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 coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF ≤ 40% who were prescribed beta-blocker therapy.
Instructions:
Reporting Frequency:
This measure is to be submitted a minimum of once per performance period 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 a diagnosis of coronary artery disease. 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.
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 CAD or history of cardiac surgery who have a current or prior LVEF ≤ 40%
Or
2) All patients with a diagnosis of CAD or history of cardiac surgery who have a prior (within the past 3 years) MI
Only patients who had at least two denominator eligible visits during the performance period will be counted for Submission Criteria 1 and Submission Criteria 2 of this measure.
Implementation Considerations:
The MIPS eligible clinician should submit data on one of the submission criteria, depending on the clinical findings. If the patient has CAD or history of cardiac surgery and a current or prior LVEF ≤ 40% (or moderate or severe LVSD), use Submission Criteria 1. If the patient has CAD or history of cardiac surgery and has a prior (within the past 3 years) MI, use Submission Criteria 2.
The 3-year lookback period for the prior MI should be from the time of the encounter that is used to qualify for the denominator and evaluate the numerator. If the patient has had an MI within the past 3 years and has a current or prior LVEF ≤ 40% (or moderate or severe LVSD), the MIPS eligible clinician should submit quality data codes for Submission Criteria 1 and this will count as appropriate submission for this patient.
Telehealth:
TELEHEALTH ELIGIBLE: This measure 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 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 CAD OR HISTORY OF CARDIAC SURGERY WHO HAVE A CURRENT OR PRIOR LVEF ≤ 40%
DENOMINATOR (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%.
DENOMINATOR NOTE:
LVEF ≤ 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction (LVSD). 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 left ventricular systolic dysfunction 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.
The history of cardiac surgery serves as a proxy for a diagnosis of CAD; a diagnosis is not needed if the patient has documented history of cardiac surgery. Only one of the two criteria – a diagnosis of CAD or history of cardiac surgery proxy – is required. To meet the denominator criteria, a patient must have an active diagnosis of CAD (or
proxy documented) at the time of the encounter that 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 CAD diagnosis criterion, the diagnosis needs to be active only at the encounter being evaluated for the numerator action. If the patient meets the proxy of a history of cardiac surgery inclusion criterion, there should be documentation of the proxy 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 coronary artery disease on date of encounter (ICD-10-CM): I20.0, I20.1, I20.2, I20.81, I20.89, I20.9, I24.0, I24.89, I24.9, I25.10, I25.110, I25.111, I25.112, I25.118, I25.119, 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
OR
History of cardiac surgery (CPT): 33140, 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536, 92920, 92924, 92928, 92930, 92933, 92937, 92941, 92943, 92945
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) ≤ 40% or documentation of moderate or severe LVSD: G8694
NUMERATOR (CRITERIA 1):
Patients who were prescribed beta-blocker therapy.
Definition:
Prescribed – May include prescription given to the patient for beta-blocker therapy at one or more visits in the measurement period OR patient already taking beta-blocker therapy as documented in current medication list.
Beta-blocker Therapy – For patients with prior LVEF ≤ 40%, “beta-blocker therapy” includes the following:
bisoprolol, carvedilol, or sustained release metoprolol succinate.
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 CAD or history of cardiac surgery proxy is documented.
Denominator Exception(s) are determined on the date of the denominator-eligible encounter
Numerator Options:
Performance Met: Beta-blocker therapy prescribed or currently being taken (G9189)
Or
Denominator Exception: Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., allergy, intolerance, other medical reasons) (G9190)
Or
Denominator Exception: ocumentation of patient reason(s) for not prescribing beta-blocker therapy (e.g., patient declined, other patient reasons) (G9191)
Or
Performance Not Met: Beta-blocker therapy not prescribed, reason not given (G9188)
Or
SUBMISSION CRITERIA 2: ALL PATIENTS WITH A DIAGNOSIS OF CAD OR HISTORY OF CARDIAC SURGERY WHO HAVE A PRIOR (WITHIN THE PAST 3 YEARS) MI
DENOMINATOR (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 prior (within the past 3 years) MI
Definition:
Prior Myocardial Infarction (MI) – for Submission Criteria 2, prior MI is limited to those occurring within the past 3 years. The 3-year lookback period for the prior MI should be from the time of the encounter that is used to qualify for the denominator and evaluate the numerator.
DENOMINATOR NOTE:
The history of cardiac surgery serves as a proxy for a diagnosis of CAD; a diagnosis is not needed if the patient has documented history of cardiac surgery. Only one of the two criteria – a diagnosis of CAD or history of cardiac surgery proxy – is required. To meet the denominator criteria, a patient must have an active diagnosis of CAD (or proxy documented) at the time of the encounter that 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 CAD diagnosis criterion, the diagnosis needs to be active only at the encounter being evaluated for the numerator action. If the patient meets the proxy of a history of cardiac
surgery inclusion criterion, there should be documentation of the proxy 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 PFS. These noncovered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases) 2:
Patients aged ≥ 18 years on date of encounter
And
Diagnosis for coronary artery disease on date of encounter (ICD-10-CM): I20.0, I20.1, I20.2, I20.81, I20.89, I20.9, I24.0, I24.89, I24.9, I25.10, I25.110, I25.111, I25.112, I25.118, I25.119, 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
OR
History of cardiac surgery (CPT): 33140, 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536, 92920, 92924, 92928, 92930, 92933, 92937, 92941, 92943, 92945
And
Diagnosis for myocardial infarction – includes patient that had a prior (within the past 3 years) 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, I21.B
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
NUMERATOR (CRITERIA 2):
Patients who were prescribed beta-blocker therapy.
Definition:
Prescribed – May include prescription given to the patient for beta-blocker therapy at one or more visits in the measurement period OR patient already taking beta-blocker therapy as documented in current medication list. Beta-blocker Therapy – For patients with prior MI, “beta-blocker therapy” includes any agent within the betablocker drug class.
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 CAD or history of cardiac surgery proxy is documented. Denominator Exception(s) are determined on the date of the denominator-eligible encounter.
Numerator Options:
Performance Met: Beta-blocker therapy prescribed or currently being taken (4008F)
Or
Denominator Exception: Documentation of medical reason(s) for not prescribing betablocker therapy (e.g., allergy, intolerance, other medical reasons) (4008F with 1P)
Or
Denominator Exception: Documentation of patient reason(s) for not prescribing betablocker therapy (e.g., patient declined, other patient reasons) (4008F with 2P)
Or
Performance Not Met: Beta-blocker therapy not prescribed, reason not otherwise specified (4008F with 8P)
Rationale:
For patients with coronary artery disease (CAD), beta-blockers are recommended for 3 years after myocardial infarction or acute coronary syndrome. Beta-blockers, particularly carvedilol, metoprolol succinate, or bisoprolol, which have been shown to reduce risk of death, are recommended indefinitely for patients with CAD and LV systolic dysfunction. These agents have proven efficacy in reducing angina onset and improving the ischemic threshold during exercise. In patients who have suffered an MI, beta-blockers significantly reduce deaths and recurrent MIs (ACCF/AHA/ACP/AATS/PCNA/SCAI/STS, 2012).
Nonadherence to cardio protective medications is prevalent among outpatients with CAD and can be associated with a broad range of adverse outcomes, including all-cause and cardiovascular mortality, cardiovascular hospitalizations, and the need for revascularization procedures (ACC/AHA, 2002).
This measure is intended to promote beta-blocker usage in select patients with CAD.
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