Documentation Requirements for MIPS 404: Anesthesiology Smoking Abstinence and Best Practices

As with all quality measures, groups are only allowed to report on measures where all the data elements of the denominator are completed and documented, and where a clinical quality action or outcome (numerator) is completed and documented. For MIPS 404: Anesthesiology Smoking Abstinence, the elements of the denominator that must be captured and documented are:

  • Current smoker (e.g. cigarette, cigar, pipe, e-cigarette, or marijuana)
  • Elective surgery with appropriate CPT Code
  • Patient received the instruction from an anesthesiologist or proxy prior to the day of surgery to abstain from smoking on the day of surgery.

For MIPS 404: Anesthesiology Smoking Abstinence, the group or individual reporting the clinical action (numerator) that the patient smoked or did not smoke on the day of surgery must also have documentation that the patient is a smoker and was counseled on the day before surgery. Such documentation must be held by the group or individual for auditing purposes. If the group cannot ascertain or document that the patient is a smoker and was not counseled prior to the day of surgery, the group or individual should not report the measure. Scenarios where reporting the measure would not be appropriate:

  • Recording that a non-smoker did not smoke on the day of surgery.
  • Recording that a person did not smoke on the day of surgery without knowing if the patient was counseled to abstain from smoking prior to the day of surgery.
  • If the counseling occurs but is not captured or documented by the group reporting the measure.
  • If the counseling occurs by the surgeon, preoperative surgical staff or other entity where the anesthesia group does not have access to or cannot confirm that counseling has taken place.
  • Having a policy that all patients are counseled prior to surgery but not documenting that counseling occurred on each case that is reported.

As you prepare your data submission for the 2020 performance period, AQI recommends reviewing the measures you are submitting and how you are capturing and documenting both the denominator and the numerator for each measure. Please contact AQI at for further questions on this measure.

It's never too early to send quality data to NACOR

NACOR Quality reporting deadlines for the 2020 performance year are approaching quickly. Practices are encouraged to start sending quality data to AQI before the deadline to allow time for review and to submit corrected files if any errors are identified.

The 2020 data completeness requirements for those reporting MIPS are six measures, including one outcome measure, for 70 percent of the eligible cases over a 12-month period (1/1/20 - 12/31/20). Quality data from January through November 2020 must be submitted by January 29, 2021. The deadline to submit all 2020 data is February 15, 2021.

New Internal Improvement Measure: Intraoperative Hypotension measure (IIM025)

Approved by the Anesthesia Quality Institute (AQI) as an internal improvement measure, the Intraoperative Hypotension (IOH) quality measure supports an increasing desire for objective quality measurement and reporting with no provider documentation burden.

ePreop and the Cleveland Clinic are co-stewarding the IOH quality measure to encourage qualified anesthesia providers to maintain an intraoperative mean arterial pressure above 65 mmHg to reduce the risk of adverse outcomes such as acute kidney injury and myocardial injury.

Clinicians reporting quality data through NACOR's Quality Concierge® can participate in the IOH measure without burden. Sign up today.

Benefits beyond MIPS

Practices and physician anesthesiologists submitting data to AQI's NACOR are finding they can use the data for business development, hospital performance goals and managed care contracts. They are also becoming more efficient in local quality improvement processes too.

NACOR Benchmarking allows practices to report their billing and administrative data, as well as continue to report quality measures (MIPS and QCDR) without submitting to CMS. Submitting data will help build consistent, year-over-year quality and outcomes data that will help you:

  • Negotiate contracts with hospitals
  • Report quality data to private insurers to negotiate fee increases
  • Benchmark performance against 15,000 participants
  • Provide support for mergers, sales and acquisitions

For more information, email

2020 Resources

NACOR News Library

Read past issues of AQI's NACOR News.

Office Hours FAQs

Question: Which NACOR reporting option(s) include national benchmarks?

NACOR Benchmarking, NACOR Quality Reporting and Quality Concierge all include national benchmarks. NACOR Basic is benchmarking at the local level only.

Question: Where do we apply for a HARP account?

HARP accounts can be obtained through the CMS enterprise portal. Visit the New User Application, then select PQRS: Physician Quality Reporting System when asked to choose your application. HARP accounts are required to review your practice's final MIPS scores.

Question: Is it possible for all providers in a practice to be non-MIPS eligible and not required to submit data as individuals, but are eligible as a group?

Yes if the individual providers do not meet the MIPS participation criteria (billed $90,000 or less in Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare secondary Payer) and have 200 or fewer Medicare Part B FFS beneficiaries) the practice can be MIPS eligible as a group if the group has billed $90,000 or more in PFS services furnished to Medicare Part B beneficiaries and have 200 or more Medicare Part B beneficiaries.