Measure Description
Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively
Instructions
This measure is to be submitted each time any procedure including surgical, therapeutic or diagnostic under an inhalational general anesthetic 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 provide the listed anesthesia services as specified in the denominator coding will submit this measure.
Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. 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 by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
Denominator
All patients, aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for POV
Definition:
Risk factors for POV -
- Surgery ≥ 30 minutes
- Age ≥ 3 years
- Strabismus surgery
- History of POV or Post-Operative Nausea and Vomiting (PONV) in patient, parent or sibling
Denominator Criteria (Eligible Cases):
Patients aged 3 through 17 years on date of service
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, 00562, 00563, 00566, 00567 00580, 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, 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, 01935, 01936, 01951, 01952, 01958, 01960, 01961, 01962, 01963, 01965, 01966, 01991, 01992
AND
Patient received inhalational anesthetic agent: 4554F
AND
Patient exhibits 2 or more risk factors for post-operative vomiting: G9954
AND NOT
DENOMINATOR EXCLUSION:
Cases in which an inhalational anesthetic is used only for induction: G9955
Numerator
Patients who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively
Definition:
Anti-emetics Therapy - The recommended pharmacologic anti-emetics for POV prophylaxis in pediatric patients at risk of POV include (but may not be limited to):
- 5-hydroxytryptamine (5-HT3) receptor antagonists (recommended as the first choice for prophylaxis for POV in children)
- Dexamethasone
- Antihistamines
- Butyrophenones
Definition Note: The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert information when prescribing medications.
Numerator Instructions:
Denominator exceptions should be determined or confirmed at the date of the denominator eligible procedure.
Numerator Options:
Performance Met: Patient received combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively (G9956)
Denominator Exception: Documentation of medical reason for not receiving combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively (e.g., intolerance or other medical reason) (G9957)
OR
Performance Not Met: Patient did not receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively (G9958)
Rationale
Postoperative nausea and vomiting (PONV) is an important patient-centered outcome of anesthesia care. PONV is highly dis-satisfying to patients, although rarely life-threatening. A large body of scientific literature has defined risk factors for PONV and has demonstrated effective prophylactic regimes based on these risk factors, and demonstrated high variability in this outcome across individual centers and providers. Between 62-73% of children experience POV when prophylactic anti-emetics are not administered. Beyond the discomfort associated with the condition, POV is a comorbidity which can cause significant postoperative complications, including dehydration and postoperative bleeding. In several studies, incidence of POV decreased significantly in children receiving combination therapy compared to control groups not receiving combination therapy for POV. Further, a number of papers have shown that performance can be assessed at the level of individual providers -- the outcome is common enough that sufficient power exists to assess variability and improvement at this level. A separate measure is needed for pediatric patients because the risk factors and recommended prophylaxis are different from adults.
Clinical Recommendation Statements
Consensus Guidelines for the Management of Postoperative Nausea and Vomiting; Society for Ambulatory Anesthesia (SAMBA), 2013:
Administer prophylactic antiemetic therapy to children at increased risk for POV; as in adults, use of combination therapy is most effective.
All prophylaxis in children at moderate or high risk for POV should include combination therapy using a 5-HT3 antagonist and a second drug. Because the effects of interventions from different drug classes are additive, combining interventions has an additive effect in risk reduction.