedure is 60 minutes or over, then you should continue to anesthesia type. 

Time that is 60 minutes or over is reported with code 4255F.

Anesthesia Type:  If the anesthesia time is 60 minutes or over (4255F), the anesthesia type should be considered in order to report the correct code.

If the anesthesia type is MAC the measure does not apply, but still must be reported with codes G9654 and 4255F.

If the anesthesia type is a PNB (peripheral nerve block) the measure does not apply, but still must be reported with codes G9770 and 4255F.

If the anesthesia type is general or neuraxial the measure applies and must be reported with 4255F AND one of the following codes:

G9771 temperature at or above 35.5C/95.9F recorded.

G9772 temperature at or above 35.5C/95.9F not recorded due to medical reason.

G9773 temperature at or above 35.5C/95.9F not recorded due to unspecified reason.

Documentation requirements:The anesthesia time and type must be clearly indicated on the anesthesia graphic record or in the EMR.  The patient’s temperature must be clearly documented on the anesthesia graphic record or in the EMR within 30 minutes before or 15 minutes immediately following anesthesia end time.

*If the anesthesia time, type and body temperature are documented clearly and correctly in the patient’s medical record, skilled coding staff can abstract the information and report it accurately.

 

By: Heather E. Golfos, CPC, CANPC Coding Department Manager