MEASURE 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 achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time
NQS DOMAIN/MEANINGFUL MEASURE AREA:
Patient Safety/Preventable Healthcare Harm
MEASURE TYPE:
Outcome
HIGH PRIORITY STATUS:
Yes
INSTRUCTIONS:
This measure is to be submitted each time any procedure including surgical, therapeutic or diagnostic is performed under general or neuraxial anesthesia during the performance period. There is no diagnosis associated with this measure. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who provide the listed anesthesia services as specified in the denominator coding will submit this measure.
MEASURE SUBMISSION TYPE:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
DENOMINATOR:
All patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer
Denominator Note: 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 procedure during the performance 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, 00731, 00732, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00811, 00812, 00813, 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, 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, 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
Denominator Exclusions: Monitored Anesthesia Care (MAC): G9654
OR
Peripheral Nerve Block (PNB): G9770
NUMERATOR:
Patients for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved 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) achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time (G9771)
OR
Performance Not Met: At least 1 body temperature measurement equal to or greater than 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) not achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time, Reason Not Given (G9773)
OR
Denominator Exception: Documentation of 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) within the 30minutes immediately before or the 15 minutes immediately after anesthesia end time (e.g., Emergency cases, Intentional hypothermia, etc.) (G9772)
RELEVANT FIELDS:
- Date of procedure
- Date of birth
- ASA CPT code
- Total anesthesia time
- Primary anesthesia used
- Postop patient temperature
RATIONALE:
A drop in core temperature during surgery, known as 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.
REPORTING CODES: