CMS Measure ID: #5
Collection Type: CQM
Reporting Frequency: 1: Once per patient/year; 2: Every Visit
Outcome: No
High Priority: No
NQS Domain: Effective Clinical Care
Measure Age: > 2 years
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.
*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 HF 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. Only patients who had at least two denominator eligible visits during the performance period will be counted for Submission Criteria 1.
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.
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 ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: Yes
Capped at 7: Yes
Decile 0: 0 – 67.34
Decile 1: 67.35 – 87.99
Minimum: 88 – 95.44
Decile 3: 95.45 – 98.54
Decile 4: 98.55 – 99.99
Decile 10: 100 – 100
eCQM
Topped out: No
Capped at 7: No
Decile 0: 0 – 23.99
Decile 1: 24 – 60.79
Minimum: 60.8 – 68.88
Decile 3: 68.89 – 73.6
Decile 4: 73.61 – 77.42
Decile 5: 77.43 – 80.02
Decile 6: 80.03 – 82.38
Decile 7: 82.39 – 85.52
Decile 8: 85.53 – 88.13
Decile 9: 88.14 – 91.66
Decile 10: 91.67 – 100
Denominator
THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:
- All patients with a diagnosis of HF assessed during an outpatient encounter
OR
- All patients with a diagnosis of HF and discharged from hospital
SUBMISSION CRITERIA 1: ALL PATIENTS WITH A DIAGNOSIS OF HF ASSESSED DURING AN OUTPATIENT ENCOUNTER
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 LVSD 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 LVSD 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 registrybased measures.
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) less than or equal to 40% or documentation of moderately or severely depressed left ventricular systolic function: M1150
AND NOT
DENOMINATOR EXCLUSION
Patients with a history of heart transplant or with a Left Ventricular Assist Device (LVAD): M1151
–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 LVSD 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 LVSD 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) less than or equal to 40% or documentation of moderately or severely depressed left ventricular systolic function: M1150
AND NOT
DENOMINATOR EXCLUSION
Patients with a history of heart transplant or with a Left Ventricular Assist Device (LVAD): M1151
Numerator
THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:
- All patients with a diagnosis of HF assessed during an outpatient encounter
OR
- All patients with a diagnosis of HF and discharged from hospital
SUBMISSION CRITERIA 1: ALL PATIENTS WITH A DIAGNOSIS OF HF ASSESSED DURING AN OUTPATIENT ENCOUNTER
NUMERATOR (SUBMISSION CRITERIA 1):
Patients who were prescribed ACE inhibitor or ARB or ARNI therapy within a 12-month period when seen in the outpatient setting
Definition:
Prescribed – Outpatient setting: prescription given to the patient for ACE inhibitor or ARB or ARNI therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB or ARNI therapy as documented in current medication list.
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. MIPS eligible clinicians who have given a prescription for or whose patient is already taking an Angiotensin-Converting Enzyme Inhibitor (ACE inhibitor) or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) would meet performance for this measure. Other combination therapies that consist of an ACE inhibitor plus diuretic, ARB + neprilysin inhibitor (ARNI), ARB plus diuretic, ACE inhibitor plus calcium channel blocker, ARB plus calcium channel blocker, or ARB plus calcium channel blocker plus diuretic would also meet performance for this measure. Denominator Exception(s) are determined on the date of the denominator eligible encounter.
Numerator Options:
Performance Met:
Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) therapy prescribed or currently being taken (G2092)
OR
Denominator Exception:
Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., hypotensive patients who are at immediate risk of cardiogenic shock, hospitalized patients who have experienced marked azotemia, allergy, intolerance, other medical reasons) (G2093)
OR
Denominator Exception:
Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., patient declined, other patient reasons) (G2094)
OR
Performance Not Met:
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) therapy was not prescribed, reason not given (G2096)
–OR–
SUBMISSION CRITERIA 2: ALL PATIENTS WITH A DIAGNOSIS OF HF AND DISCHARGED FROM HOSPITAL
NUMERATOR (SUBMISSION CRITERIA 2):
Patients who were prescribed ACE inhibitor or ARB or ARNI therapy at hospital discharge
Definition:
Prescribed – Inpatient setting: prescription given to the patient for ACE inhibitor or ARB or ARNI therapy at discharge OR ACE inhibitor or ARB or ARNI therapy to be continued after discharge as documented in the discharge medication list.
NUMERATOR NOTE: To meet the intent of the measure, the numerator quality action must be performed at each denominator eligible discharge. MIPS eligible clinicians who have given a prescription for or whose patient is already taking an Angiotensin-Converting Enzyme Inhibitor (ACE inhibitor) or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) would meet performance for this measure. Other combination therapies that consist of an ACE inhibitor plus diuretic, ARB + neprilysin inhibitor (ARNI), ARB plus diuretic, ACE inhibitor plus calcium channel blocker, ARB plus calcium channel blocker, or ARB plus calcium channel blocker plus diuretic would also meet performance for this measure. Denominator Exception(s) are determined on the date of the denominator eligible encounter.
Numerator Options:
Performance Met:
Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) therapy prescribed or currently being taken (G2092)
OR
Denominator Exception:
Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., hypotensive patients who are at immediate risk of cardiogenic shock, hospitalized patients who have experienced marked azotemia, allergy, intolerance, other medical reasons) (G2093)
OR
Denominator Exception:
Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., patient declined, other patient reasons) (G2094)
OR
Performance Not Met:
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) therapy was not prescribed, reason not given (G2096)