* Measure #30: Perioperative Care: Timing of Prophylactic Antibiotics – Administering Physician

2009 PQRI REPORTING OPTIONS: CLAIMS-BASED, REGISTRY

DESCRIPTION:

Percentage of surgical patients aged 18 years and older who have an order for a parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) for whom administration of prophylactic antibiotic has been initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required)

INSTRUCTIONS:

This measure is to be reported each time an anesthesia service in the denominator is provided for surgical patients during the reporting period. There is no diagnosis associated with this measure. It is anticipated that clinicians who provide anesthesia services, as specified in the denominator coding, will submit this measure – reporting on the timeliness of antibiotic administration. The clinician providing anesthesia services does not need to be the clinician who ordered the prophylactic antibiotic.

If the clinician providing anesthesia services orders AND administers the prophylactic antibiotic within the appropriate timeframe, report quality-data code CPT II 4048F. Report CPT II 4048F with the 1P modifier in circumstances where the prophylactic antibiotic was not given for medical reasons (eg, contraindicated, patient already receiving antibiotics).

Measure Reporting via Claims:

CPT codes and patient demographics are used to identify patients who are included in the measure's denominator. CPT Category II codes are used to report the numerator of the measure.

When reporting the measure via claims, submit the appropriate CPT Category II code OR the appropriate CPT Category II code with the modifier on the same claim containing the anesthesia codes listed in the denominator. The modifiers allowed for this measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM as the denominator codes.

NUMERATOR:

Surgical patients with an order for a prophylactic antibiotic for whom administration of the prophylactic antibiotic has been initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required)

Numerator Instructions: This measure seeks to identify the timely administration of prophylactic antibiotic. This administration should begin within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision.

Numerator Quality-Data Coding Options for Reporting Satisfactorily:

The antimicrobial drugs listed below are considered prophylactic antibiotics for the purposes of this measure.

  • Ampicillin/sulbactam
  • Aztreonam
  • Cefazolin
  • Cefmetazole
  • Cefotetan
  • Cefoxitin
  • Cefuroxime
  • Ciprofloxacin
  • Clindamycin
  • Ertapenem
  • Erythromycin base
  • Gatifloxacin
  • Gentamicin
  • Levofloxacin
  • Metronidazole
  • Moxifloxacin
  • Neomycin
  • Vancomycin

NUMERATOR NOTE: Includes instances where the clinician providing anesthesia services orders AND administers the prophylactic antibiotic within the appropriate timeframe, report quality-data code CPT II 4048F.

Documentation that Prophylactic Antibiotic was Given Within Specified Timeframe CPT II 4048F: Documentation that prophylactic antibiotic was given within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required)

OR

Prophylactic Antibiotic not Given for Medical Reasons (eg, contraindicated, patient already receiving antibiotics)

Append a modifier (1P) to CPT Category II code 4048F to report documented circumstances that appropriately exclude patients from the denominator.

4048F with 1P: Documentation of medical reason(s) for not giving antibiotics within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required)

OR

If patient is not eligible for this measure because prophylactic antibiotic not ordered, report:

Prophylactic Antibiotic not Ordered

Append a reporting modifier (8P) to CPT Category II code 4047F to report circumstances when the patient is not eligible for the measure.

4047F with 8P: No documentation of order for prophylactic antibiotics to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required)

OR

Prophylactic Antibiotic Ordered but not Given Within One Hour, Reason not Specified

Append a reporting modifier (8P) to CPT Category II code 4048F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

4048F with 8P: Prophylactic antibiotic was not given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required), reason not otherwise specified

DENOMINATOR:

All patients aged 18 years and older who require anesthesia services where a prophylactic antibiotic is commonly indicated for associated surgical procedures.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Patient encounter during the reporting period (CPT): Anesthesia codes for which prophylactic antibiotics are commonly indicated for associated surgical procedure(s): 00100, 00102, 00103, 00120, 00140, 00145, 00147, 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, 00450, 00452, 00454, 00470, 00472, 00474, 00500, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00600, 00604, 00620, 00622, 00625, 00626, 00630, 00632, 00634, 00670, 00700, 00730, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00820, 00830, 00832, 00840, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 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, 01120, 01140, 01150, 01170, 01173, 01180, 01190, 01202, 01210, 01212, 01214, 01215, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01360, 01382, 01392, 01400, 01402, 01404, 01430, 01432, 01440, 01442, 01444, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01500, 01502, 01520, 01522, 01610, 01622, 01630, 01632, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01710, 01712, 01714, 01716, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01924, 01925, 01926, 01951, 01952, 01953, 01961, 01962, 01963, 01965, 01966, 01968, 01969

RATIONALE:

The appropriate timing of administration of prophylactic antibiotics has been demonstrated to reduce the incidence of surgical wound infections. Available evidence suggests that although most surgical patients receive a prophylactic antibiotic, many do not receive the drug within one hour before incision as recommended.

CLINICAL RECOMMENDATION STATEMENTS:

The anti-infective drug should ideally be given within 30 minutes to 1 hour before the initial incision to ensure its presence in an adequate concentration in the targeted tissues. For most procedures, scheduling administration at the time of induction of anesthesia ensures adequate concentrations during the period of potential contamination. Exceptions: cesarean procedures (after cross clamping of the umbilical cord); colonic procedures (starting 19 hours before the scheduled time of surgery). (ASHP)

Infusion of the first antimicrobial dose should begin within 60 minutes before incision. However, when a fluoroquinolone or vancomycin is indicated, the infusion should begin within 120 minutes before incision to prevent antibiotic-associated reactions. Although research has demonstrated that administration of the antimicrobial at the time of anesthesia induction is safe and results in adequate serum and tissue drug levels at the time of incision, there was no consensus that the infusion must be completed before incision. (SIPGWW)