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CMS Approves AQI’s National Anesthesia Clinical Outcomes Registry for MIPS Participation

A list of approved qualified clinical data registries (QCDRs) was finally released in late May, five months into the first reporting period for the Centers for Medicare and Medicaid Services’ (CMS) Merit-based Incentive Payment System (MIPS). Among the list of approved QCDRs was the Anesthesia Quality Institute’s (AQI) National Anesthesia Clinical Outcomes Registry (NACOR). CMS had already approved NACOR as a qualified registry earlier in the year.

NACOR was approved for two of the three MIPS categories for the 2017 reporting year: Improvement Activities and Quality. Because most anesthesiologists are “hospital-based” and “non-patient-facing,” the Advancing Care Information category, which in effect replaced CMS’s EHR Meaningful Use program, will not apply. AQI also is available for both individual and group reporting.

In submitting their QCDR for approval by CMS, AQI said they are providing “participating providers with custom continuous performance monitors; performance gap analysis, outlier identification, and peer-to-peer benchmarks.” Using NACOR for the 2017 reporting year is a “complimentary benefit” provided at no additional charge to ASA members. Non-member physician anesthesiologists and independent nurse anesthetists will be charged a $150 quality reporting fee plus registry participation fees. However, remember that QCDRs are just one method for reporting MIPS measures. Other reporting mechanisms include claims, qualified registries, EHR, and web interface.

NACOR supports the following MIPS quality measures, which also are included as part of the MIPS Anesthesia specialty care set:

  • Q044 – Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
  • Q076 – Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections
  • Q130 – Documentation of Current Medications in the Medical Record
  • Q317 – Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
  • Q404 – Anesthesiology Smoking Abstinence
  • Q424 – Perioperative Temperature Management
  • Q426 – Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)
  • Q427 – Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)
  • Q430 – Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy

A few other MIPS quality measures, which are not part of the Anesthesia specialty care set, are supported by NACOR:

  • Q039 – Screening for Osteoporosis for Women Aged 65-85 Years of Age
  • Q046 – Medication Reconciliation Post-Discharge
  • Q047 – Care Plan
  • Q109 – Osteoarthritis (OA): Function and Pain Assessment
  • Q110 – Preventive Care and Screening: Influenza Immunization
  • Q111 – Pneumococcal Vaccination Status for Older Adults
  • Q128 – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
  • Q131 – Pain Assessment and Follow-Up
  • Q134 – Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
  • Q145 – Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy
  • Q154 – Falls: Risk Assessment
  • Q155 – Falls: Plan of Care
  • Q181 – Elder Maltreatment Screen and Follow-Up Plan
  • Q226 – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
  • Q238 – Use of High-Risk Medications in the Elderly
  • Q276 – Sleep Apnea: Assessment of Sleep Symptoms
  • Q342 – Pain Brought Under Control Within 48 Hours
  • Q402 – Tobacco Use and Help with Quitting Among Adolescents
  • Q408 – Opioid Therapy Follow-up Evaluation
  • Q412 – Documentation of Signed Opioid Treatment Agreement
  • Q414 – Evaluation or Interview for Risk of Opioid Misuse
  • Q435 – Quality of Life Assessment For Patients With Primary Headache Disorders

Among the many benefits of reporting MIPS via a QCDR are the additional quality measures each QCDR supports that are not included in the MIPS quality measure set. These measures are developed by the QCDR and approved by CMS for inclusion in the program. Many specialty-specific QCDRs, like NACOR, believe their non-MIPS measures provide more meaningful information for members of their specialty than the standard MIPS measures do. Also, unlike other reporting options, QCDRs collect data on all patients, not just Medicare patients, which also makes the data more meaningful to providers.

For 2017, NACOR supports the following non-MIPS measures:

  • Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite
  • Anesthesia: Patient Experience Survey
  • Application of Lung-Protective Ventilation during General Anesthesia
  • Assessment of Patients for Obstructive Sleep Apnea
  • Coronary Artery Bypass Graft (CABG): Post-Operative Renal Failure – Inverse Measure
  • Coronary Artery Bypass Graft (CABG): Prolonged Intubation – Inverse Measure
  • Coronary Artery Bypass Graft (CABG): Stroke – Inverse Measure
  • New Corneal Injury Not Diagnosed in the Postanesthesia Care Unit/Recovery Area after Anesthesia Care
  • Perioperative Cardiac Arrest – Inverse Measure
  • Perioperative Mortality Rate
  • Postanesthesia Care Unit (PACU) Reintubation Rate – Inverse Measure
  • Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)
  • Procedural Safety for Central Line Placement
  • Surgical Safety Checklist – Applicable Safety Checks Completed Before Induction of Anesthesia
  • Treatment of Hyperglycemia with Insulin

For more information about the various QCDRs approved by CMS for 2017, including others that support Anesthesia measures, review the recently released Merit-Based Incentive Payment System (MIPS): 2017 CMS-Approved Qualified Clinical Data Registries (QCDRs) from the Quality Payment Program (QPP) website. Also, learn more about NACOR at AQI’s website.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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