2026 #243 MIPS Measure Cardiac Rehabilitation Patient Referral from an Outpatient Setting

‌2026 COLLECTION TYPE:

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)

‌MEASURE TYPE:

Process – High Priority

‌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.

‌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 evaluated for outpatient cardiac rebab. 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 one strata defined by a single submission criteria. This measure produces a single performance rate.

‌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.

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.

‌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 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 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

Patient encounter during the performance period (CPT or HCPCS): 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, G0438, G0439

AND

Diagnosis for Chronic Stable Angina on date of encounter (ICD-10-CM): I20.1, I20.2, I20.81, I20.89, I20.9, I25.112, I25.702, I25.712, I25.722, I25.732, I25.752, I25.762, I25.792

OR

Diagnosis of Acute Myocardial Infarction on date of encounter (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, I22.0, I22.1, I22.2, I22.8, I22.9, I25.2

OR

Coronary Artery Bypass Graft Surgery (CPT): 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536

OR

Percutaneous Coronary Intervention (CPT): 92920, 92924, 92928, 92930, 92933, 92937, 92941, 92943, 92945

OR

Cardiac Valve Surgery (CPT): 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0646T, 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, 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.

Definition:

Referral – A “referral” is defined as: 1. Documented communication* between the healthcare 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 months 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.

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. Telehealth/virtual CR service should be delivered via real-time audio/visual services by a provider. If alternative CR approaches are used, they should be designed to meet appropriate safety standards.

NUMERATOR 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.

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)

RATIONALE

Cardiac rehabilitation services have been shown to help reduce morbidity and mortality in persons who have experienced a recent coronary artery disease event, but these services are used in less than 30% of eligible patients (1). A key component to CR utilization is the appropriate and timely referral of patients to an outpatient CR program. While referral takes place generally while the patient is hospitalized for a qualifying event (MI, CSA, CABG, PCI, cardiac valve surgery, or heart transplantation), there are many instances in which a patient can and should be referred from an outpatient clinical practice setting (e.g., when a patient does not receive such a referral while in the hospital, or when the patient fails to follow through with the referral for whatever reason).

This performance measure has been developed to help health care systems implement effective steps in their systems of care that will optimize the appropriate referral of a patient to an outpatient CR program. This measure is designed to serve as a stand-alone measure or, preferably, to be included within other performance measurement sets that involve disease states or other conditions for which CR services have been found to be appropriate and beneficial (e.g., following MI, CABG surgery) (2, 3). This performance measure is provided in a format that is meant to allow easy and flexible inclusion into such performance measurement sets.