Measure Description
The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include:
- Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg --AND
- Most recent tobacco status is Tobacco Free -- AND
- Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND
- Statin Use Unless Contraindicated
Instructions
This measure is to be submitted a minimum of once per performance period for all patients seen during the performance period. The most recent quality-data code submitted will be used for performance calculation. 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 ischemic vascular disease 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.
THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:
1) Patients with coronary artery disease (CAD) or a CAD Risk-Equivalent Condition 18-75 years of age and alive as of the last day of the measurement period and a minimum of two CAD or CAD Risk-Equivalent Condition coded office visits with a Primary Care Provider (PCP) / Cardiologist in 24 months and one office visit in 12 months
OR
2) Patients with one Acute Coronary Event (Acute Myocardial Infarction [AMI], Percutaneous Coronary Intervention [PCI], or Coronary Artery Bypass Graft [CABG]) 18-75 years of age and alive as of the last day of the measurement period) from a hospital visit (excluding Emergency and Lab Only visits) and have been seen by a primary care provider (PCP) / Cardiologist for two office visits in 24 months and one office visit in 12 months
SUBMISSION CRITERIA 1: PATIENTS WITH CORONARY ARTERY DISEASE (CAD) OR A CAD RISKEQUIVALENT CONDITION 18-75 YEARS OF AGE AND ALIVE AS OF THE LAST DAY OF THE MEASUREMENT PERIOD AND A MINIMUM OF TWO CAD OR CAD RISK-EQUIVALENT CONDITION CODED OFFICE VISITS WITH A PRIMARY CARE PROVIDER (PCP) / CARDIOLOGIST IN 24 MONTHS AND ONE OFFICE VISIT IN 12 MONTHS
Denominator (Submission Criteria 1)
Patients with CAD or a CAD Risk-Equivalent Condition (other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease) 18-75 years of age and alive as of the last day of the measurement period and a minimum of two CAD or CAD Risk-Equivalent Condition coded office visits with a Primary Care Provider (PCP) / Cardiologist in 24 months and one office visits in 12 months
DENOMINATOR NOTE: To meet the denominator criteria, the 24-month look back period applies to the performance period plus prior year. **This measure requires two patient encounters. At least one of the encounters should occur during the performance period to be eligible.
*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 through 75 years
AND
Diagnosis for CAD (ICD-10-CM): I20.0, I20.1, I20.8, I20.9, 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, I22.8, I22.9, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.2, 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, Z95.818, Z95.820, Z95.828, Z95.9, Z98.61, Z98.62
OR
Diagnosis for CAD Risk-Equivalent Condition (ICD-10-CM): I63.00, I63.011, I63.012, I63.013, I63.019, I63.02, I63.031, I63.032, I63.033, I63.039, I63.09, I63.10, I63.111, I63.112, I63.113, I63.119, I63.12, I63.131, I63.132, I63.133, I63.139, I63.19, I63.211, I63.212, I63.213, I63.219, I63.20, I63.22, I63.29, I63.231, I63.232, I63.233, I63.239, I63.30, I63.311, I63.312, I63.313, I63.319, I63.321, I63.322, I63.323, I63.329, I63.331, I63.332, I63.333, I63.339, I63.341, I63.342, I63.349, I63.39, I63.40, I63.411, I63.412, I63.413, I63.419, I63.421, I63.422, I63.423, I63.429, I63.431, I63.432, I63.433, I63.439, I63.441, I63.442, I63.449, I63.49, I63.50, I63.511, I63.512, I63.513, I63.519, I63.521, I63.522, I63.523, I63.529, I63.531, I63.532, I63.533, I63.539, I63.541, I63.542, I63.543, I63.549, I63.59, I63.6, I63.81, I63.89, I63.9, I65.01, I65.02, I65.03, I65.09, I65.1, I65.21, I65.22, I65.23, I65.29, I65.8, I65.9, I66.01, I66.02, I66.03, I66.09, I66.11, I66.12, I66.13, I66.19, I66.21, I66.22, I66.23, I66.29, I66.3, I66.8, I66.9, I70.1, I70.201, I70.202, I70.203, I70.208, I70.209, I70.211, I70.212, I70.213, I70.218, I70.219, I70.221, I70.222, I70.223, I70.228, I70.229, I70.231, I70.232, I70.233, I70.234, I70.235, I70.238, I70.239, I70.241, I70.242, I70.243, I70.244, I70.245, I70.248, I70.249, I70.25, I70.261, I70.262, I70.263, I70.268, I70.269, I70.291, I70.292, I70.293, I70.298, I70.299, I70.301, I70.302, I70.303, I70.308, I70.309, I70.311, I70.312, I70.313, I70.318, I70.319, I70.321, I70.322, I70.323, I70.328, I70.329, I70.331, I70.332, I70.333, I70.334, I70.335, I70.338, I70.339, I70.341, I70.342, I70.343, I70.344, I70.345, I70.348, I70.349, I70.35, I70.361, I70.362, I70.363, I70.368, I70.369, I70.391, I70.392, I70.393, I70.398, I70.399, I70.401, I70.402, I70.403, I70.408, I70.409, I70.411, I70.412, I70.413, I70.418, I70.419, I70.421, I70.422, I70.423, I70.428, I70.429, I70.431, I70.432, I70.433, I70.434, I70.435, I70.438, I70.439, I70.441, I70.442, I70.443, I70.444, I70.445, I70.448, I70.449, I70.45, I70.461, I70.462, I70.463, I70.468, I70.469, I70.491, I70.492, I70.493, I70.498, I70.499, I70.501, I70.502, I70.503, I70.508, I70.509, I70.511, I70.512, I70.513, I70.518, I70.519, I70.521, I70.522, I70.523, I70.528, I70.529, I70.531, I70.532, I70.533, I70.534, I70.535, I70.538, I70.539, I70.541, I70.542, I70.543, I70.544, I70.545, I70.548, I70.549, I70.55, I70.561, I70.562, I70.563, I70.568, I70.569, I70.591, I70.592, I70.593, I70.598, I70.599, I70.601, I70.602, I70.603, I70.608, I70.609, I70.611, I70.612, I70.613, I70.618, I70.619, I70.621, I70.622, I70.623, I70.628, I70.629, I70.631, I70.632, I70.633, I70.634, I70.635, I70.638, I70.639, I70.641, I70.642, I70.643, I70.644, I70.645, I70.648, I70.649, I70.65, I70.661, I70.662, I70.663, I70.668, I70.669, I70.691, I70.692, I70.693, I70.698, I70.699, I70.701, I70.702, I70.703, I70.708, I70.709, I70.711, I70.712, I70.713, I70.718, I70.719, I70.721, I70.722, I70.723, I70.728, I70.729, I70.731, I70.732, I70.733, I70.734, I70.735, I70.738, I70.739, I70.741, I70.742, I70.743, I70.744, I70.745, I70.748, I70.749, I70.75, I70.761, I70.762, I70.763, I70.768, I70.769, I70.791, I70.792, I70.793, I70.798, I70.799, I70.92, I74.01, I74.09, I74.10, I74.11, I74.19, I74.2, I74.3, I74.4, I74.5, I74.8, I74.9, I75.011, I75.012, I75.013, I75.019, I75.021, I75.022, I75.023, I75.029, I75.81, I75.89
AND
At least two patient encounters within 24 months (one encounter during the reporting year)** (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, 99461, 99490, 99491, 99495, 99496, G0402, G0438, G0439
AND
Patient alive as of the last day of the measurement year: G9787
AND NOT
DENOMINATOR EXCLUSION:
Patient receiving hospice services any time during the measurement period: G9690
Numerator (All or Nothing)
The number of IVD patients who meet ALL of the following targets:
- Most recent BP is less than or equal to 140/90 mm Hg
- Most recent tobacco status is Tobacco Free (NOTE: If there is No Documentation of Tobacco Status the patient is not compliant for this measure)
- Daily Aspirin or Other Antiplatelet Unless Contraindicated
- Statin Use Unless Contraindicated
Numerator Options:
COMPONENT 1:
Most recent BP is less than or equal to 140/90 mm Hg
NUMERATOR NOTE: Submit G9789 for blood pressures recorded during Inpatient Stays, Emergency Room Visits, Urgent Care Visits, and Patient Self-Reported BP’s. In order to meet performance, the most recent blood pressure should be recorded within the performance period.
Component Options:
Performance Met: Most recent BP is less than or equal to 140/90 mmHg (G9788)
OR
Denominator Exception: Blood pressure recorded during inpatient stays, Emergency Room Visits, Urgent Care Visits, and Patient Self-Reported BP’s (Home and Health Fair BP results) (G9789)
OR
Performance Exception: Procedure-related BP’s not taken during an outpatient visit. Examples include Same Day Surgery, Ambulatory Service Center, G.I. Lab, Dialysis, Infusion Center, Chemotherapy (G2129)
OR
Performance Not Met: Most recent BP is greater than 140/90 mm Hg, or blood pressure not documented (G9790)
AND
COMPONENT 2:
Most recent tobacco status is tobacco free
NUMERATOR NOTE: Submit G9792, if there is no documentation of tobacco status. In order to meet performance, the most recent tobacco status should be recorded within the performance period.
Component Options:
Performance Met: Most recent tobacco status is tobacco free (G9791)
OR
Performance Not Met: Most recent tobacco status is not tobacco free (G9792)
AND
COMPONENT 3:
Daily aspirin or other antiplatelet unless contraindicated
Component Options:
Performance Met: Patient is currently on a daily aspirin or other antiplatelet (G9793)
OR
Performance Met: Documentation of medical reason(s) for not on a daily aspirin or other antiplatelet (e.g. history of gastrointestinal bleed, intra-cranial bleed, blood disorders, Idiopathic Thrombocytopenic Purpura (ITP), Gastric Bypass or documentation of active anticoagulant use during the measurement period) (G2128)
OR
Performance Not Met: Patient is not currently on a daily aspirin or other antiplatelet (G9795)
AND
COMPONENT 4:
Statin Use
Component Options:
Performance Met: Patient is currently on a statin therapy (G9796)
OR
Performance Met: Documentation of medical reason(s) for not on a statin (e.g. Pregnancy, In Vitro Fertilization, Clomiphene RX, ESRD, Cirrhosis, Muscular Pain and Disease during the measurement period or prior year) (G9940)
OR
Performance Not Met: Patient is not on a statin therapy (G9797)
OR
SUBMISSION CRITERIA 2: PATIENTS WITH ONE ACUTE CORONARY EVENT (ACUTE MYOCARDIAL INFARCTION [AMI], PERCUTANEOUS CORONARY INTERVENTION [PCI], OR CORONARY ARTERY BYPASS GRAFT [CABG]) 18-75 YEARS OF AGE AND ALIVE AS OF THE LAST DAY OF THE MEASUREMENT PERIOD) FROM A HOSPITAL VISIT (EXCLUDING EMERGENCY AND LAB ONLY VISITS) AND HAVE BEEN SEEN BY A PRIMARY CARE PROVIDER (PCP) / CARDIOLOGIST FOR TWO OFFICE VISITS IN 24 MONTHS AND ONE OFFICE VISIT IN 12 MONTHS
Denominator (Submission Criteria 2)
Patients with one Acute Coronary Event (AMI, PCI or CABG) 18-75 years of age and alive as of the last day of the measurement period from a hospital visit (excluding Emergency and Lab Only visits) and been seen by a PCP / Cardiologist for two office visits in 24 months and one office visit in 12 months
DENOMINATOR NOTE: To meet the denominator criteria, the 24-month look back period applies to the reporting year plus prior year. **This measure requires two patient encounters. At least one of the encounters should occur during the performance period to be eligible. If the patient has the history of AMI, PCI or CABG inclusion criterion, there should be documentation of the diagnosis or procedure 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 through 75 years
AND
History of diagnosis for AMI - include patients that had a prior (within the past 24 months) (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, I22.8, I22.9
OR
History of procedures for PCI - include patients that had a prior (within the past 24 months) (CPT or HCPCS): 92920, 92921, 92924, 92925, 92933, 92937, 92938, 92941, 92943, 92944, C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, C9608
OR
History of procedure for CABG - include patients that had a prior (within the past 24 months) (CPT or HCPCS): 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536, 92920, 92924, 92928, 92933, S2205*, S2206*, S2207*, S2208*, S2209*
AND
At least two patient encounters within 24 months (one encounter during the reporting year)** (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, 99461, 99490, 99491, 99495, 99496, G0402, G0438, G0439
AND
Patient alive as of the last day of the measurement year: G9787
AND NOT
DENOMINATOR EXCLUSION:
Patient receiving hospice services any time during the measurement period: G9690
Numerator (All or Nothing)
The number of IVD patients who meet ALL of the following targets:
- Most recent BP is less than or equal to 140/90 mm Hg
- Most recent tobacco status is Tobacco Free (NOTE: If there is No Documentation of Tobacco Status the patient is not compliant for this measure)
- Daily Aspirin or Other Antiplatelet Unless Contraindicated • Statin Use Unless Contraindicated
Numerator Options:
COMPONENT 1:
Most recent BP is less than or equal to 140/90 mm Hg
NUMERATOR NOTE: Submit G9789, if blood pressures recorded during inpatient stays, Emergency Room Visits, Urgent Care Visits, and Patient Self-Reported BP’s do not qualify. In order to meet performance, the most recent blood pressure should be recorded within the performance period.
Component Options:
Performance Met: Most recent BP is less than or equal to 140/90 mmHg (G9788)
OR
Denominator Exception: Blood pressure recorded during inpatient stays, Emergency Room Visits, Urgent Care Visits, and Patient Self-Reported BP’s (Home and Health Fair BP results) (G9789)
OR
Denominator Exception: Procedure-related BP’s not taken during an outpatient visit. Examples include Same Day Surgery, Ambulatory Service Center, G.I. Lab, Dialysis, Infusion Center, Chemotherapy (G2129)
OR
Performance Not Met: Most recent BP is greater than 140/90 mm Hg, orblood pressure not documented (G9790)
AND
COMPONENT 2:
Most recent tobacco status is tobacco free
NUMERATOR NOTE: Submit G9792, if there is no documentation of tobacco status. In order to meet performance, the most recent tobacco status should be recorded within the performance period.
Component Options:
Performance Met: Most recent tobacco status is tobacco free (G9791)
OR
Performance Not Met: Most recent tobacco status is not tobacco free (G9792)
AND
COMPONENT 3:
Daily aspirin or other antiplatelet unless contraindicated
Component Options:
Performance Met: Patient is currently on a daily aspirin or other antiplatelet (G9793)
OR
Performance Met: Documentation of medical reason(s) for not on a daily aspirin or other antiplatelet (e.g. history of gastrointestinal bleed, intra-cranial bleed, blood disorders, Idiopathic Thrombocytopenic Purpura (ITP), Gastric Bypass or documentation of active anticoagulant use during the measurement period) (G2128)
OR
Performance Not Met: Patient is not currently on a daily aspirin or other antiplatelet (G9795)
AND
COMPONENT 4:
Statin Use
Component Options:
Performance Met: Patient is currently on a statin therapy (G9796)
OR
Performance Met: Documentation of medical reason(s) for not on a statin (e.g. Pregnancy, In Vitro Fertilization, Clomiphene RX, ESRD, Cirrhosis, Muscular Pain and Disease during the measurement period or prior year) (G9940)
OR
Performance Not Met: Patient is not on a statin therapy (G9797)
Rationale
There has been important evidence from clinical trials that further supports and broadens the merits of risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease.
Rationale
References: Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, Goldberg AC, Gordon D, Levy D, LloydJones DM, McBride P, Schwartz JS, Shero ST, Smith SC Jr, Watson K, Wilson PWF. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;00:000–000.
Clinical Recommendation Statements
The American College of Cardiology (ACC) and the American Heart Association (AHA) recommend that high-intensity statin therapy should be initiated or continued as first-line therapy in women and men less than or equal to 75 years of age who have clinical atherosclerotic cardiovascular disease, unless contraindicated.
In November 2013, the ACC and AHA Task Force on Practice Guidelines released updated guidance for the treatment of blood cholesterol. The new recommendations remove treatment targets for LDL-C for the primary or secondary prevention of atherosclerotic cardiovascular disease (ASCVD) and recommend high or moderate intensity statin therapy based on patient risk factors. Four major statin benefit groups were identified for whom ASCVD risk clearly outweighs the risk of adverse events. Individuals with ASCVD are one of the identified groups.
Based on trials involving other secondary prevention therapies, the ACC and AHA recommend aspirin in all patients, unless contraindicated, with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. The ACC and AHA also recommend the use of other antiplatelet agents based on disease type and clinical conditions.
Patients with blood pressure greater than or equal to 140/90 mm Hg should be treated, as tolerated, with blood pressure medication, treating initially with beta blockers and/or ACE inhibitors, with addition of other drugs as needed to achieve goal blood pressure.
The ACC and AHA recommends secondary prevention for patients with Coronary and other Vascular Disease that includes strongly encouraging patient and family to stop smoking and to avoid secondhand smoke through the provision of counseling, pharmacological therapy and formal smoking cessation programs as appropriate. The goal is for complete smoking cessation.