CMS Measure ID: #118
Collection Type: CQM
Reporting Frequency: Once per patient per year
Outcome: No
High Priority: No
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 CAD 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 CAD 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 and 2 of this measure.
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-based submissions; however, these codes may be submitted for those registries that utilize claims data.
Description
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) ≤ 40% who were prescribed ACE inhibitor or ARB therapy
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: No
Capped at 7: No
Decile 0: 0 – 55.55
Decile 1: 55.56 – 70.68
Minimum: 70.69 – 76.66
Decile 3: 76.67 – 79.61
Decile 4: 79.62 – 82.08
Decile 5: 82.09 – 84.95
Decile 6: 84.96 – 87.49
Decile 7: 87.5 – 90.31
Decile 8: 90.32 – 96.14
Decile 9: 96.15 – 99.99
Decile 10: 100 – 100
Denominator
THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:
- Patients who are 18 years and older with a diagnosis of CAD with LVEF ≤ 40%
OR
- Patients who are 18 years and older with a diagnosis of CAD who have diabetes
The MIPS eligible clinician should submit data on one of the submission criteria, depending on the clinical findings. If the patient has CAD and LVSD (without a diagnosis of Diabetes), use Denominator Submission Criteria 1. If the patient has CAD and Diabetes, use Denominator Submission Criteria 2. If the patient has both diabetes and LVSD, the eligible professional may submit quality data for Submission Criteria 2 and this will count as appropriate submission for this patient.
SUBMISSION CRITERIA 1: ALL PATIENTS WITH A DIAGNOSIS OF CAD WITH LVEF ≤ 40% (WITHOUT A DIAGNOSIS OF DIABETES)
DENOMINATOR (SUBMISSION CRITERIA 1):
All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a current or prior LVEF ≤ 40%
Definition:
LVEF ≤ 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction
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 Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for coronary artery disease (ICD-10-CM): I20.0, I20.1, I20.2, I20.8, I20.9, 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, I24.0, I24.8, I24.9, I25.10, I25.110, I25.111, I25.112, I25.118, I25.119, I25.2, I25.5, I25.6, I25.700, I25.701, I25.702, I25.708, I25.709, I25.710, I25.711, I25.712, I25.718, I25.719, I25.720, I25.721, I25.722, I25.728, I25.729, I25.730, I25.731, I25.732, I25.738, I25.739, I25.750, I25.751, I25.752, I25.758, I25.759, I25.760, I25.761, I25.762, I25.768, I25.769, I25.790, I25.791, I25.792, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.83, I25.84, I25.89, I25.9, Z95.1, Z95.5, Z98.61
AND
Patient encounter during the 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
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: G8934
–OR–
SUBMISSION CRITERIA 2: ALL PATIENTS WITH A DIAGNOSIS OF CAD WHO HAVE DIABETES
DENOMINATOR (SUBMISSION CRITERIA 2):
All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes
Definition:
If a patient has both diabetes and LVSD, submission criteria #2 will count as appropriate submission for this patient.
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 Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for coronary artery disease (ICD-10-CM): I20.0, I20.1, I20.2, I20.8, I20.9, 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, I24.0, I24.8, I24.9, I25.10, I25.110, I25.111, I25.112, I25.118, I25.119, I25.2, I25.5, I25.6, I25.700, I25.701, I25.702, I25.708, I25.709, I25.710, I25.711, I25.712, I25.718, I25.719, I25.720, I25.721, I25.722, I25.728, I25.729, I25.730, I25.731, I25.732, I25.738, I25.739, I25.750, I25.751, I25.752, I25.758, I25.759, I25.760, I25.761, I25.762, I25.768, I25.769, I25.790, I25.791, I25.792, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.83, I25.84, I25.89, I25.9, Z95.1, Z95.5, Z98.61
AND
Diagnosis for diabetes (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.36, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.10, E11.11, E11.21, E11.22, E11.29, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319, E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.36, E13.37X1, E13.37X2, E13.37X3, E13.37X9, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83
AND
Patient encounter during the 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
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
Numerator
THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:
- Patients who are 18 years and older with a diagnosis of CAD with LVEF ≤ 40%
OR
- Patients who are 18 years and older with a diagnosis of CAD who have diabetes
The MIPS eligible clinician should submit data on one of the submission criteria, depending on the clinical findings. If the patient has CAD and LVSD (without a diagnosis of Diabetes), use Denominator Submission Criteria 1. If the patient has CAD and Diabetes, use Denominator Submission Criteria 2. If the patient has both diabetes and LVSD, the eligible professional may submit quality data for Submission Criteria 2 and this will count as appropriate submission for this patient.
SUBMISSION CRITERIA 1: ALL PATIENTS WITH A DIAGNOSIS OF CAD WITH LVEF ≤ 40% (WITHOUT A DIAGNOSIS OF DIABETES)
NUMERATOR (SUBMISSION CRITERIA 1):
Patients who were prescribed ACE inhibitor or ARB therapy
Definition:
Prescribed – May include prescription given to the patient for ACE inhibitor or ARB therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB therapy as documented in current medication list.
NUMERATOR NOTE: Eligible clinicians who have given a prescription to the patient for or whose patient is currently taking a combination medication therapy, which contains either an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) (e.g., angiotensin receptor neprilysin inhibitor [ARNI, sacubitril/valsartan], ACE inhibitor+diuretic, ARB+diuretic, (ACE inhibitor+calcium channel blocker) would meet performance for this measure.
Numerator Options:
Performance Met:
Clinician prescribed angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy (G8935)
OR
Denominator Exception:
Clinician documented that patient was not an eligible candidate for angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy (e.g., allergy, intolerance, pregnancy, renal failure due to ACE inhibitor, diseases of the aortic or mitral valve, other medical reasons) or (e.g., patient declined, other patient reasons) or (e.g., lack of drug availability, other reasons attributable to the health care system) (G8936)
OR
Performance Not Met:
Clinician did not prescribe angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy, reason not given (G8937)
–OR–
SUBMISSION CRITERIA 2: ALL PATIENTS WITH A DIAGNOSIS OF CAD WHO HAVE DIABETES
NUMERATOR (SUBMISSION CRITERIA 2):
Patients who were prescribed ACE inhibitor or ARB therapy
Definition:
Prescribed – May include prescription given to the patient for ACE inhibitor or ARB therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB therapy as documented in current medication list.
NUMERATOR NOTE: Eligible clinicians who have given a prescription to the patient for or whose patient is currently taking a combination medication therapy, which contains either an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) (e.g., angiotensin receptor neprilysin inhibitor [ARNI, sacubitril/valsartan], (ACE inhibitor+diruretic, ARB+diruretic, ACE inhibitor+calcium channel blocker) would meet performance for this measure.
Numerator Options:
Performance Met:
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy prescribed (G8473)
OR
Denominator Exception:
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy not prescribed for reasons documented by the clinician (e.g., allergy, intolerance, pregnancy, renal failure due to ACE inhibitor, diseases of the aortic or mitral valve, other medical reasons) or (e.g., patient declined, other patient reasons) or (e.g., lack of drug availability, other reasons attributable to the health care system) (G8474)
OR
Performance Not Met:
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy not prescribed, reason not given (G8475)
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