2024 MIPS Measure #008: Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Measure Description

Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.

Instructions

This measure is to be submitted for all heart failure patients a minimum of once per performance period when seen in the outpatient setting AND submitted at each hospital discharge (99238 and 99239) during the performance period. Only patients who had at least two denominator eligible visits during the performance period will be counted for Submission Criteria 1.

NOTE: When submitting CPT code 99238 and 99239, it is recommended the measure be submitted each time the code is submitted for hospital discharge.

This measure is intended to reflect the quality of services provided for patients with heart failure and decreased left ventricular systolic function. 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, 95, POS 02, POS 10) 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)  All patients with a diagnosis of HF seen in the outpatient setting

OR

2) All patients with a diagnosis of HF and discharged from hospital

SUBMISSION CRITERIA 1: ALL PATIENTS WITH A DIAGNOSIS OF HF SEEN IN THE OUTPATIENT SETTING

Denominator (Submission Criteria 1)

All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF ≤ 40%

DENOMINATOR NOTE: LVEF ≤ 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction. The left ventricular systolic dysfunction may be determined by quantitative or qualitative assessment, which may be current or historical. Examples of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a numerical value of left ventricular systolic dysfunction or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD can be used to identify patients.

To meet the denominator criteria, a patient must have an active diagnosis of heart failure at the time of the encounter which is used to qualify for the denominator and evaluate the numerator.

The encounter used to evaluate the numerator counts as 1 of the 2 encounters required for denominator inclusion. If the patient meets the heart failure diagnosis criterion, the diagnosis needs to be active only 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) 1:

Patients aged ≥ 18 years on date of encounter

AND

Diagnosis for heart failure (ICD-10-CM): I11.0, I13.0, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.814, I50.82, I50.83, I50.84, I50.89, I50.9

AND

Patient encounter during performance period – to be used for numerator evaluation (CPT): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99424, 99426

AND

At least one additional patient encounter during performance period (CPT): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99424, 99426

AND

Left ventricular ejection fraction (LVEF) ≤ 40% or documentation of moderately or severely depressed left ventricular systolic function: G8923

AND

NOT DENOMINATOR EXCLUSION:

Patients with a history of heart transplant or with a Left Ventricular Assist Device (LVAD): M1152

Numerator (Submission Criteria 1):

Patients who were prescribed beta-blocker therapy within a 12-month period when seen in the outpatient setting

Definitions:

Prescribed – Outpatient Setting – Prescription given to the patient for beta-blocker therapy at one or more visits in the measurement period OR patient already taking beta-blocker therapy as documented in current medication list.

Beta-blocker Therapy – For patients with current or prior LVEF ≤ 40%, “beta-blocker therapy” should include bisoprolol, carvedilol, or sustained release metoprolol succinate.

NUMERATOR NOTE: To meet the intent of the measure, the numerator quality action must be performed at the encounter at which the active diagnosis of heart failure is documented. Denominator Exception(s) are determined on the date of the denominator eligible encounter

Numerator Options:

Performance Met: Beta-blocker therapy prescribed (G8450)

OR

Denominator Exception: Beta-Blocker Therapy for LVEF ≤ 40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient declined, other patient reasons) (G8451)

OR

Performance Not Met: Beta-blocker therapy not prescribed (G8452)

OR

SUBMISSION CRITERIA 2: ALL PATIENTS WITH A DIAGNOSIS OF HF AND DISCHARGED FROM HOSPITAL

Denominator (Submission Criteria 2):

All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF ≤ 40%

DENOMINATOR NOTE: LVEF ≤ 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction. The left ventricular systolic dysfunction may be determined by quantitative or qualitative assessment, which may be current or historical. Examples of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a numerical value of left ventricular systolic dysfunction or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD can be used to identify patients.

Denominator Criteria (Eligible Cases) 2:

Patients aged ≥ 18 years on date of encounter

AND

Diagnosis for heart failure (ICD-10-CM): I11.0, I13.0, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.814, I50.82, I50.83, I50.84, I50.89, I50.9

AND

Patient encounter during performance period (CPT): 99238, 99239

AND

Left ventricular ejection fraction (LVEF) ≤ 40% or documentation of moderately or severely depressed left ventricular systolic function: G8923

AND

NOT DENOMINATOR EXCLUSION:

Patients with a history of heart transplant or with a Left Ventricular Assist Device (LVAD): M1152

Numerator (Submission Criteria 2):

Patients who were prescribed beta-blocker therapy at each hospital discharge

Definitions:

Prescribed – Inpatient Setting – Prescription given to the patient for beta-blocker therapy at discharge OR beta-blocker therapy to be continued after discharge as documented in the discharge medication list.

Beta-blocker Therapy – For patients with current or prior LVEF ≤ 40%, “beta-blocker therapy” should include bisoprolol, carvedilol, or sustained release metoprolol succinate.

NUMERATOR NOTE: To meet the intent of the measure, the numerator quality action must be performed at each denominator eligible discharge. Denominator Exception(s) are determined on the date of the denominator eligible discharge.

Numerator Options:

Performance Met: Beta-blocker therapy prescribed (G8450)

OR

Denominator Exception: Beta-Blocker Therapy for LVEF ≤ 40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient declined, other patient reasons) (G8451)

OR

Performance Not Met: Beta-blocker therapy not prescribed (G8452)

Rationale

Beta blockers improve survival and reduce hospitalization for patients with stable heart failure and reduced LVEF (HFrEF). Treatment should be initiated as soon as a patient is diagnosed with reduced LVEF and does not have prohibitively low systemic blood pressure, fluid overload, or recent treatment with an intravenous positive inotropic agent. Beta blockers have also been shown to lessen the symptoms of heart failure, improve the clinical status of patients, and reduce future clinical deterioration. Despite these benefits, use of beta blockers in eligible patients remains suboptimal.

Clinical Recommendation Statements

In patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations. (Class 1, Level of Evidence A) (AHA/ACC/HFSA, 2022).

Drugs Commonly Used for Stage C HFrEF (abbreviated to align with focus of measure to include only Beta-blocker therapy)

Table 1: Drugs Commonly Used for Stage C HFrEF Beta Blocker Therapy

For the hospitalized patient:

In patients with HFrEF requiring hospitalization, preexisting GDMT* should be continued and optimized to improve outcomes, unless contra-indicated (Class 1, Level of Evidence B-NR) (AHA/ACC/HFSA, 2022).

In patients with HFrEF, GDMT should be initiated during hospitalization after clinical stability is achieved (Class 1, Level of Evidence B-NR) (AHA/ACC/HFSA, 2022).

In patients with HFrEF, if discontinuation of GDMT is necessary during hospitalization, it should be reinitiated and further optimized as soon as possible (Class 1, Level of Evidence B-NR) (AHA/ACC/HFSA, 2022).

*Guideline-Directed Medical Therapy