2023 # 424 Perioperative Temperature Management

CMS Measure ID: #424

Collection Type: CQM, MVP

Reporting Frequency: Every visit

Outcome: Yes

High Priority: Yes

NQS Domain: Patient Safety

Measure Age: > 2 years

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 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

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

2022 Benchmarks (from 2020 CMS data)

Registry

Topped out: Yes
Capped at 7: No

Minimum: 0 – 98.39
Decile 3: 98.4 – 99.55
Decile 4: 99.56 – 99.88
Decile 5: 99.89 – 99.96
Decile 6: 99.97 – 99.99
Decile 10: 100 – 100

Denominator

All patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer

Denominator Instructions:
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, 01937, 01938, 01939, 01940, 01941, 01942, 01951, 01952, 01961, 01962, 01963, 01965, 01966

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02

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

Denominator Exception:

Documentation of one of the following 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 30 minutes immediately before or the 15 minutes immediately after anesthesia end time (e.g., Emergency cases, Intentional hypothermia, etc.) (G9772)

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)


Tags

CQM-2023, CQM-MVP-2023, MVP-2023