ePreop 31 · Intraoperative Hypotension (IOH) among Non-Emergent Noncardiac Surgical Cases

Steward: Provation Anesthesia Quality Registry (AQR QCDR) / Cleveland Clinic | First Performance Year: 2020 2026 Status: Approved by CMS for the 2026 MIPS performance period. Available in the Anesthesia MVP.

MEASURE DESCRIPTION

Percentage of general, neuraxial, or regional anesthesia care cases in which the mean arterial pressure (MAP) fell below 65 mmHg for a cumulative total of 15 minutes or more.

MEASURE TYPE: Intermediate Outcome HIGH PRIORITY STATUS: Yes | HIGH PRIORITY TYPE: Outcome INVERSE MEASURE: Yes. A lower score indicates better quality. Note that providers are not expected to receive a score of zero, because some patients will have a MAP below 65 for reasons outside a provider's control. RISK ADJUSTED: Yes. The 1st performance rate is risk-adjusted. PROPORTIONAL MEASURE: No. This is a ratio measure that scores greater than or equal to zero. NUMBER OF PERFORMANCE RATES: 1 CARE SETTING: Hospital, Ambulatory Surgical Center, Hospital Inpatient, Hospital Outpatient TELEHEALTH: No DATA SOURCE: Administrative claims data, claims, EHR (AIMS, patient record) REPORTING OPTIONS: MVP and Traditional MIPS CBE NUMBER: Not applicable | eCQM: Not applicable

2026 BENCHMARK

No historical benchmark. CMS may establish a performance-period benchmark using 2026 submissions. This is not a new measure, so new-measure floors do not apply; other CMS rules, including small-practice exceptions, may affect scoring.

Practical implication: ePreop 31 requires appropriate electronic data capture. Consider its clinical usefulness and reporting requirements without assuming that the missing historical benchmark determines the final score.

ELIGIBILITY CONSTRAINT, READ THIS FIRST

Denominator-eligible cases must be sent from an electronic reporting facility to qualify. Reporting clinicians who track information manually are not eligible to report this measure. This is a hard gate. A group without an AIMS or equivalent electronic vitals capture cannot report ePreop 31.

INSTRUCTIONS

This measure evaluates the proportion of cases in which the patient's MAP is below 65 mmHg for 15 minutes or more, cumulatively over the course of surgery. The numerator condition is met when MAP is below 65 mmHg for one continuous period lasting 15 minutes or more, or when the patient has several discrete periods below 65 mmHg that collectively sum to 15 minutes or more.

This measure is not intended to substitute for clinical judgment about managing intraoperative hypotension for any given patient. For some patients the clinician may manage blood pressure using a higher or lower target MAP, for example a higher target in patients with chronic hypertension.

Data capture rules: - MAP data may be transmitted directly from the monitor to the AIMS or entered manually into an AIMS or other electronic data capture system. If a record includes both monitor-pulled and manually recorded vitals with the same timestamp, only the monitor values are used. - The first blood pressure reading defines the measure start time (anesthesia start). The measure end time is anesthesia end time. - A given reading is attributed to the period running from the time it was recorded to the time of either the next reading or the measure end time. If that period exceeds five minutes, the reading is only attributed for five minutes. - If two MAPs are available at the same point in time from different monitoring methods, the invasive value is used. - The measure attributes the full case to all reporting clinicians who provide care during any portion of the case. - If MAP values are not available, the clinician may submit paired systolic and diastolic pressures. The registry calculates MAP as MAP = 1/3 (SBP) + 2/3 (DBP).

Artifact rejection. Because longitudinal blood pressure data contains artifactual values (for example, an inaccurate reading caused by the surgeon leaning on the cuff), the measure drops readings meeting any of the following: - Documented as an artifact by the clinician - SBP greater than or equal to 300 mmHg, or less than or equal to 20 mmHg - DBP less than or equal to 5 mmHg, or greater than or equal to 225 mmHg - SBP and DBP within 5 mmHg of each other - MAP less than or equal to 30 mmHg, or greater than or equal to 250 mmHg

Non-emergency surgeries include both elective and urgent surgeries.

DENOMINATOR

- Unadjusted measure score: All cases in which adults aged 18 and older undergoing noncardiac, non-emergency surgery require general, neuraxial, or regional anesthesia care. - Risk adjusted measure score: The expected number of cases in which patients have a MAP below 65 mmHg exceeding a cumulative 15 minutes, with noncardiac non-emergency surgery requiring general, neuraxial, or regional anesthesia care, based on the risk adjustment model.

Denominator Criteria (Eligible Cases): - Patient aged 18 years and older - AND Anesthesia Type: General, Neuraxial, or Regional - AND Patient encounter during the reporting period matching the measure's CPT list (224 codes; the full list appears at the end of this measure)

DENOMINATOR EXCLUSIONS

- 99A16 Patients with a baseline MAP below 65 mmHg. Baseline MAP is the most recent reading from the preoperative holding area. If no such reading is available, the measure uses the most recent MAP taken in the operating room before induction. - 99A19 Patients where electronically recorded MAP or blood pressure readings are unavailable. - CPT 99135 Surgeries where the add-on code for anesthesia complicated by utilization of controlled hypotension is listed separately in addition to the primary anesthesia procedure code. - ASA Physical Status Classification of 1, 5, or 6 - Emergency cases - Cardiac procedures - Obstetric non-operative procedures - Liver or lung transplant procedures - Cataract procedures

NUMERATOR

Patients who have a MAP below 65 mmHg exceeding a cumulative length of 15 minutes.

Performance Met: 99A17 MAP below 65 mmHg exceeding a cumulative length of 15 minutes OR Performance Not Met: 99A18 MAP does not fall below 65 mmHg for a cumulative length of 15 minutes

Note on inverse scoring: as with AQI 18, "Performance Met" here records the undesirable outcome. A lower rate is better.

RATIONALE

MAP below 60 to 70 mmHg among adults having non-cardiac surgery is associated with increased risk of acute kidney injury, myocardial injury, and mortality, and the risk is a function of both hypotension severity and duration (Sessler et al. 2019). Noncardiac surgery patients are at increased risk from intraoperative hypotension, and the anesthesia care team is the party positioned to detect and correct it in real time.

RELEVANT FIELDS (Graphium capture)

- Date of procedure, date of birth - ASA CPT code and add-on codes (99135) - ASA physical status - Emergency status - Anesthesia type (general, neuraxial, regional) - Preoperative holding area MAP (baseline) - All intraoperative MAP values with timestamps, or paired SBP/DBP with timestamps - Invasive vs. non-invasive monitoring source per reading - Artifact flags - Anesthesia start and end times - Procedure category exclusion flags (cardiac, obstetric non-operative, liver/lung transplant, cataract)

REPORTING CODES

DENOMINATOR CPT CODES

A case must carry one of the codes below to enter this measure's denominator. The other denominator criteria above still apply - a matching code makes a case eligible for consideration, not automatically countable.

224 anesthesia CPT codes:

Excluded by CPT (1) - a case carrying one of these is taken back out of the denominator:

Source: 2026 AQI NACOR QCDR Measure Book. CPT copyright American Medical Association.