Measure Description
Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (Stages 1-5, not receiving Renal Replacement Therapy (RRT)) and proteinuria who were prescribed ACE inhibitor or ARB therapy within a 12-month period.
Instructions
This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of CKD (Stages 1-5, not receiving Renal Replacement Therapy (RRT)) and proteinuria 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 (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 aged 18 years and older with the diagnosis of CKD (Stages 1-5, not receiving RRT) and proteinuria
Definitions:
Proteinuria:
- 1. >300mg of albumin in the urine per 24 hours OR
- 2. Urine albumin-to-creatinine ratio (ACR) >300 mg/g OR
- 3. Urine protein-to-creatinine ratio (PCR) > 0.3 g/g
Renal Replacement Therapy (RRT) – For the purposes of this measure, RRT includes hemodialysis, peritoneal dialysis, and kidney transplantation.
Patients receiving RRT –
The following codes would be sufficient to define the Denominator Exclusion (M1199) of receiving RRT: 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, I70.1, N18.6, Z49.31, Z49.32, Z99.2
Denominator Criteria (Eligible Cases):
All patients aged 18 years and older on the date of the encounter
AND
Diagnosis of CKD (Stages 1-5) (ICD-10-CM): E11.22, N18.1, N18.2, N18.30, N18.31, N18.32, N18.4, N18.5, N18.9
AND
Diagnosis of Proteinuria (ICD-10-CM): R80.1, R80.8, R80.9
AND
Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350
AND NOT
DENOMINATOR EXCLUSION:
Patients receiving RRT: M1199
Numerator
Patients who were prescribed ACE inhibitor or ARB therapy within a 12-month period
Definition:
Prescribed – May include prescription given to the patient for ACE Inhibitor or ARB therapy OR patient already taking ACE Inhibitor or ARB therapy as documented in the current medication list.
Numerator Options:
Performance Met: ACE Inhibitor (ACE-I) or ARB therapy prescribed during the measurement period (M1200)
OR
Denominator Exception: Documentation of medical reason(s) for not prescribing ACE inhibitor (ACE-I) or ARB therapy during the measurement period (e.g., pregnancy, history of angioedema to ACE-I, other allergy to ACE-I and ARB, hyperkalemia or history of hyperkalemia while on ACE-I or ARB therapy, acute kidney injury due to ACE-I or ARB therapy, other medical reasons.) (M1201)
OR
Denominator Exception: Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB therapy during the measurement period (e.g., patient declined, other patient reasons). (M1202)
OR
Performance Not Met: ACE inhibitor or ARB therapy not prescribed during the measurement period, reason not given (M1203)
Rational
This measure is aimed at increasing the number of patients with CKD and proteinuria who are prescribed ACE inhibitor or ARB therapy. ACE inhibitors and ARBs are preferred agents for diabetic kidney disease and nondiabetic kidney diseases with proteinuria (albuminuria), even in the absence of hypertension. In these diseases, ACE inhibitors and ARBs lower blood pressure, reduce proteinuria (albuminuria), slow the progression of kidney disease, and likely reduce cardiovascular disease risk by mechanisms in addition to lowering blood pressure. These benefits have been shown across high quality, multi-center, randomized controlled trials such as RENAAL (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan) (Brenner et al., New England Journal of Medicine, 2001). A meta-analysis of randomized trials showed that ACEi/ARB therapy lowered the odds of kidney failure (also known as end-stage renal disease [ESRD]) by 30-39 percent and of cardiovascular disease events by 18 percent-24 percent (Xie et al., Am J Kidney Dis, 2016). In a meta-analysis including primarily diabetic patients with proteinuria, use of ACEi/ARB therapy had a 0.36 to 0.78 odds of incident kidney failure (Cai et al., Nephrology, dialysis, transplantation, 2018). Similarly, in a Cochrane meta-analysis, patients with early (stage 1 to 3) non-diabetic CKD who were treated versus not treated with ACEi/ARB had 31 percent lower risk of kidney failure (Jafar et al., Annals of internal medicine, 2001). Based upon this robust evidence, ACE inhibitors and ARBs are recommended for patients with CKD and proteinuria by the Kidney Disease: Improving Global Outcomes (KDIGO) international guidelines and the Kidney Disease Outcomes Quality Initiative.
CKD is a major public health problem; a total of 37 million Americans have CKD. There is a clear performance gap in ACE inhibitor and ARB usage among patients with CKD, with only 40 percent of CKD patients receiving an ACEi/ARB in NHANES data (Murphy et al., JASN, 2019). Population health efforts to increase the use of ACEi/ARB in American Indians and Alaska Natives have been associated with a decrease in incident kidney failure related to diabetic kidney disease (Bullock et al., MMWR Morbidity and mortality weekly report, 2017). In summary, this measure is a central component of high-quality nephrology care, as ACE inhibitors and ARBs decrease the rate of kidney failure, cardiovascular outcomes, and mortality in patients with CKD and proteinuria.
Clinical Recommendation Statements
Clinical practice guidelines support the use of ACE and ARB in CKD patients not on RRT.
The Kidney Disease Improving Global Outcomes (KDIGO) 2012 guidelines for the evaluation and management of CKD recommend that “an ARB or ACE-I be used in both diabetic and non-diabetic adults with CKD and urine albumin excretion >300 mg/24 hours (or equivalent)” (Recommendation 3.1.7, 1B). Guideline available at https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf.
The KDIGO 2021 Clinical Practice Guideline on the Management of Blood Pressure (BP) in CKD recommends “starting renin-angiotensin-system inhibitors (RASi) (ACEi or ARB) for people with high BP, CKD, and severely increased albuminuria (G1–G4, A3) without diabetes” and “for people with high BP, CKD, and moderately-to-severely increased albuminuria (G1–G4, A2 and A3) with diabetes” (Recommendations 3.2.1 and 3.2.3, 1B). Guideline available at https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2021-BP-GL.pdf.
This measure was rated as HIGH for Overall Measure Validity in Mendu ML, Tummalapalli SL, Lentine KL, Erickson KF, Lew SQ, Liu F, Gould E, Somers M, Garimella PS, O'Neil T, White DL, Meyer R, Bieber SD, Weiner DE. Measuring Quality in Kidney Care: An Evaluation of Existing Quality Metrics and Approach to Facilitating Improvements in Care Delivery. J Am Soc Nephrol. 2020 Mar;31(3):602-614. doi: 10.1681/ASN.2019090869. Epub 2020 Feb 13. PMID: 32054692; PMCID: PMC7062216.