By Lee Broadston, President & CEO, BCS Incorporated, Waconia, Minn.
Member of the AANA Anesthesia Payment Advisory Panel
At the request and involvement of AANA, an act of Congress enacted late 2006 ensures that the Medicare agency includes Certified Registered Nurse Anesthetists in Centers for Medicare & Medicaid Services (CMS) quality reporting systems. As you may already be aware, CRNAs have been included in the quality reporting measurement incentive program offered by Medicare/CMS entitled “Physician Quality Reporting Initiative,” or PQRI. PQRI has established various quality measurements within many aspects of the delivery of healthcare services and asks that CRNAs consider reporting to achieve the one quality measurement that is related to anesthesia administration at this time.
The quality measurement outlined by PQRI for anesthesia is the administration of, as well as the documentation of, the administration of antibiotics administered within 60 minutes prior to surgical start time, or the decision not to administer antibiotics within 60 minutes of surgical cut time. Or, in the cases of fluoroquinolone or vancomycin administration within 120 minutes (2 hours) prior to surgical start time. CPT Surgical procedures codes that are eligible for this measurement reporting have been identified by CMS and are referred to as the Denominator Code. A listing of all eligible Denominator codes can be found in the attached document from the Medicare agency. There will be situations where this measurement is ordered by the surgeon and administered to the patient by someone other than yourself or a member of your anesthesia group. There may also be instances where CRNAs working in the anesthesiologist medically directed practice environment might have anesthesia professionals who are not a member of your group administering these antibiotics.
Throughout this process Medicare would like anesthesia professionals to report those antibiotics that a member of your group actually orders and/or administers, or those cases when a member of your group makes the decision NOT to administer antibiotics prior to surgical start time.
This is case-specific performance data and therefore CRNAs will have to note these occurrences on the anesthesia patient record in order for the CRNAs’ billing department or agency to pick up the data and consequently report it to Medicare. In turn for reporting this data, Medicare, through the PQRI program, will pay 1.5% of the Medicare allowable fee for the case in which PQRI data is reported in a lump sum payment during the first quarter of 2008. There is a cap on the total incentive payments that CRNAs or their groups will be allowed to receive; however, that cap has not yet been posted by Medicare.
It is highly recommended that CRNAs take the necessary steps to report this information to CMS since non-participation will be obvious in the Medicare system if the data is not reported. In the near future, likely as soon as early 2008, measurements similar to these will be expanded and may eventually play a critical role in the overall Medicare reimbursement that CRNAs and their groups receive in the future. CRNAs can begin reporting these events to CMS at any time, since the agency’s testing period has already begun. The actual performance measurement period however, will commence with dates of service July 1, 2007 through December 31, 2007. 2008 PQRI program measurements are currently being discussed amongst the many healthcare professional associations and it is anticipated that, at minimum, this practice measurement will continue to include the participation of CRNAs and will continue into the 2008 PQRI program's reporting period.
As noted above, there are certain CPT surgical procedure codes that CMS has identified as "Denominator" codes. This is simply a listing of those surgical procedures CMS acknowledges customarily involve the pre-operative administration of antibiotics. The attached files from CMS include a listing of these eligible surgical codes/procedures.
Therefore, the appropriate and eligible CPT surgical procedure code -- referred to by CMS as the Denominator Code -- and the CPT Level II code established for this measurement must appear as additional charge lines within the anesthesia claim data, whether they are electronic or on a CMS 1500 claim form. They will be submitted with a charge of $0.00. Medicare's system will read this information and record the information as a reported PQRI measurement for the provider number/NPI and tax identification number contained within the claim data. Essentially each Medicare claim that contains PQRI reporting data will have at minimum a total of three charge lines. The first line is for the actual anesthesia services billed utilizing the correct CPT Anesthesia Code, the second line is for the CPT Surgical Code with $0.00 (CMS has indicated that $0.01 will be acceptable in the case where patient accounting systems will not allow a charge line within the claim data with a zero charge), and lastly the CPT Level II code noted below. The following are the CPT level II codes -testing and production- that would be used to report the administration of the pre-operative antibiotic within 60 minutes of surgical cut time.
For live claims use the following:
For testing claims use the following:
The remaining claim data for each charge line that is submitted for the PQRI data, namely the date of service, the type of service, the place of service, and diagnosis indicator, and National Provider Identifier (NPI) number will be the same as the actual anesthesia administration charge line. The units/frequency information for these PQRI reporting lines should be zero. There are no modifiers used on these two reporting lines, such as anesthesia HCPCs modifiers QX, QY, or QS, or any PQRI modifiers.
If the CRNA is the individual responsible for the decision to withhold the administration of the antibiotic -vs. the surgeon- then the CRNA may use the following CPT level II code with the appropriate PQRI modifier. It is imperative to note that it must be the decision of the provider reporting this CPT level II code to withhold administration of the antibiotic not just the act of withholding. In most instances this decision will NOT be made by the CRNA.
To report withholding the administration of the antibiotic use the following code along with the appropriate PQRI reason code modifier. 4047F must be used with a PQRI modifier 1P not administered due to medical reasoning OR 8P antibiotic not ordered within 60 minutes of surgical time for reasons not otherwise specified.
You will need to work with your information system staff and your business office or billing office staff to make certain you establish a procedure to convey this information to the correct internal staff members so that this information is properly reported to CMS on your behalf for each occurrence.
At this time here is a listing of the antimicrobial drugs that are considered prophylactic antibiotics for the purpose of this measurement:
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Ampicillin/sulbactam
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Aztreonam
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Cefazolin
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Cefotetan
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Cefoxitin
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Cefuroxime
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Ciprofloxacin
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Clindamycin
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Erythromycin base
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Gatifloxacin
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Gentamicin
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Levofloxacin
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Metronidazole
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Moxifloxacin
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Neomycin
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Vancomycin
It is strongly suggested that you take the time to read over the attached documentation from CMS discussing PQRI and the reporting requirements in detail. Extensive additional information is also available at the
PQRI CMS
website.