What is MIPS or PQRS Measure?

The Physician Quality Reporting System (PQRS) was a reporting program of the Centers for Medicare and Medicaid Services (CMS). It gave eligible professionals (EPs) the opportunity to assess the quality of care they were providing to their patients, helping to ensure that patients get the right care at the right time. Now it is called as Merit-based Incentive Payment System (MIPS) Quality Measures. Today we will learn about coding Measures (Measure 076, Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections).

The Merit-based Incentive Payment System (MIPS) track of Medicare’s Quality Payment Program (QPP) includes four performance categories: quality, cost, improvement activities, and promoting interoperability (PI). The quality performance category requires clinicians to report on six measures, including at least one outcome measure. Since most family physicians will participate in MIPS and therefore are required to report quality measures, it is important they select measures appropriate for their practice needs and capabilities.

Measure specifications are detailed descriptions and instructions for each measure, and include definitions of the action/outcome required (numerator), population being measured (denominator), exceptions/exclusions to the measure, measure codes, and other details needed to correctly collect data and report the measure. Their are different Measures like Measure 076, 014, 021, 145, 146, 225 etc, which has to be coded only to specific CPT codes. We will learn specifically for each measure in detail. 

Remember: These Measures should be used only with Medicare Payer Encounters.

MIPS/PQRS Measure #076 Description

Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

This measure is to be submitted each time a CVC insertion is performed during the performance period. There is no diagnosis associated with this measure. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who perform CVC insertion will submit this measure.

Eligible Criteria for Measure 076:

All patients, regardless of age, who undergo CVC insertion

Patient procedure during the performance period (CPT): 36555, 36556, 36557, 36558, 36560, 36561, 36563, 36565, 36566, 36568, 36569, 36570, 36571, 36572, 36573, 36578, 36580, 36581, 36582, 36583, 36584, 36585, 93503

Patients for whom central venous catheter (CVC) was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

Maximal Sterile Barrier Technique – includes all of the following elements: Cap AND mask AND sterile gown AND sterile gloves AND sterile full body drape.

Sterile Ultrasound Techniques – require sterile gel and sterile probe covers.

Hand Hygiene—Washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR)

All elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed (6030F)

Documentation of medical reason(s) for not following all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques during CVC insertion (including increased risk of harm to patient if adherence to aseptic technique would cause delay in CVC insertion) (6030F with 1P)

All elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques not followed, reason not otherwise specified (6030F with 8P)