2023 # 398 Optimal Asthma Control

CMS Measure ID: #398

Collection Type: CQM

Reporting Frequency: Once per patient per year

Outcome: Yes

High Priority: Yes

NQS Domain: Effective Clinical Care

Measure Age: > 2 years

Instructions

This measure is to be submitted a minimum of once per performance period for all patients with a diagnosis of asthma 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 for the primary management of patients with asthma based on the services provided and the measure-specific denominator coding.

This measure will be calculated with 7 performance rates:

1. Overall Percentage for patients (aged 5-50 years) with well-controlled asthma, without elevated risk of exacerbation.
2. Percentage of pediatric patients (aged 5-17 years) with well-controlled asthma, without elevated risk of exacerbation.
3. Percentage of adult patients (aged 18-50 years) with well-controlled asthma, without elevated risk of exacerbation.
4. Asthma well-controlled (submit the most recent specified asthma control tool result ) for patients 5 to 17 with Asthma
5. Asthma well-controlled (submit the most recent specified asthma control tool result ) for patients 18 to 50 with Asthma
6. Patient not at elevated risk of exacerbation for patients 5 to 17 with Asthma
7. Patient not at elevated risk of exacerbation for patients 18 to 50 with Asthma

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:

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 for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

Description

Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: No
Capped at 7: No

Decile 0: 0 – 4.43
Decile 1: 4.44 – 41.93
Minimum: 41.94 – 52.26
Decile 3: 52.27 – 61.28
Decile 4: 61.29 – 69.69
Decile 5: 69.7 – 85.7
Decile 6: 85.71 – 97.05
Decile 7: 97.06 – 99.99
Decile 10: 100 – 100

Denominator

DENOMINATOR (SUBMISSION CRITERIA 1):

Patients ages 5 to 17 with asthma

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.

Visits to a primary care setting, regardless of the reason for the visit or the scheduling status of the visit (e.g., walk-in) are to be included. In a multi-specialty clinic setting, patients who have visits from both the primary care setting and the urgent care setting during the performance period are to be included. M1021 may be used if the patient is only evaluated at an urgent care visit and is not considered an established patient to allow for care coordination or follow up.

Denominator Criteria (Eligible Cases) 1:

Patients aged 5-17 years

AND

Diagnosis for asthma (ICD-10-CM): J45.20, J45.21, J45.22, J45.30, J45.31, J45.32, J45.40, J45.41, J45.42, J45.50, J45.51, J45.52, J45.901, J45.902, J45.909, J45.990, J45.991, J45.998

AND

Patient had a diagnosis of asthma with any contact during the current or prior performance period OR had asthma present on an active problem list any time during the performance period

AND

Established patient office visit during the performance period (CPT): 99211, 99212, 99213, 99214, 99215, 99392*, 99393*, 99394*, 99395*, 99396*, 99421, 99422, 99423, 99441, 99442, 99443

AND NOT

DENOMINATOR EXCLUSIONS:

Diagnosis for chronic obstructive pulmonary disease, emphysema, cystic fibrosis, or acute respiratory failure

– The following codes would be sufficient to define the Denominator Exclusion of chronic obstructive pulmonary disease, emphysema, cystic fibrosis, or acute respiratory failure: E84.0, E84.11, E84.19, E84.8, E84.9, J43.0, J43.1, J43.2, J43.8, J43.9, J44.0, J44.1, J44.9, J68.4, J96.00, J96.01, J96.02, J96.20, J96.21, J96.22, J98.2, J98.3.

– For historical reference purposes these ICD-9 codes if documented would be sufficient to define the Denominator Exclusion of chronic obstructive pulmonary disease, emphysema, cystic fibrosis, or acute respiratory failure: 277.00, 277.01, 277.02, 277.03, 277.09, 491.20, 491.21, 491.22, 492.0, 492.8, 493.20, 493.21, 493.22, 496, 506.4, 518.1, 518.2, 518.81

OR

Patient died prior to the end of the performance period

OR

Patient was a permanent nursing home resident any time during the performance period

OR

Patient was in hospice or receiving palliative care services at any time during the performance period

OR

Patient had only urgent care visits during the performance period:
M1021

DENOMINATOR (SUBMISSION CRITERIA 2):

Patients ages 18 to 50 with asthma

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.

Visits to a primary care setting, regardless of the reason for the visit or the scheduling status of the visit (e.g., walk-in) are to be included. In a multi-specialty clinic setting, patients who have visits from both the primary care setting and the urgent care setting during the performance period are to be included. M1021 may be used if the patient is only evaluated at an urgent care visit and is not considered an established patient to allow for care coordination or follow up.

Denominator Criteria (Eligible Cases) 2:

Patients aged 18-50 years

AND

Diagnosis for asthma (ICD-10-CM): J45.20, J45.21, J45.22, J45.30, J45.31, J45.32, J45.40, J45.41, J45.42, J45.50, J45.51, J45.52, J45.901, J45.902, J45.909, J45.990, J45.991, J45.998

AND

Patient had a diagnosis of asthma with any contact during the current or prior performance period OR had asthma present on an active problem list any time during the performance period

AND

Established patient office visit during the performance period (CPT): 99211, 99212, 99213, 99214, 99215, 99392*, 99393*, 99394*, 99395*, 99396*, 99421, 99422, 99423, 99441, 99442, 99443

AND NOT

DENOMINATOR EXCLUSIONS:

Diagnosis for chronic obstructive pulmonary disease, emphysema, cystic fibrosis, or acute respiratory failure

– The following codes would be sufficient to define the Denominator Exclusion of chronic obstructive pulmonary disease, emphysema, cystic fibrosis, or acute respiratory failure: E84.0, E84.11, E84.19, E84.8, E84.9, J43.0, J43.1, J43.2, J43.8, J43.9, J44.0, J44.1, J44.9, J68.4, J96.00, J96.01, J96.02, J96.20, J96.21, J96.22, J98.2, J98.3.

– For historical reference purposes these ICD-9 codes if documented would be sufficient to define the Denominator Exclusion of chronic obstructive pulmonary disease, emphysema, cystic fibrosis, or acute respiratory failure: 277.00, 277.01, 277.02, 277.03, 277.09, 491.20, 491.21, 491.22, 492.0, 492.8, 493.20, 493.21, 493.22, 496, 506.4, 518.1, 518.2, 518.81

OR

Patient died prior to the end of the performance period

OR

Patient was a permanent nursing home resident any time during the performance period

OR

Patient was in hospice or receiving palliative care services at any time during the performance period

OR

Patient had only urgent care visits during the performance period:
M1021

Numerator

NUMERATOR (SUBMISSION CRITERIA 1, ALL OR NOTHING):

The number of asthma patients who meet ALL of the following targets

Numerator Options:

Each component should be submitted in order to determine the data completeness and performance rate for the overall percentage of patients that meet ALL targets represented as the numerator.

COMPONENT 1:

Asthma well-controlled (submit the most recent asthma control tool result available during the measurement period)

• Asthma Control Test™ (ACT) result of 20 or above – ages 12 and older
• Childhood Asthma Control Test™ (C-ACT) result of 20 or above – ages 11 and younger
• Asthma Control Questionnaire (ACQ) result of 0.75 or lower – ages 17 and older
• Asthma Therapy Assessment Questionnaire (ATAQ) result of 0 – Pediatric (ages 5 – 17) or Adult (ages 18 and older)

Component Options:

Performance Met: Asthma well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score and results documented (G9432)

OR

Performance Not Met:

Asthma not well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score, OR specified asthma control tool not used, reason not given (G9434)

AND

COMPONENT 2:

Patient not at elevated risk of exacerbation

NUMERATOR NOTE: To meet performance for this component, documentation of the sum of the patient’s submitted values for the following questions must be less than two:

• Number of emergency department visits not resulting in a hospitalization due to asthma in last 12 months
• Number of inpatient hospitalizations requiring an overnight stay due to asthma in last 12 months.

Component Options:

Performance Met:

Total number of emergency department visits and inpatient hospitalizations less than two in the past 12 months (G9521)

OR

Performance Not Met:

Total number of emergency department visits and inpatient hospitalizations equal to or greater than two in the past 12 months OR patient not screened, reason not given (G9522)

NUMERATOR (SUBMISSION CRITERIA 2, ALL OR NOTHING):

The number of asthma patients who meet ALL of the following targets

Numerator Options:

Each component should be submitted in order to determine the data completeness and performance rate for the overall percentage of patients that meet ALL targets represented as the numerator.

COMPONENT 1:

Asthma well-controlled (submit the most recent asthma control tool result available during the measurement period)

• Asthma Control Test™ (ACT) result of 20 or above – ages 12 and older
• Asthma Control Questionnaire (ACQ) result of 0.75 or lower – ages 17 and older
• Asthma Therapy Assessment Questionnaire (ATAQ) result of 0 – Pediatric (ages 5 – 17) or Adult (ages 18 and older)

Component Options:

Performance Met:

Asthma well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score and results documented (G9432)

OR

Performance Not Met:

Asthma not well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score, OR specified asthma control tool not used, reason not given (G9434)

AND

COMPONENT 2:

Patient not at elevated risk of exacerbation

NUMERATOR NOTE: To meet performance for this component, documentation of the sum of the patient’s submitted values for the following questions must be less than two:

• Number of emergency department visits not resulting in a hospitalization due to asthma in last 12 months
• Number of inpatient hospitalizations requiring an overnight stay due to asthma in last 12 months

Component Options:

Performance Met:

Total number of emergency department visits and inpatient hospitalizations less than two in the past 12 months (G9521)

OR

Performance Not Met:

Total number of emergency department visits and inpatient hospitalizations equal to or greater than two in the past 12 months OR patient not screened, reason not given (G9522)