Measure Description
Percentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribed an FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period.
Instructions
This measure is to be submitted a minimum of once per performance period for patients with AF or atrial flutter 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.
NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, POS 02, POS 10) are allowable. Please note that effective January 1, 2025, while a measure may be denoted as telehealth eligible, specific denominator codes within the encounter may no longer be eligible due to changes outlined in the CY 2024 PFS Final Rule List of Medicare Telehealth Services.
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.
Denominator
All patients aged 18 years and older with AF or atrial flutter who do not have a documented CHA2DS2-VASc risk score of 0 or 1 for men; or 0, 1, or 2 for women
Definition:
Comfort Care Only – Refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort. It includes attention to the psychological and spiritual needs of the patient and support for both the dying patient and the patient's family. Comfort Measures Only is commonly referred to as "comfort care” by the general public. It may be completed in an inpatient, outpatient, or home environment. Comfort Measures Only includes hospice, palliative and supportive treatment for patients who are suffering from a terminal illness—e.g., AIDS, cancer—or who have refused life-sustaining treatment. In order to use G9930, a patient must be on comfort care measures only and not be receiving any other types of care. It is not equivalent to a physician order to withhold emergency resuscitative measures such as Do Not Resuscitate (DNR).
CHA2DS2-VASc Stroke Risk Assessment – The assessment of patients with AF or atrial flutter, assessment of thromboembolic risk should include:
CHA2DS2-VASc Criteria - Score
Congestive HF - 1
Hypertension - 1
Age>= 75 years - 2
Diabetes Mellitus - 1
Stroke/Transient Ischemic Attack (TIA)/Thromboembolism (TE) - 2
Vascular disease (prior myocardial infarction [MI], peripheral artery disease [PAD], or aortic plaque) - 1
Age 65-74 years - 1
Sex category (i.e.; female) - 1
DENOMINATOR NOTE: Denominator Exclusions are determined on the date of the denominator eligible encounter. The intent of the denominator exclusion G9931 is to allow patients with a low risk for a thromboembolic event (i.e., a CHA2DS2-VASc score of 0 or 1 for men; or 0, 1, or 2 for women) to be excluded from the sample. This denominator exclusion serves as documentation that a patient’s risk for a thromboembolic event was appropriately assessed using the CHA2DS2-VASc scoring tool and that the risk was low enough to not warrant anticoagulation treatment. In order to exclude low risk patients, eligible clinicians must use the CHA2DS2-VASc assessment tool to determine a patient’s risk score and must document either the numeric score (i.e., 0 or 1 for men; or 0, 1, or 2 for women) or all the individual risk factors assessed to support an assessment of the CHA2DS2-VASc score.
DENOMINATOR NOTE: *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):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for atrial fibrillation or atrial flutter on date of encounter (ICD-10-CM): I48.0, I48.3, I48.4, I48.11, I48.19, I48.20, I48.21, I48.91, I48.92
AND
Patient encounter during the performance period (CPT): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99315, 99316, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99424, 99426
AND NOT
DENOMINATOR EXCLUSIONS:
Patient with transient or reversible cause of AF (e.g., pneumonia, hyperthyroidism, pregnancy, cardiac surgery): G9929
OR
Patients who are receiving comfort care only: G9930
OR
Documentation of CHA2DS2-VASc risk score of 0 or 1 for men; or 0, 1, or 2 for women: G9931
OR
Patients with moderate or severe mitral stenosis: G0044
OR
Patients with mechanical prosthetic heart valve: G0043
Numerator
Patients with AF or atrial flutter for whom an FDA-approved oral anticoagulant was prescribed
Definition:
Prescribed – Also satisfied by documentation in current medication list.
NUMERATOR NOTE: Denominator Exception(s) are determined on the date of the denominator eligible encounter.
Numerator Options:
Performance Met: FDA-approved oral anticoagulant is prescribed (G8967)
OR
Denominator Exception: Documentation of medical reason(s) for not prescribing an FDA-approved anticoagulant (e.g., present or planned atrial appendage occlusion or ligation or patient being currently enrolled in a clinical trial related to AF/atrial flutter treatment) (G8968)
OR
Denominator Exception: Documentation of patient reason(s) for not prescribing an oral anticoagulant that is FDA approved for the prevention of thromboembolism (e.g., patient preference for not receiving anticoagulation) (G8969)
OR
Performance Not Met: FDA-approved anticoagulant not prescribed, reason not given (G9928)
Rationale
A high risk for stroke or systemic embolism is about 2% per year, and all the DOAC trials (Re-LY [Randomized Evaluation of Long-Term Anticoagulation Therapy]; ROCKET AF [Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation]; ARISTOTLE; and ENGAGE AF-TIMI 48 [Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation – Thrombolysis in Myocardial Infarction 48]) included patients with this level of risk. Patients at intermediate risk (1%-2%/y) can also benefit from anticoagulation, and the RE-LY and ARISTOTLE trials included this population. Stroke risk scores applied to cohorts give different stroke rates, and therefore any score should be viewed as only an estimate of true risk; in addition, some scores used stroke, while others used thromboembolic events. Nonetheless, it is practical to use a validated risk score, such as CHA2DS2-VASc, ATRIA, or GARFIELD-AF. Future research may yield improved risk scores that refine how to incorporate risk modifiers, such as female sex and other parameters such as AF burden. Anticoagulation has also been shown to be superior to antiplatelet therapy to reduce stroke risk.
Clinical Recommendation Statements
2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation (ACC/AHA/ACCP/HRS, 2024)
1. For patients with AF and an estimated annual thromboembolic risk of ≥2% per year (e.g., CHA2DS2- VASc score of ≥2 in men and ≥3 in women), anticoagulation is recommended to prevent stroke and systemic thromboembolism. (Class 1, Level of Evidence: A)
2. For patients with AF receiving warfarin (excludes patients with mechanical valves), a target INR between 2 and 3 is recommended, as well as optimal management of drug-drug interactions, consistency in vitamin K dietary intake, and routine INR monitoring to improve time in therapeutic range and to minimize risks of preventable thromboembolism or major bleeding. (Class 1, Level of Evidence: B-R).
3. In patients with rheumatic mitral stenosis or mitral stenosis of moderate or greater severity and history of AF, long-term anticoagulation with warfarin is recommended over DOACs, independent of the CHA2DS2-VASc score to prevent cardiovascular events, including stroke or death. (Class 1, Level of Evidence B-R).