2023 # 441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)

CMS Measure ID: #441

Collection Type: CQM, MVP

Reporting Frequency: Once per patient per year

Outcome: No

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 seen during the performance period. The most recent quality-data code submitted will be used for performance calculation. 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 ischemic vascular disease 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, telephone visits, online visits and eVisits) 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

The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization’s total IVD denominator. All-or-None Outcome Measure (Optimal Control) – Using the IVD denominator optimal results include:

  • Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg — AND
  • Most recent tobacco status is Tobacco Free — AND
  • Daily Aspirin or Other Antiplatelet Unless Contraindicated — AND
  • Statin Use Unless Contraindicated

2022 Benchmarks (from 2020 CMS data)

Registry

Topped out: No
Capped at 7: No

Minimum: 0 – 28.23
Decile 3: 28.24 – 39.01
Decile 4: 39.02 – 47.37
Decile 5: 47.38 – 59.46
Decile 6: 59.47 – 66.66
Decile 7: 66.67 – 72.21
Decile 8: 72.22 – 76.34
Decile 10: 80.61 – 100
Decile 9: 76.35 – 80.6

Denominator

THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:

1) Patients with coronary artery disease (CAD) or a CAD Risk-Equivalent Condition 18-75 years of age and alive as of the last day of the measurement period and a minimum of two CAD or CAD Risk-Equivalent Condition coded office visits with a Primary Care Provider (PCP) / Cardiologist in 24 months and one office visit in 12 months

OR

2) Patients with one Acute Coronary Event (Acute Myocardial Infarction [AMI], Percutaneous Coronary Intervention [PCI], or Coronary Artery Bypass Graft [CABG]) 18-75 years of age and alive as of the last day of the measurement period) from a hospital visit (excluding Emergency and Lab Only visits) and have been seen by a primary care provider (PCP) / Cardiologist for two office visits in 24 months and one office visit in 12 months

SUBMISSION CRITERIA 1PATIENTS WITH CORONARY ARTERY DISEASE (CAD) OR A CAD RISK-EQUIVALENT CONDITION 18-75 YEARS OF AGE AND ALIVE AS OF THE LAST DAY OF THE MEASUREMENT PERIOD AND A MINIMUM OF TWO CAD OR CAD RISK-EQUIVALENT CONDITION CODED OFFICE VISITS WITH A PRIMARY CARE PROVIDER (PCP) / CARDIOLOGIST IN 24 MONTHS AND ONE OFFICE VISIT IN 12 MONTHS

DENOMINATOR (SUBMISSION CRITERIA 1):
Patients with CAD or a CAD Risk-Equivalent Condition (other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease) 18-75 years of age and alive as of the last day of the measurement period and a minimum of two CAD or CAD Risk-Equivalent Condition coded office visits with a Primary Care Provider (PCP) / Cardiologist in 24 months and one office visits in 12 months

DENOMINATOR NOTE: To meet the denominator criteria, the 24-month look back period applies to the performance period plus prior year. **This measure requires two patient encounters. At least one of the encounters should occur during the performance period to be eligible.

*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) 1:

Patients aged 18 through 75 years

AND

Diagnosis for CAD (ICD-10-CM): I20.0, I20.1, 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.A1, I21.A9, I22.0, I22.1, I22.8, I22.9, I24.0, I24.1, 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, I25.89, I25.9, Z95.1, Z95.5, Z95.818, Z95.820, Z95.828, Z95.9, Z98.61, Z98.62

OR

Diagnosis for CAD Risk-Equivalent Condition (ICD-10-CM): I63.00, I63.011, I63.012, I63.013, I63.019, I63.02, I63.031, I63.032, I63.033, I63.039, I63.09, I63.10, I63.111, I63.112, I63.113, I63.119, I63.12, I63.131, I63.132, I63.133, I63.139, I63.19, I63.211, I63.212, I63.213, I63.219, I63.20, I63.22, I63.29, I63.231, I63.232, I63.233, I63.239, I63.30, I63.311, I63.312, I63.313, I63.319, I63.321, I63.322, I63.323, I63.329, I63.331, I63.332, I63.333, I63.339, I63.341, I63.342, I63.349, I63.39, I63.40, I63.411, I63.412, I63.413, I63.419, I63.421, I63.422, I63.423, I63.429, I63.431, I63.432, I63.433, I63.439, I63.441, I63.442, I63.449, I63.49, I63.50, I63.511, I63.512, I63.513, I63.519, I63.521, I63.522, I63.523, I63.529, I63.531, I63.532, I63.533, I63.539, I63.541, I63.542, I63.543, I63.549, I63.59, I63.6, I63.81, I63.89, I63.9, I65.01, I65.02, I65.03, I65.09, I65.1, I65.21, I65.22, I65.23, I65.29, I65.8, I65.9, I66.01, I66.02, I66.03, I66.09, I66.11, I66.12, I66.13, I66.19, I66.21, I66.22, I66.23, I66.29, I66.3, I66.8, I66.9, I70.1, I70.201, I70.202, I70.203, I70.208, I70.209, I70.211, I70.212, I70.213, I70.218, I70.219, I70.221, I70.222, I70.223, I70.228, I70.229, I70.231, I70.232, I70.233, I70.234, I70.235, I70.238, I70.239, I70.241, I70.242, I70.243, I70.244, I70.245, I70.248, I70.249, I70.25, I70.261, I70.262, I70.263, I70.268, I70.269, I70.291, I70.292, I70.293, I70.298, I70.299, I70.301, I70.302, I70.303, I70.308, I70.309, I70.311, I70.312, I70.313, I70.318, I70.319, I70.321, I70.322, I70.323, I70.328, I70.329, I70.331, I70.332, I70.333, I70.334, I70.335, I70.338, I70.339, I70.341, I70.342, I70.343, I70.344, I70.345, I70.348, I70.349, I70.35, I70.361, I70.362, I70.363, I70.368, I70.369, I70.391, I70.392, I70.393, I70.398, I70.399, I70.401, I70.402, I70.403, I70.408, I70.409, I70.411, I70.412, I70.413, I70.418, I70.419, I70.421, I70.422, I70.423, I70.428, I70.429, I70.431, I70.432, I70.433, I70.434, I70.435, I70.438, I70.439, I70.441, I70.442, I70.443, I70.444, I70.445, I70.448, I70.449, I70.45, I70.461, I70.462, I70.463, I70.468, I70.469, I70.491, I70.492, I70.493, I70.498, I70.499, I70.501, I70.502, I70.503, I70.508, I70.509, I70.511, I70.512, I70.513, I70.518, I70.519, I70.521, I70.522, I70.523, I70.528, I70.529, I70.531, I70.532, I70.533, I70.534, I70.535, I70.538, I70.539, I70.541, I70.542, I70.543, I70.544, I70.545, I70.548, I70.549, I70.55, I70.561, I70.562, I70.563, I70.568, I70.569, I70.591, I70.592, I70.593, I70.598, I70.599, I70.601, I70.602, I70.603, I70.608, I70.609, I70.611, I70.612, I70.613, I70.618, I70.619, I70.621, I70.622, I70.623, I70.628, I70.629, I70.631, I70.632, I70.633, I70.634, I70.635, I70.638, I70.639, I70.641, I70.642, I70.643, I70.644, I70.645, I70.648, I70.649, I70.65, I70.661, I70.662, I70.663, I70.668, I70.669, I70.691, I70.692, I70.693, I70.698, I70.699, I70.701, I70.702, I70.703, I70.708, I70.709, I70.711, I70.712, I70.713, I70.718, I70.719, I70.721, I70.722, I70.723, I70.728, I70.729, I70.731, I70.732, I70.733, I70.734, I70.735, I70.738, I70.739, I70.741, I70.742, I70.743, I70.744, I70.745, I70.748, I70.749, I70.75, I70.761, I70.762, I70.763, I70.768, I70.769, I70.791, I70.792, I70.793, I70.798, I70.799, I70.92, I74.01, I74.09, I74.10, I74.11, I74.19, I74.2, I74.3, I74.4, I74.5, I74.8, I74.9, I75.011, I75.012, I75.013, I75.019, I75.021, I75.022, I75.023, I75.029, I75.81, I75.89

AND

At least two patient encounters within 24 months (one encounter during the reporting year)** (CPT or HCPCS): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99424, 99426, 99429*, 99461, 99490, 99491, 99495, 99496, G0402, G0438, G0439, 99441, 99442, 99443, 99421, 99422, 99423, G2010, G2012, 99341, 99342, 99343, 99344, 99345

AND

Patient alive as of the last day of the measurement year: G9787

AND NOT

DENOMINATOR EXCLUSION:
Patient receiving hospice services any time during the measurement period: G9690

–OR–

SUBMISSION CRITERIA 2: PATIENTS WITH ONE ACUTE CORONARY EVENT (ACUTE MYOCARDIAL INFARCTION [AMI], PERCUTANEOUS CORONARY INTERVENTION [PCI], OR CORONARY ARTERY BYPASS GRAFT [CABG]) 18-75 YEARS OF AGE AND ALIVE AS OF THE LAST DAY OF THE MEASUREMENT PERIOD) FROM A HOSPITAL VISIT (EXCLUDING EMERGENCY AND LAB ONLY VISITS) AND HAVE BEEN SEEN BY A PRIMARY CARE PROVIDER (PCP) / CARDIOLOGIST FOR TWO OFFICE VISITS IN 24 MONTHS AND ONE OFFICE VISIT IN 12 MONTHS

DENOMINATOR (SUBMISSION CRITERIA 2):

Patients with one Acute Coronary Event (AMI, PCI or CABG) 18-75 years of age and alive as of the last day of the measurement period from a hospital visit (excluding Emergency and Lab Only visits) and been seen by a PCP / Cardiologist for two office visits in 24 months and one office visit in 12 months

DENOMINATOR NOTE: To meet the denominator criteria, the 24-month look back period applies to the reporting year plus prior year. **This measure requires two patient encounters. At least one of the encounters should occur during the performance period to be eligible. If the patient has the history of AMI, PCI or CABG inclusion criterion, there should be documentation of the diagnosis or procedure 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 MIPS CQMs.

Denominator Criteria (Eligible Cases) 2:

Patients aged 18 through 75 years

AND

History of diagnosis for AMI – include patients that had a prior (within the past 24 months) (ICD-10-CM): I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I21.9, I21.A1, I21.A9, I22.0, I22.1, I22.8, I22.9

OR

History of procedures for PCI – include patients that had a prior (within the past 24 months) (CPT or HCPCS): 92920, 92924, 92933, 92937, 92941, 92943, C9600, C9602, C9604, C9606, C9607

OR

History of procedure for CABG – include patients that had a prior (within the past 24 months) (CPT or HCPCS): 33509, 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536, 92920, 92924, 92928, 92933, S2205*, S2206*, S2207*, S2208*, S2209*

AND

At least two patient encounters within 24 months (one encounter during the reporting year)** (CPT or HCPCS): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99424, 99426, 99429*, 99461, 99490, 99491, 99495, 99496, G0402, G0438, G0439, 99441, 99442, 99443, 99421, 99422, 99423, G2010, G2012, 99341, 99342, 99343, 99344, 99345

AND

Patient alive as of the last day of the measurement period: G9787

AND NOT

DENOMINATOR EXCLUSION:
Patient receiving hospice services any time during the measurement period: G9690

Numerator

SUBMISSION CRITERIA 1PATIENTS WITH CORONARY ARTERY DISEASE (CAD) OR A CAD RISK-EQUIVALENT CONDITION 18-75 YEARS OF AGE AND ALIVE AS OF THE LAST DAY OF THE MEASUREMENT PERIOD AND A MINIMUM OF TWO CAD OR CAD RISK-EQUIVALENT CONDITION CODED OFFICE VISITS WITH A PRIMARY CARE PROVIDER (PCP) / CARDIOLOGIST IN 24 MONTHS AND ONE OFFICE VISIT IN 12 MONTHS

NUMERATOR (ALL OR NOTHING):

The number of IVD patients who meet ALL of the following targets:

  • Most recent BP is less than or equal to 140/90 mm Hg
  • Most recent tobacco status is Tobacco Free (NOTE: If there is No Documentation of Tobacco Status the patient is not compliant for this measure)
  • Daily Aspirin or Other Antiplatelet Unless Contraindicated
  • Statin Use Unless Contraindicated

Numerator Options:

COMPONENT 1:

Most recent BP is less than or equal to 140/90 mm Hg

NUMERATOR NOTE: 

  • Submit G9789 for blood pressures recorded during Inpatient Stays, Emergency Room Visits, or Urgent Care Visits. In order to meet performance, the most recent blood pressure should be recorded within the performance period.
  • Home BP results which can be obtained digitally, in writing or verbally, and are able to be stored in the EMR in a discrete field can be included. Accepting these BP results is at the discretion of the provider.

Component Options:

Performance Met:

Most recent BP is less than or equal to 140/90 mm Hg (G9788)

OR

Denominator Exception:

Blood pressure recorded during inpatient stays, Emergency Room Visits, or Urgent Care Visits (G9789)

OR

Denominator Exception:

Procedure-related BP’s not taken during an outpatient visit. Examples include Same Day Surgery, Ambulatory Service Center, G.I. Lab, Dialysis, Infusion Center, Chemotherapy (G2129)

OR

Performance Not Met:

Most recent BP is greater than 140/90 mm Hg, or blood pressure not documented (G9790)

AND

COMPONENT 2:

Most recent tobacco status is tobacco free

NUMERATOR NOTE: Submit G9792, if there is no documentation of tobacco status. In order to meet performance, the most recent tobacco status should be recorded within the performance period.

Component Options:

Performance Met:

Most recent tobacco status is tobacco free (G9791)

OR

Performance Not Met:

Most recent tobacco status is not tobacco free (G9792)

AND

COMPONENT 3:

Daily aspirin or other antiplatelet unless contraindicated

Component Options:

Performance Met:

Patient is currently on a daily aspirin or other antiplatelet (G9793)

OR

Performance Met:

Documentation of medical reason(s) for not on a daily aspirin or other antiplatelet (e.g. history of gastrointestinal bleed, intra-cranial bleed, blood disorders, Idiopathic Thrombocytopenic Purpura (ITP), Gastric Bypass or documentation of active anticoagulant use during the measurement period) (G2128)

OR

Performance Not Met:

Patient is not currently on a daily aspirin or other antiplatelet (G9795)

AND

COMPONENT 4:

Statin Use

Component Options:

Performance Met:

Patient is currently on a statin therapy (G9796)

OR

Performance Met:

Documentation of medical reason(s) for not on a statin (e.g. Pregnancy, In Vitro Fertilization, Clomiphene RX, ESRD, Cirrhosis, Muscular Pain and Disease during the measurement period or prior year) (G9940)

OR

Performance Not Met:

Patient is not on a statin therapy (G9797)

–OR–

SUBMISSION CRITERIA 2PATIENTS WITH ONE ACUTE CORONARY EVENT (ACUTE MYOCARDIAL INFARCTION [AMI], PERCUTANEOUS CORONARY INTERVENTION [PCI], OR CORONARY ARTERY BYPASS GRAFT [CABG]) 18-75 YEARS OF AGE AND ALIVE AS OF THE LAST DAY OF THE MEASUREMENT PERIOD) FROM A HOSPITAL VISIT (EXCLUDING EMERGENCY AND LAB ONLY VISITS) AND HAVE BEEN SEEN BY A PRIMARY CARE PROVIDER (PCP) / CARDIOLOGIST FOR TWO OFFICE VISITS IN 24 MONTHS AND ONE OFFICE VISIT IN 12 MONTHS

NUMERATOR (All or Nothing):

The number of IVD patients who meet ALL of the following targets:

  • Most recent BP is less than or equal to 140/90 mm Hg
  • Most recent tobacco status is Tobacco Free (NOTE: If there is No Documentation of Tobacco Status the patient is not compliant for this measure)
  • Daily Aspirin or Other Antiplatelet Unless Contraindicated
  • Statin Use Unless Contraindicated

Numerator Options:

COMPONENT 1:

Most recent BP is less than or equal to 140/90 mm Hg

NUMERATOR NOTE:

  • Submit G9789, if blood pressures recorded during inpatient Stays, Emergency Room Visits, Urgent Care Visits, and Patient Self-Reported BP’s do not qualify. In order to meet performance, the most recent blood pressure should be recorded within the performance period.
  • Home BP results which can be obtained digitally, in writing or verbally, and are able to be stored in the EMR in a discrete field can be included. Accepting these BP results is at the discretion of the provider

Component Options:

Performance Met:

Most recent BP is less than or equal to 140/90 mm Hg (G9788)

OR

Denominator Exception:

Blood pressure recorded during inpatient stays, Emergency Room Visits or Urgent Care Visits (G9789)

OR

Denominator Exception:

Procedure-related BP’s not taken during an outpatient visit. Examples include Same Day Surgery, Ambulatory Service Center, G.I. Lab, Dialysis, Infusion Center, Chemotherapy (G2129)

OR

Performance Not Met:

Most recent BP is greater than 140/90 mm Hg, or blood pressure not documented (G9790)

AND

COMPONENT 2:

Most recent tobacco status is tobacco free

NUMERATOR NOTE: Submit G9792, if there is no documentation of tobacco status. In order to meet performance, the most recent tobacco status should be recorded within the performance period.

Component Options:

Performance Met:

Most recent tobacco status is tobacco free (G9791)

OR

Performance Not Met:

Most recent tobacco status is not tobacco free (G9792)

AND

COMPONENT 3:

Daily aspirin or other antiplatelet unless contraindicated

Component Options:

Performance Met:

Patient is currently on a daily aspirin or other antiplatelet (G9793)

OR

Performance Met:

Documentation of medical reason(s) for not on a daily aspirin or other antiplatelet (e.g. history of gastrointestinal bleed, intra-cranial bleed, blood disorders, Idiopathic Thrombocytopenic Purpura (ITP), Gastric Bypass or documentation of active anticoagulant use during the measurement period) (G2128)

OR

Performance Not Met:

Patient is not currently on a daily aspirin or other antiplatelet (G9795)

AND

COMPONENT 4:

Statin Use

Component Options:

Performance Met:

Patient is currently on a statin therapy (G9796)

OR

Performance Met:

Documentation of medical reason(s) for not on a statin (e.g. Pregnancy, In Vitro Fertilization, Clomiphene RX, ESRD, Cirrhosis, Muscular Pain and Disease during the measurement period or prior year) (G9940)

OR

Performance Not Met:

Patient is not on a statin therapy (G9797)


Tags

CQM-2023, CQM-MVP-2023, MVP-2023