2020 MIPS Measure #326: Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

Measure Description

Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another 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 nonvalvular 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.

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 a diagnosis of nonvalvular AF or atrial flutter who do not have a documented CHA₂DS₂-VASc risk score of 0 or 1

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)

CHA₂DSC₂-VASc Stroke Risk Assessment - The assessment of patients with nonvalvular 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: 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) 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 CHA₂ DS₂-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) or all the individual risk factors assessed to support an assessment of the CHA₂DS₂-VASc score.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Diagnosis for nonvalvular atrial fibrillation or atrial flutter (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): 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 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: G9931

Numerator

Patients with nonvalvular AF or atrial flutter for whom warfarin or another FDA-approved oral anticoagulant was prescribed

Definition:

Prescribed – also satisfied by documentation in current medication list.

NUMERATOR NOTE: Denominator Exclusions/Exception(s) are determined on the date of the denominator eligible encounter.

Numerator Options:

Performance Met: Warfarin OR another FDA-approved oral anticoagulant is prescribed (G8967)

OR

Denominator Exception: Documentation of medical reason(s) for not prescribing warfarin OR another FDA-approved anticoagulant (eg, atrial appendage device in place) (G8968)

OR

Denominator Exception: Documentation of patient reason(s) for not prescribing warfarin OR another FDA-approved oral anticoagulant that is FDA-approved for the prevention of thromboembolism (eg, patient choice of having atrial appendage device placed) (G8969)

OR

Denominator Exception: Documentation of system reason(s) for not prescribing warfarin OR another FDA-approved anticoagulation due to patient being currently enrolled in a clinical trial related to AF/atrial flutter treatment (G9927)

OR

Performance Not Met: Warfarin OR another FDA-approved anticoagulant not prescribed, reason not given (G9928)

Rationale

AF, whether paroxysmal, persistent, or permanent and whether symptomatic or silent, significantly increases the risk of thromboembolic ischemic stroke. Nonvalvular atrial fibrillation increases the risk of stroke 5 times, and AF in the setting of mitral stenosis increases the risk of stroke 20 times over that of patients in sinus rhythm.

Thromboembolism occurring with AF is associated with a greater risk of recurrent stroke, more severe disability, and mortality. Silent AF is also associated with ischemic stroke. The appropriate use of antithrombotic therapy and the control of other risk factors, including hypertension and hypercholesterolemia, substantially reduce stroke risk.

One meta-analysis has stratified ischemic stroke risk among patients with nonvalvular AF using the following point scoring systems: AF Investigators; CHA2 DS2 (congestive heart failure, hypertension, age 75 years, diabetes mellitus, prior stroke or TIA or thromboembolism [doubled]), or CHA2 DS2 -VASc (congestive heart failure, hypertension, age 75 years [doubled], diabetes mellitus, prior stroke or TIA or thromboembolism [doubled], vascular disease, age 65 to 74 years, sex category).

When compared with the CHA2 DS2 score, the CHA2 DS2 -VASc score for nonvalvular AF has a broader score range (0 to 9) and includes a larger number of risk factors (female sex, 65 to 74 years of age, and vascular disease).

The selection of an antithrombotic agent should be based on shared decision making that takes into account risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the INR therapeutic range if the patient has been on warfarin, irrespective of whether the AF pattern is paroxysmal, persistent, or permanent.

Clinical Recommendation Statements

1. In patients with AF, antithrombotic therapy should be individualized based on shared decision-making after discussion of the absolute and RRs of stroke and bleeding, and the patient’s values and preferences. (Class I, Level of Evidence: C)
2. Selection of antithrombotic therapy should be based on the risk of thromboembolism irrespective of whether the AF pattern is paroxysmal, persistent, or permanent. (Class I, Level of Evidence: B)
3. In patients with nonvalvular AF, the CHA2 DS2 -VASc score is recommended for assessment of stroke risk. (Class I, Level of Evidence: B) 
4. For patients with AF who have mechanical heart valves, warfarin is recommended and the target international normalized ratio (INR) intensity (2.0 to 3.0 or 2.5 to 3.5) should be based on the type and location of the prosthesis. (Class I, Level of Evidence: B)
5. For patients with nonvalvular AF with prior stroke, TIA, or a CHA2DS2-VASc score of 2 or greater, oral anticoagulants are recommended. Options include: warfarin (INR 2.0 to 3.0) (Class I, Level of Evidence: A), dabigatran (Class I, Level of Evidence: B), rivaroxaban (Class I, Level of Evidence: B), or apixaban. (Class I, Level of Evidence: B)
6. Among patients treated with warfarin, the INR should be determined at least weekly during initiation of antithrombotic therapy and at least monthly when anticoagulation (INR in range) is stable. (Class I, Level of Evidence: A)
7. For patients with nonvalvular AF unable to maintain a therapeutic INR level with warfarin, use of a direct thrombin or factor Xa inhibitor (dabigatran, rivaroxaban, or apixaban) is recommended. (Class I, Level of Evidence: C)
8. Re-evaluation of the need for and choice of antithrombotic therapy at periodic intervals is recommended to reassess stroke and bleeding risks. (Class I, Level of Evidence: C)
9. For patients with atrial flutter, antithrombotic therapy is recommended according to the same risk profile used for AF. (Class I, Level of Evidence: C)