MIPS Clinical Quality Measures (CQMS)
MEASURE TYPE: Process – High Priority
Description
Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain management.
Instructions
This measure is to be reported each time a patient undergoes a selected surgical procedure during the reporting period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible anesthesia providers and clinicians who provide denominator-eligible services 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
Patients, aged 18 years and older, who undergo selected surgical procedures
DENOMINATOR NOTE: Selected surgical procedures include both elective and urgent open and laparoscopic intraabdominal, spinal, pelvic, thoracic, breast, joint, head, neck, orthopedic and fracture repair surgeries.
Denominator Criteria (Eligible Cases):
Patients aged 18 years and older on date of encounter
AND
Patient procedures during reporting period (CPT): 00102, 00120, 00160, 00162, 00172, 00174, 00190, 00222, 00300, 00320, 00402, 00404, 00406, 00450, 00470, 00472, 00500, 00528, 00529, 00539, 00540, 00541, 00542, 00546, 00548, 00600, 00620, 00625, 00626, 00630, 00670, 00700, 00730, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00797, 00800, 00820, 00830, 00832, 00840, 00844, 00846, 00848, 00860, 00862, 00864, 00865, 00866, 00870, 00872, 00873, 00880, 00902, 00906, 00910, 00912, 00914, 00916, 00918, 00920, 00940, 00942, 00948, 01120, 01160, 01170, 01173, 01210, 01214, 01215, 01220, 01230, 01360, 01392, 01400, 01402, 01480, 01482, 01484, 01486, 01630, 01634, 01636, 01638, 01740, 01742, 01744, 01760, 01830, 01832, 01961
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10
AND NOT
Denominator Exclusion:
Emergent cases: M1142
Numerator
Patients for whom multimodal pain management is administered in the perioperative period from 6 hours prior to anesthesia start time until discharged from the post-anesthesia care unit
Definition:
Multimodal pain management is defined as the use of two or more drugs and/or interventions, NOT including systemic opioids, that act by different mechanisms for providing analgesia. These drugs and/or interventions can be administered via the same route or by different routes. Opioids may be administered for pain relief when indicated but will not count toward this measure.
NUMERATOR NOTE: Documentation of qualifying medications or interventions provided from six hours prior to anesthesia start time through post-anesthesia care unit discharge count toward meeting the numerator.
Numerator Options:
Performance Met: Multimodal pain management was used (G2148)
OR
Denominator Exception: Documentation of medical reason(s) for not using multimodal pain management (e.g., allergy to multiple classes of analgesics, intubated patient, hepatic failure, patient reports no pain during PACU stay, other medical reason(s)) (G2149)
OR
Performance Not Met: Multimodal pain management was not used (G2150)
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