CMS Measure ID: #404
Collection Type: CQM
Reporting Frequency: Every visit
Outcome: No
High Priority: Yes
NQS Domain: Effective Clinical Care
Measure Age: > 2 years
Instructions
This measure is to be submitted each time an elective surgery, diagnostic, or pain procedure is performed under anesthesia during the performance period. There is no diagnosis associated with this measure. It is anticipated that eligible clinicians who provide the listed anesthesia services as specified in the denominator coding will submit this measure.
Measure Submission Type:
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 for registry submissions; however, these codes may be submitted for those registries that utilize claims data.
Description
The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: No
Capped at 7: No
Decile 0: 0 – 7.63
Decile 1: 7.64 – 30.96
Minimum: 30.97 – 49.99
Decile 3: 50 – 61.66
Decile 4: 61.67 – 69.95
Decile 5: 69.96 – 76.13
Decile 6: 76.14 – 80.32
Decile 7: 80.33 – 86.43
Decile 8: 86.44 – 91.93
Decile 9: 91.94 – 97.05
Decile 10: 97.06 – 100
Denominator
All patients aged 18 years and older who are evaluated in preparation for elective surgical, diagnostic, or pain procedure requiring anesthesia services and identified as a current smoker prior to the day of the surgery or procedure with instruction from anesthesiologist or proxy to abstain from smoking on the day of surgery or procedure
DENOMINATOR NOTE: Preoperative smoking cessation instruction can be performed by an anesthesiologist or proxy, including but not limited to a surgeon, nursing staff, or other preoperative care team member, as part of preoperative evaluation.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
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, 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, 00563, 00566, 00567, 00580, 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00731, 00732, 00750, 00752, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00811, 00812, 00813, 00820, 00830, 00832, 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, 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01937, 01938, 01939, 01940, 01941, 01942, 01951, 01952, 01958, 01960, 01961, 01966, 01991, 01992, 27095, 27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64400, 64405, 64408, 64415, 64416, 64417, 64418, 64420, 64425, 64430, 64435, 64445, 64446, 64447, 64448, 64449, 64450, 64455, 64461, 64463, 64479, 64483, 64486, 64487, 64488, 64489, 64490, 64493, 64505, 64510, 64517, 64520, 64530
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02
AND
Current smoker (e.g. cigarette, cigar, pipe, e-cigarette or marijuana): G9642
AND
Elective surgery: G9643
AND
Received instruction from the anesthesiologist or proxy prior to the day of surgery to abstain from smoking on the day of surgery: G9497
Numerator
Patients who abstained from smoking prior to anesthesia on the day of surgery or procedure
Definition:
Abstinence – Defined by either patient self-report or an exhaled carbon monoxide level of < 10 ppm.
Numerator Options:
Performance Met:
Patients who abstained from smoking prior to anesthesia on the day of surgery or procedure (G9644)
OR
Performance Not Met:
Patients who did not abstain from smoking prior to anesthesia on the day of surgery or procedure (G9645)