PQRS Measure 76


Lafayette, LA
Best answers
Hello Everyone, I was hoping to get some feedback from those that are filing anesthesia PQRS measures. My co-worker and my self were discussing the filing of the measure (s).
If your group is in ASC that never places CVC's you will not be able to report any of the anesthesia PQRS measures, leaving them to be fined in the future for not reporting. We have no problems in the hospital setting, but it is the smaller "get them in and out" places that prevent us from reporting. How are you all handeling the situation? :confused:

I have always understood measure 76 is only reported when performed. It tracks the percentage of patients who undergo CVC insertion when the provider uses all elements of maximal sterile barrier technique. Requirements dictate that providers use cap, mask, sterile gown, sterile gloves, a large sterile sheet, hand hygiene, and 2 percent chlorhexidine for cutaneous antisepsis.

Thanks in advance!!!!
•Measure #30 Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics

•Measure #193 Perioperative Temperature Management

•Measure #76 Prevention of Catheter-Related Bloodstream Infections


In the above link, the author mentions the above measures for anesthesia and he also mentions if you are only reporting 2 measures that apply

"...in the past, physicians and nurse anesthetists can qualify for the PQRS bonus without reporting on all three measures. If an EP does report on fewer than three measures, however, CMS will use the Measure Applicability Validation (MAV) test to determine whether there are other measures that the EP should have reported. The MAV is a two-part test. First CMS will examine whether other services were clinically related and therefore potentially applicable. “Clinical relation,� for these purposes, has been defined in a set of measure “clusters.� Second, CMS will apply a minimum threshold test to see whether another measure in the cluster was applicable to the EP's practice because s/he had reported it at least once. If the EP reports any measure 15 or more times throughout 2012, it will apply."

appreciate the feed back... though the question still remains what to do when a CVC is not performed. I looked at the article before I posted, my understanding of it was that though you may report just two using "cliusters" the CVC is still apart of both of those.
My understanding after reviewing measure 76 was that it would only be reported if performed. What I took from the article is they might look at why measure 76 is not reported if you are reporting measure 30 for example, but if you don't have any claims submited with the performance of that procedure they can't say that you had instances where you could of reported it.
I agree. The denominator is the CVC code. They will only penalize you if you report a CVC code without also reporting the PQRS measure 6030F. If you don't ever place central catheters you don't have to report on that measure.
Agreed, I have previously asked CMS about this as we have many groups that do not perform CVC insertions. My answer was: "Since measure 30 is in a cluster with measure 76, they will then check to see the number of applicable cases the provider had for hte reporting period for measure 76. If it is less than 15, then the provider will earn the incentive. If it is 15 or more, the provider will not earn the incentive, since they did not report measure 76 also when there were 15 or more cases available to report."

I would say as long as you are reporting the other measure in the cluster correctly you will not be penalized since there were no CVC's done.