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

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 outpatientCR program. This also includes a written or electronic communication between the healthcare provideror 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 includethe 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)

“