MEDAC BILLING & COMPLIANCE ALERT
November 25, 2009

By: Bellinger P. Moody RHIA,CPC, CCP
Executive Vice President of Compliance

New PQRI Measure in 2010 for Anesthesia

As part of the final rule, CMS has approved another quality measure for anesthesia reporting in 2010.  You will be able to report on a third measure:  Perioperative Temperature Management.   Currently there are two reportable measures for anesthesia:  (1) Measure #30 – Administration of prophylactic antibiotics; and (2) Measure #76 – Central Line Sterile Technique measure.
The newly reportable anesthesia measure – Measure #76, Perioperative Temperature Management – will be reported on patients 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 98.6 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.

CMS also placed additional limits on providers’ eligibility to receive incentive payments through PQRI reporting.  These limits were added primarily to urge providers to report on three or more quality measures.  These limits are what Medicare refers to as a Measure Applicability Validation mechanism.  CMS required by statue that the 2010 PQRI will include validation processes.  Under the claims-based reporting method of individual measure(s), the determination of satisfactory reporting, as defined by statute, will itself serve as a general validation because the analysis will assess whether quality-data codes are appropriately submitted in a sufficient proportion of the instances when a reporting opportunity exists.  In addition, for those professionals who satisfactorily submit quality-data codes for fewer than three (3) PQRI measures, a measure-applicability validation process will determine whether they should have submitted quality-data codes for additional measures.

CMS will apply a two-step process to operationalize measure-applicability validation:  (1) a “clinical relation” test, has been proposed and (2) a “minimum threshold” test has been proposed.  Those who fail the validation process will not earn the PQRI incentive payment for 2009.  CMS may determine that it is necessary to modify the measure-applicability validation process after the start of the 2010 reporting period.  However, any changes will probably result in the process being applied more leniently, thereby (1) allowing a greater number of professionals to pass validation and (2) causing no professional who would otherwise have passed to fail.

Prerequisites for Measure-Applicability Validation

Eligible professionals who submit quality-data codes for only one or only two PQRI measures for at least 80 percent of their patients or encounters eligible for each measure – and who do not submit any quality-data codes for any other measure – will be subject to the measure-applicability validation process.  Selection of professionals for measure –applicability validation may be accomplished via a sampling mechanism.

What does all this mean to you as an Anesthesia Provider?

Well, it means that you will have three measures to report on in 2010 and it answers that question that many of you have asked recurrently:  How many measures must I successfully report on in order to qualify for the PQRI incentive bonus payment?  Well, currently, CMS requires that you report on three measures – unless there are less than three measures that apply to your specialty and/or your practice.  As you know, anesthesiologists have only had two reportable measures that apply to anesthesia.  However, in the 2010 Medicare Final Rule, CMS has defined “clusters” of measures that anesthesiologists will have to report in order to earn their PQRI bonuses.  Therefore, if you report Measure #30 you must also report Measure #76; if you report the new Perioperative Temperature Management measure, Measure #193, you must also report measure #76; if you only report Measure #76 and you do not report either Measure #30 or Measure #139 at all, you will still qualify for the PQRI payment – due to the fact that multiple specialties are able to report the central line sterile technique measure (measure #76).  The PQRI bonus payment remain at 2 percent of all Medicare allowed charges.  

There is more to come on the appropriate reporting methodologies for PQRI in 2010.  We will provide additional guidance on PQRI reporting in future alerts.   

The information presented herein reflects general information that is current as of the date it is first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information and any general advice previously published might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.