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2021 MIPS Measure #243: Cardiac Rehabilitation Patient Referral from an Outpatient Setting

Quality ID 243
NQF 0643
High Priority Measure Yes
Specifications Registry
Measure Type Process
Specialty Cardiology Family Medicine Internal Medicine

Measure Description

Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program

Definition:

Referral - A referral is defined as an official communication between the health care provider and the patient to recommend and carry out a referral order to an outpatient CR program. This includes the provision of all necessary information to the patient that will allow the patient to enroll in an outpatient CR program. This also includes a written or electronic communication between the healthcare provider or healthcare system and the cardiac rehabilitation program that includes the patient's enrollment information for the program. A hospital discharge summary or office note may potentially be formatted to include the necessary patient information to communicate to the CR program (the patient’s cardiovascular history, testing, and treatments, for instance). According to standards of practice for cardiac rehabilitation programs, care coordination communications are sent to the referring provider, including any issues regarding treatment changes, adverse treatment responses, or new non-emergency condition (new symptoms, patient care questions, etc.) that need attention by the referring provider. These communications also include a progress report once the patient has completed the program. All communications must maintain an appropriate level of confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act (HIPAA).

NOTE: A patient with a qualifying diagnosis should have a referral to CR within the subsequent 12 months. In the event that the patient has a second (recurrent) qualifying event before the original 12 month “referral” period has ended, a new 12 month “referral” period for CR referral starts at the time of the second qualifying event, since the patient again becomes eligible for CR at that time.

 

Instructions

This measure is to be submitted a minimum of once per performance period for all patients seen during the performance period who had a qualifying diagnosis within the previous 12 months and who have not already participated in an outpatient CR program. 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 (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

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 age ≥ 18 years evaluated in the outpatient setting during the reporting period who have a qualifying event/diagnosis who do not meet any of the denominator exceptions (medical factors, health care system factors, previous cardiac rehabilitation for qualifying cardiac event completed)

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 Instructions:

Chronic Stable Angina, Coronary Artery Bypass Graft, Percutaneous Coronary Intervention, Cardiac Valve surgery, Cardiac Transplant or Acute Myocardial Infarction are all considered qualifying events. In order to meet the criteria for inclusion of the measure, the qualifying event must have occurred or been performed within 12 months of date of encounter.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Patient encounter during the performance period (CPT or HCPCS): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307,99308, 99309, 99310, 99241*, 99242*, 99243*, 99244*, 99245*, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0438, G0439

AND

Diagnosis for Chronic Stable Angina (ICD-10-CM): I20.1, I20.8, I20.9

OR

Diagnosis of Acute 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.A9, I22.0, I22.1, I22.2, I22.8, I22.9, I25.2

OR

Coronary Artery Bypass Graft Surgery (CPT): 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536

OR

Percutaneous Coronary Intervention (CPT): 92920, 92924, 92928, 92933, 92937, 92941, 92943

OR

Cardiac Valve Surgery (CPT): 0345T, 0483T, 0484T, 33361, 33362, 33363, 33364, 33365, 33366, 33390, 33391, 33404, 33405, 33406, 33410, 33411, 33412, 33413, 33414, 33415, 33416, 33417, 33418, 33420, 33422, 33425, 33426,33427, 33430, 33440, 33460, 33463, 33464, 33465, 33468, 33470, 33471, 33474, 33475, 33476, 33477, 33478, 33496, 33600, 33602

OR

Cardiac Transplantation (CPT): 33935, 33945

AND

Qualifying cardiac event/diagnosis in previous 12 months: 1460F

 

Numerator

Patients who have had a qualifying event/diagnosis within the previous 12 months, who have been referred to an outpatient cardiac rehabilitation/secondary prevention (CR) program

Numerator Instructions:

CR programs may include a traditional CR program based on face-to-face interactions and training sessions or other options that include home-based approaches. If alternative CR approaches are used, they should be designed to meet appropriate safety standards.

Numerator Options:

Performance Met: Referred to an outpatient cardiac rehabilitation program (4500F)

OR

Denominator Exception: Documentation of medical reason(s) for not referring to an outpatient CR program (4500F with 1P)

OR

Denominator Exception: Documentation of patient reason(s) for not referring to an outpatient CR program (4500F with 2P)

OR

Denominator Exception: Documentation of system reason(s) for not referring to an outpatient CR program (4500F with 3P)

OR

Denominator Exception: Previous cardiac rehabilitation for qualifying cardiac event completed (4510F)

OR

Performance Not Met: Patient not referred to outpatient CR/secondary prevention program, reason not otherwise specified (4500F with 8P)

 

Rationale

Cardiac rehabilitation services have been shown to help reduce morbidity and mortality in persons who have experienced a recent coronary artery disease event, but these services are used in less than 30% of eligible patients (1). A key component to CR utilization is the appropriate and timely referral of patients to an outpatient CR program. While referral takes place generally while the patient is hospitalized for a qualifying event (MI, CSA, CABG, PCI, cardiac valve surgery, or heart transplantation), there are many instances in which a patient can and should be referred from an outpatient clinical practice setting (e.g., when a patient does not receive such a referral while in the hospital, or when the patient fails to follow through with the referral for whatever reason).

This performance measure has been developed to help health care systems implement effective steps in their systems of care that will optimize the appropriate referral of a patient to an outpatient CR program.

This measure is designed to serve as a stand-alone measure or, preferably, to be included within other performance measurement sets that involve disease states or other conditions for which CR services have been found to be appropriate and beneficial (e.g., following MI, CABG surgery) (2, 3). This performance measure is provided in a format that is meant to allow easy and flexible inclusion into such performance measurement sets.

Referral of appropriate outpatients to a CR program is the responsibility of the health care provider within a health care system that is providing the primary cardiovascular care to the patient in the outpatient setting.

 

Clinical Recommendation Statements

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery (4)
Class I

Cardiac rehabilitation is recommended for all eligible patients after CABG. (Level of Evidence: A)

2013 ACC/AHA Guideline for the Management of ST-Elevation Myocardial Infarction (5)
Class I

Exercise-based cardiac rehabilitation/secondary prevention programs are recommended for patients with STEMI. (Level of Evidence: B)

2014 ACC/AHA Guideline for the Management of Patients with Non–ST-Segment Elevation Acute Coronary Syndromes (6)
Class I

All eligible patients with NSTE-ACS should be referred to a comprehensive cardiovascular rehabilitation program either before hospital discharge or during the first outpatient visit. (Level of Evidence: B)

2012 ACCF/AHA/ ACP/AATS/PCNA/SCAI/STS Guideline for the Management of Patients With Stable Ischemic Heart Disease (7)
Class I

Medically supervised programs (cardiac rehabilitation) and physician-directed, home-based programs are recommended for at-risk patients at first diagnosis. (Level of Evidence: A)

2013 ACCF/AHA Guideline for the Management of Heart Failure (8)
Class I

Exercise training (or regular physical activity) is recommended as safe and effective for patients with HF who are able to participate to improve functional status. (Level of Evidence: A)

Effectiveness-based Guidelines for the Prevention of Cardiovascular Disease in Women — 2011 update: A Guideline from the American Heart Association (9)
Class I

A comprehensive CVD risk-reduction regimen such as cardiovascular or stroke rehabilitation or a physician-guided home- or community-based exercise training program should be recommended to women with a recent acute coronary syndrome or coronary revascularization, new-onset or chronic angina, recent cerebrovascular event, peripheral arterial disease (Class I; Level of Evidence A) or current/prior symptoms of heart failure and an LVEF ≤35%. (Class I; Level of Evidence B)

2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention (10)
Class I

Medically supervised exercise programs (cardiac rehabilitation) should be recommended to patients after PCI, particularly for moderate- to high-risk patients for whom supervised exercise training is warranted. (Class I; Level of Evidence A)

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