#005: Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Quality ID

005

eMeasure ID

CMS135v6

NQF

0081

High Priority Measure

No

Specifications

EHR Registry

Measure Type

Process

Specialty

Cardiology Family Medicine Hospitalists Internal Medicine

Measure Description

Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge

 

Instructions

This measure is to be submitted for all heart failure patients a minimum of once per performance period when seen in the outpatient setting AND submitted at each hospital discharge (99238* and 99239*) during the performance period.

*NOTE: When submitting CPT code 99238 and 99239, it is recommended the measure be submitted each time the code is submitted for hospital discharge.

This measure is intended to reflect the quality of services provided for patients with HF and decreased left ventricular systolic function. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Only patients who had at least two denominator eligible visits during the performance period will be counted for Submission Criteria 1.

Measure Submission:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-submissions; however, these codes may be submitted for those registries that utilize claims data.

 

THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:

1) Patients who are 18 years and older with a diagnosis of HF with a current or prior LVEF < 40% seen in the outpatient setting with two denominator eligible visits

OR

2) Patients who are 18 years and older with a diagnosis of HF with a current or prior LVEF < 40% and discharged from hospital

 

SUBMISSION CRITERIA 1: ALL PATIENTS WITH A DIAGNOSIS OF HF ASSESSED DURING AN OUTPATIENT ENCOUNTER

Denominator (Submission Criteria 1)

All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40%

DENOMINATOR NOTE: LVEF < 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction. The LVSD may be determined by quantitative or qualitative assessment, which may be current or historical. Examples of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a numerical value of LVSD or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD can be used to identify patients. To meet the denominator criteria, a patient must have an active diagnosis of heart failure at the time of the encounter which is used to qualify for the denominator and evaluate the numerator. The encounter used to evaluate the numerator counts as 1 of the 2 encounters required for denominator inclusion. If the patient meets the heart failure diagnosis criterion, the diagnosis needs to be active only at the encounter being evaluated for the numerator action. *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registrybased measures.

Denominator Criteria (Eligible Cases) 1:

Patients aged ≥ 18 years on date of encounter

AND

Diagnosis for heart failure (ICD-10-CM): I11.0, I13.0, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89, I50.9

AND

Patient encounter during performance period – to be used for numerator evaluation (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350

WITHOUT

Telehealth Modifier: GQ, GT, 95, POS 02

AND

At least one additional patient encounter during performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350

WITHOUT

Telehealth Modifier: GQ, GT, 95, POS 02

AND

Left ventricular ejection fraction (LVEF) less than 40% or documentation of moderately or severely depressed left ventricular systolic function: 3021F

 

Numerator (Submission Criteria 1)

Patients who were prescribed ACE inhibitor or ARB therapy within a 12 month period when seen in the outpatient setting

Definition:

Prescribed – Outpatient setting: prescription given to the patient for ACE inhibitor or ARB therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB therapy as documented in current medication list.

NUMERATOR NOTE: To meet the intent of the measure, the numerator quality action must be performed at the encounter at which the active diagnosis of heart failure is documented. Eligible clinicians who have given a prescription to the patient for or whose patient is currently taking a combination medication therapy, which contains either an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) (e.g., angiotensin receptor neprilysin inhibitor [ARNI, sacubitril/valsartan], ACEI+diruretc, ARB+diruretic, ACEI+calcium channel blocker) would meet performance for this measure. Denominator Exception(s) are determined on the date of the denominator eligible encounter.

Numerator Options:

Performance Met: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) therapy prescribed or currently being taken (4010F)

OR

Denominator Exception: Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, hypotensive patients who are at immediate risk of cardiogenic shock, hospitalized patients who have experienced marked azotemia, allergy, intolerance, other medical reasons) (4010F with 1P)

OR

Denominator Exception: Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, patient declined, other patient reasons) (4010F with 2P)

OR

Denominator Exception: Documentation of system reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, other system reasons) (4010F with 3P)

OR

Performance Not Met: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy was not prescribed, reason not otherwise specified (4010F with 8P)

 

OR

 

SUBMISSION CRITERIA 2: ALL PATIENTS WITH A DIAGNOSIS OF HF AND DISCHARGED FROM HOSPITAL

Denominator (Submission Criteria 2)

All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40%

DENOMINATOR NOTE: LVEF < 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction. The LVSD may be determined by quantitative or qualitative assessment, which may be current or historical. Examples of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a numerical value of LVSD or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD can be used to identify patients.

Denominator Criteria (Eligible Cases) 2:

Patients aged ≥ 18 years on date of encounter

AND

Diagnosis for heart failure (ICD-10-CM): I11.0, I13.0, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89, I50.9

AND

Patient encounter during performance period (CPT): 99238, 99239

AND

Left ventricular ejection fraction (LVEF) less than 40% or documentation of moderately or severely depressed left ventricular systolic function: 3021F

 

Numerator (Submission Criteria 2)

Patients who were prescribed ACE inhibitor or ARB therapy at hospital discharge

Definition:

Prescribed – Inpatient setting: prescription given to the patient for ACE inhibitor or ARB therapy at discharge OR ACE inhibitor or ARB therapy to be continued after discharge as documented in the discharge medication list

NUMERATOR NOTE: To meet the intent of the measure, the numerator quality action must be performed at the each denominator eligible discharge. Eligible clinicians who have given a prescription to the patient for or whose patient is currently taking a combination medication therapy, which contains either an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) (e.g., angiotensin receptor neprilysin inhibitor [ARNI, sacubitril/valsartan], ACEI+diruretc, ARB+diruretic, ACEI+calcium channel blocker) would meet performance for this measure. Denominator Exception(s) are determined on the date of the denominator eligible encounter.

Numerator Options:

Performance Met: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) therapy prescribed or currently being taken (4010F)

OR

Denominator Exception: Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, hypotensive patients who are at immediate risk of cardiogenic shock, hospitalized patients who have experienced marked azotemia, allergy, intolerance, other medical reasons) (4010F with 1P)

OR

Denominator Exception: Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, patient declined, other patient reasons) (4010F with 2P)

OR

Denominator Exception: Documentation of system reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, other system reasons) (4010F with 3P)

OR

Performance Not Met: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy was not prescribed, reason not otherwise specified (4010F with 8P)

 

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