2023 # 243 Cardiac Rehabilitation Patient Referral from an Outpatient Setting

CMS Measure ID: #243

Collection Type: CQM

Reporting Frequency: Once per patient per year

Outcome: No

High Priority: Yes

NQS Domain: Communication and Care Coordination

Measure Age: > 2 years

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:

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

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 1. Documented communication* between the health care provider and the patient to recommend an outpatient CR program AND 2A. Official referral order† is sent to outpatient CR program OR 2B. Documentation of patient refusal to justify why patient information was not sent to the CR program‡Note: Performance is met if steps 1 AND either 2A (official referral order transmitted) OR 2B (patient refusal documented in the patient’s medical record) are completed and documented. If a patient has had multiple qualifying events, at least 1 referral made in the past 12 mo should be captured.* All communications must maintain appropriate confidentiality as outlined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).†All patient information required for enrollment should be transmitted to the CR program. Necessary patient information may be found in the hospital discharge summary.‡Patients who refuse a CR referral should not have their data transmitted to the receiving CR program against their will.

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.

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: No
Capped at 7: No

Decile 0: 0 – 0.68
Decile 1: 0.69 – 5.15
Minimum: 5.16 – 11.23
Decile 3: 11.24 – 18.08
Decile 4: 18.09 – 26.97
Decile 5: 26.98 – 32.97
Decile 6: 32.98 – 38.34
Decile 7: 38.35 – 51.91
Decile 8: 51.92 – 64.57
Decile 9: 64.58 – 95.04
Decile 10: 95.05 – 100

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, 99315, 99316, 99242*, 99243*, 99244*, 99245*, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99424, 99426, G0438, G0439

AND

Diagnosis for Chronic Stable Angina (ICD-10-CM): I20.1, I20.2, 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): 33509, 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, 0543T, 0544T, 0545T, 0569T, 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, 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)