2026 COLLECTION TYPE:
MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)
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.
Instructions:
Reporting Frequency:
This measure is to be submitted a minimum of once per performance period for denominator eligible cases seen in the outpatient setting AND submitted at each hospital discharge (99238 and 99239) for denominator eligible cases as defined in the denominator criteria.
Intent and Clinician Applicability:
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.
Measure Strata and Performance Rates:
This measure contains two strata defined by two submission criteria.
This measure produces a single performance rate using a weighted average.
There are 2 Submission Criteria for this measure:
1) All patients with a diagnosis of HF assessed during an outpatient encounter
Or
2) All patients with a diagnosis of HF and discharged from hospital
Both submission criteria should be submitted as appropriate.
Implementation Considerations:
For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code will be used if the measure is submitted more than once. Only patients who had at least two denominator eligible visits during the performance period will be counted for Submission Criteria 1.
When submitting CPT code 99238 and 99239, it is recommended the measure be submitted each time the code is submitted for hospital discharge.
Telehealth:
SUBMISSION CRITERIA 1:
TELEHEALTH ELIGIBLE: This measure submission criteria is appropriate for and applicable to the telehealth setting. Patient encounters conducted via telehealth using encounter code(s) found in the denominator encounter criteria are allowed for this measure. Therefore, if the patient meets all denominator criteria for a telehealth encounter, it would be appropriate to include them in the denominator eligible patient population. Telehealth eligibility is at the measure submission criteria level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.
SUBMISSION CRITERIA 2:
NOT TELEHEALTH ELIGIBLE: This measure submission criteria is not appropriate for nor applicable to the telehealth setting. Patient encounters for this measure conducted via telehealth should be removed from the denominator eligible patient population. Therefore, if the patient meets all denominator criteria but the encounter is
conducted via telehealth, it would be appropriate to remove them from the denominator eligible patient population. Telehealth eligibility is at the measure submission criteria level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.
Measure Submission:
The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this collection type for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. The coding provided to identify the measure criteria: Denominator or Numerator, may be an example of coding that could be used to identify patients that meet the intent of this clinical topic. When implementing this measure, please refer to the ‘Reference Coding’ section to determine if other codes or code languages that meet the intent of the criteria may also be used within the medical record to identify and/or assess patients. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
SUBMISSION CRITERIA 1: ALL PATIENTS WITH A DIAGNOSIS OF HF ASSESSED DURING AN OUTPATIENT ENCOUNTER
DENOMINATOR (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 MIPS CQMs.
Denominator Criteria (eligible Cases) 1:
Patients aged ≥ 18 years on date of encounter
And
Diagnosis for heart failure on date of encounter (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): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 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): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 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
Current or prior 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 Exclusions:
Patients with a history of heart transplant or with a Left Ventricular Assist Device (LVAD): M1151
NUMERATOR (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 ReceptorNeprilysin 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
DENOMINATOR (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
WITHOUT
Encounters conducted via telehealth: M1426
And
Current or prior 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 Exclusions:
Patients with a history of heart transplant or with a Left Ventricular Assist Device (LVAD): M1151
NUMERATOR (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 ReceptorNeprilysin 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)
Rationale:
Use of ACE inhibitor, ARB, or ARNI therapy has been associated with improved outcomes in patients with reduced LVEF.
Long-term therapy with ARBs have also been shown to reduce morbidity and mortality, especially in ACE inhibitor– intolerant patients. More recently, ARNI therapy has also been shown to more significantly improve outcomes, such that the newest guidelines recommend replacement of ACE inhibitors or ARBs with ARNI therapy in eligible patients. However, despite the benefits of these drugs, use of ACE inhibitor, ARB, or ARNI remains suboptimal.
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