Measure Description
Percentage of patients aged 18 years and older with a diagnosis of COPD with a documented FEV1/FVC < 70% measured by spirometry, who are symptomatic, and were prescribed a long-acting inhaled bronchodilator.
Instructions
This measure is to be submitted a minimum of once per performance period for all COPD patients seen during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
This measure will be calculated with 2 performance rates:
- Percentage of patients aged 18 years and older with a diagnosis of COPD who have a documented airflow obstruction (FEV1/FVC < 70%) as measured by spirometry.
- Percentage of patients aged 18 years and older with a diagnosis of COPD who have documented airflow obstruction (FEV1/FVC < 70%) and are symptomatic, who were prescribed a long acting inhaled bronchodilator.
Submission of the two performance rates is required for this measure. A simple average, which is the sum of the performance rates divided by the number of the performance rates will be used to calculate performance.
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.
THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:
- Patients diagnosed with COPD who have documented airflow obstruction (FEV1/FVC < 70%) as measured by spirometry in the medical record.
- Patients diagnosed with COPD who have documented airflow obstruction (FEV1/FVC < 70%) and are symptomatic, who were prescribed a long acting bronchodilator.
This measure contains two submission criteria which together ensure that the proper evaluation and treatment is provided for patients with COPD and that patients without COPD are not provided inappropriate therapy. Submission Criteria 1 evaluates whether spirometry was performed for patients diagnosed with COPD and results confirming airflow obstruction are documented. Submission Criteria 2 evaluates whether a long-acting inhaled bronchodilator was prescribed for COPD patients who have symptoms.
DENOMINATOR (SUBMISSION CRITERIA 1):
All patients aged 18 and older with a diagnosis of COPD
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for COPD (ICD-10-CM): J41.0, J41.1, J41.8, J42, J43.0, J43.1, J43.2, J43.8, J43.9, J44.0, J44.1, J44.89, J44.9
AND
Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99424, 99426
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10
NUMERATOR (SUBMISSION CRITERIA 1):
Patients with documented spirometry and confirmed airflow obstruction (FEV1/FVC < 70%)
Numerator Instructions:
Documentation of spirometry results of (FEV1/FVC < 70%) can take place before the performance period. The intent of Submission Criteria 1 is to ensure accurate diagnosis of COPD in patients with respiratory symptoms such as dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease is appropriate by having documentation of spirometry results of FEV1/FVC < 70%, which is required to make the COPD diagnosis.
NUMERATOR NOTE: Denominator Exception(s) are determined on the date of the denominator eligible encounter. If there is a diagnosis of COPD, but there is no documented spirometry within five years of the date of the encounter, and the current spirometry result is ≥ 70%, an exception may be reported.
Numerator Options:
Performance Met: Spirometry results with confirmed airflow obstruction (FEV1/FVC < 70%) documented and reviewed (M1214)
OR
Denominator Exception: Documentation of medical reason(s) for not documenting and reviewing spirometry results (e.g., patients with dementia or tracheostomy) (M1215)
OR
Denominator Exception: No history of spirometry results with confirmed airflow obstruction (FEV1/FVC < 70%) and present spirometry is ≥ 70% (M1213)
OR
Denominator Exception: Documentation of system reason(s) for not documenting and reviewing spirometry results (e.g., spirometry equipment not available at the time of the encounter) (M1217)
OR
Performance Not Met: No spirometry results with confirmed airflow obstruction (FEV1/FVC < 70%) documented and/or no spirometry performed with results documented during the encounter (M1216)
DENOMINATOR (SUBMISSION CRITERIA 2):
All patients aged 18 years and older with a diagnosis of COPD with spirometry results documented (FEV1/FVC < 70%), and have symptoms (e.g., dyspnea, cough/sputum, wheezing)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for COPD (ICD-10-CM): J41.0, J41.1, J41.8, J42, J43.0, J43.1, J43.2, J43.8, J43.9, J44.0, J44.1, J44.89, J44.9
AND
Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99424, 99426
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10
AND
Spirometry results documented (FEV1/FVC < 70%): G8924
AND
Patient has COPD symptoms (e.g., dyspnea, cough/sputum, wheezing): M1218
NUMERATOR (SUBMISSION CRITERIA 2):
Symptomatic COPD patients who were prescribed a long-acting inhaled bronchodilator
Definition:
Prescribed – Includes patients who were “prescribed” medication at an encounter during the performance period, even if the prescription for that medication was ordered prior to the encounter.
NUMERATOR NOTE: Denominator Exception(s) are determined on the date of the denominator eligible encounter.
Numerator Options:
Performance Met: Long-acting inhaled bronchodilator prescribed (G9695)
OR
Denominator Exception: Documentation of medical reason(s) for not prescribing a long-acting inhaled bronchodilator (e.g., patient intolerance or history of side effects) (G9696)
OR
Denominator Exception: Documentation of system reason(s) for not prescribing a long-acting inhaled bronchodilator (e.g., cost of treatment or lack of insurance) (G9698)
OR
Performance Not Met: Long-acting inhaled bronchodilator not prescribed, reason not otherwise specified (G9699)
Rationale
Despite major efforts to broadly disseminate the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines and use of COPD performance measures across different specialty societies, diagnosis and management of COPD, and specifically prescription for long-acting inhaled bronchodilators, remains suboptimal.
Although spirometry use has increased, it remains underutilized to confirm airflow obstruction and accurately diagnose COPD (CDC, 2012; Nishi et al., 2013; Rodwin et al., 2022). Studies show proper COPD diagnosis with spirometry is done on just over half of patients in the US and Canada (Boulet et al., 2013; Bourbeau et al., 2008; Collins et al., 2015; Nishi et al., 2013; Perez et al., 2011; Yu et al., 2013). A study of physician-diagnosed COPD patients hospitalized for exacerbations found that 22% of patients did not have COPD upon spirometry testing (Prieto Centurion, et al., 2012). Treatment of presumed COPD without accurate diagnosis and understanding of true etiology of symptoms results in patients not receiving medication that would improve symptoms and quality of life, prevent exacerbations and reduce costly use of emergency and hospital services. Patients may be exposed to adverse effects of unneeded medication and or delays in true diagnosis and management of another condition increasing overall cost of care (Boulet et al., 2013; Bourbeau et al., 2008; CDC, 2012; Collins et al., 2015; Joo et al., 2011).
Several recent studies emphasize the association between both under- and over- diagnosis of COPD with increased respiratory symptoms and health care utilization (Gershon et al, 2018; Farooqi et al, 2022).
Studies show a wide range of deficiencies in adherence to guidelines regarding long-acting inhaled bronchodilator use across different settings (Asche et al., 2012; CDC, 2012; Fitch, et al., 2011; Nantsupawat et al., 2012; Perez et al., 2011; Sharif, et al., 2013; Keller, et al., 2020,Ghosh, et al, 2019). Underuse of bronchodilators were found related to hospital readmissions and to increased total costs of services when compared to patient care adhering to GOLD guidelines (Asche et al., 2012; Nantsupawat et al., 2012).
Suboptimal COPD management has implications for severity of illness, disease progression, patient quality of life and health status, exacerbations (and associated costs) and mortality. Improved adherence to COPD management guidelines, specifically appropriate use of long-acting inhaled bronchodilators, has the potential to improve clinical outcomes and cost of care related to COPD. As a result, we believe this measure will continue to increase appropriate long-acting inhaled bronchodilator use, improving patient management and total costs of COPD. Although recent guidelines state dual long-acting bronchodilator medication are “preferred” for treatment initiation, patients well-controlled on one long-acting bronchodilator do not necessarily require escalation. For this reason, prescription of one or more long-acting bronchodilators is all that is required to meet the measure.
Clinical Recommendation Statements
Spirometry:
Recommendation 1: ACP, ACCP, ATS, and ERS recommend that spirometry should be obtained to diagnose airflow obstruction in patients with respiratory symptoms (Grade: strong recommendation, moderate-quality evidence). Spirometry should not be used to screen for airflow obstruction in individuals without respiratory symptoms (Grade: strong recommendation, moderate-quality evidence)” (Qaseem et al, 2011).
“COPD should be considered in any patient with dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease. Spirometry is required to make the diagnosis in this clinical context; the presence of post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD in patients with appropriate symptoms and significant exposure to noxious stimuli. Spirometry is the most reproducible and objective measurement of airflow limitation. It is a noninvasive and readily available test” (GOLD 2022).
Inhaled Bronchodilators:
In patients with chronic obstructive pulmonary disease who complain of dyspnea or exercise intolerance, we recommend long-acting beta-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy (strong recommendation, moderate quality evidence) (Nicci et al, 2020).
LABA and LAMAs are preferred over short-acting agents except for patients with only occasional dyspnea (Evidence A), and for immediate relief of symptoms in patients already on long-acting bronchodilators for maintenance therapy. When initiating treatment with long-acting bronchodilators, the preferred choice is a combination of a LAMA and a LABA. In patients with persistent dyspnea on a single long-acting bronchodilator treatment should be escalated to two (Evidence A). The combination can be given as a single inhaler or multiple inhaler treatment (GOLD 2023).