Measure Description
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy
Instructions
This measure is to be submitted a minimum of once per performance period for all patients with a diagnosis of CAD seen during the performance period. Only patients who had at least two denominator eligible visits during the performance period will be counted for Submission Criteria 1 and Submission Criteria 2 of this measure. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure for the primary management of patients with CAD based on the services provided and the measure-specific denominator coding.
This measure will be calculated with 2 performance rates:
1) Percentage of patients with a diagnosis of CAD or history of cardiac surgery who have a current or prior LVEF < 40% who were prescribed beta-blocker therapy
2) Percentage of patients with a diagnosis of CAD or history of cardiac surgery who have a prior (within the past 3 years) myocardial infarction who were prescribed beta-blocker therapy
The Merit-based Incentive Payment System (MIPS) eligible clinician should submit data on one of the submission criteria, depending on the clinical findings. If the patient has CAD or history of cardiac surgery and a current or prior LVEF < 40%, use Submission Criteria 1. If the patient has CAD or history of cardiac surgery and has a prior (within the past 3 years) MI, use Submission Criteria 2. The 3 year lookback period for the prior MI should be from the time of the encounter which is used to qualify for the denominator and evaluate the numerator. If the patient has both prior (within the past 3 years) MI and LVEF < 40%, the Merit-based Incentive Payment System (MIPS) eligible clinician may submit quality-data codes for Submission Criteria 1 and this will count as appropriate submission for this patient.
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:
1) All patients with a diagnosis of CAD or history of cardiac surgery who have a current or prior LVEF < 40%
OR
2) All patients with a diagnosis of CAD or history of cardiac surgery who have a prior (within the past 3 years) myocardial infarction
SUBMISSION CRITERIA 1: ALL PATIENTS WITH A DIAGNOSIS OF CAD OR HISTORY OF CARDIAC SURGERY WHO HAVE A CURRENT OR PRIOR LVEF < 40%
Denominator (Submission Criteria 1)
All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a current or prior LVEF < 40%
DENOMINATOR NOTE: The history of cardiac surgery serves as a proxy for a diagnosis of CAD; a diagnosis is not needed if the patient has documented history of cardiac surgery. Only one of the two criteria – a diagnosis of CAD or history of cardiac surgery proxy – is required. To meet the denominator criteria, a patient must have an active diagnosis of CAD (or proxy documented) 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 CAD diagnosis criterion, the diagnosis needs to be active only at the encounter being evaluated for the numerator action. If the patient meets the proxy of a history of cardiac surgery inclusion criterion, there should be documentation of the proxy 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 MIPS CQMs.
Denominator Criteria (Eligible Cases) 1:
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for coronary artery disease (ICD-10-CM): I20.0, I20.1, I20.8, I20.9, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750, I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.83, I25.89, I25.9, Z95.1, Z95.5, Z98.61
OR
History of cardiac surgery (CPT): 33140, 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536, 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92980, 92981, 92982, 92984, 92995, 92996
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) < 40%: G8694
Numerator (Submission Criteria 1)
Patients who were prescribed beta-blocker therapy
Definitions:
Prescribed – May include prescription given to the patient for beta-blocker therapy at one or more visits in the measurement period OR patient already taking beta-blocker therapy as documented in current medication list.
Beta-blocker Therapy – For patients with prior LVEF < 40%, beta-blocker therapy includes the following: bisoprolol, carvedilol, or sustained release metoprolol succinate.
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 CAD or history of cardiac surgery proxy is documented. Denominator Exception(s) are determined on the date of the denominator eligible encounter.
Numerator Options:
Performance Met: Beta-blocker therapy prescribed or currently being taken (G9189)
OR
Denominator Exception: Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., allergy, intolerance, other medical reasons) (G9190)
OR
Denominator Exception: Documentation of patient reason(s) for not prescribing beta-blocker therapy (e.g., patient declined, other patient reasons) (G9191)
OR
Denominator Exception: Documentation of system reason(s) for not prescribing beta-blocker therapy (e.g., other reasons attributable to the health care system) (G9192)
OR
Performance Not Met: Beta-blocker therapy not prescribed, reason not given (G9188)
OR
SUBMISSION CRITERIA 2: ALL PATIENTS WITH A DIAGNOSIS OF CAD OR HISTORY OF CARDIAC SURGERY WHO HAVE A PRIOR (WITHIN THE PAST 3 YEARS) MYOCARDIAL INFARCTION
Denominator (Submission Criteria 2)
All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have prior (within the past 3 years) MI
Definition:
Prior Myocardial Infarction (MI) – for Submission Criteria 2, prior MI is limited to those occurring within the past 3 years.
DENOMINATOR NOTE: The history of cardiac surgery serves as a proxy for a diagnosis of CAD; a diagnosis is not needed if the patient has documented history of cardiac surgery. Only one of the two criteria – a diagnosis of CAD or history of cardiac surgery proxy – is required. To meet the denominator criteria, a patient must have an active diagnosis of CAD (or proxy documented) 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 CAD diagnosis criterion, the diagnosis needs to be active only at the encounter being evaluated for the numerator action. If the patient meets the proxy of a history of cardiac surgery inclusion criterion, there should be documentation of the proxy 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 MIPS CQMs.
Denominator Criteria (Eligible Cases) 2:
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for coronary artery disease (ICD-10-CM): I20.0, I20.1, I20.8, I20.9, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750, I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.83, I25.89, I25.9, Z95.1, Z95.5, Z98.61
OR
History of cardiac surgery (CPT): 33140, 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536, 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92980, 92981, 92982, 92984, 92995, 92996
AND
Diagnosis for myocardial infarction– includes patient that had a prior (within the past 3 years) myocardial infarction (ICD-10-CM): I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I21.9, I21.A1, I21.A9, I22.0, I22.1, I22.2, I22.8, I22.9, I24.1, I25.2
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
Numerator (Submission Criteria 2)
Patients who were prescribed beta-blocker therapy
Definitions:
Prescribed – May include prescription given to the patient for beta-blocker therapy at one or more visits in the measurement period OR patient already taking beta-blocker therapy as documented in current medication list.
Beta-blocker Therapy – For patients with prior MI, beta-blocker therapy includes any agent within the beta- blocker drug class. As of 2015, no recommendations or evidence are cited in current stable ischemic heart disease guidelines for preferential use of specific agents.
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 CAD or history of cardiac surgery proxy is documented. Denominator Exception(s) are determined on the date of the denominator eligible encounter.
Numerator Options:
Performance Met: Beta-blocker therapy prescribed or currently being taken (4008F)
OR
Denominator Exception: Documentation of medical reason(s) for not prescribing beta-blocker therapy (eg, allergy, intolerance, other medical reasons) (4008F with 1P)
OR
Denominator Exception: Documentation of patient reason(s) for not prescribing beta-blocker therapy (eg, patient declined, other patient reasons) (4008F with 2P)
OR
Denominator Exception: Documentation of system reason(s) for not prescribing beta-blocker therapy (eg, other reasons attributable to the health care system) (4008F with 3P)
OR
Performance Not Met: Beta-blocker therapy not prescribed, reason not otherwise specified (4008F with 8P)