2026 #326 MIPS Measure Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

‌2026 COLLECTION TYPE:

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

‌MEASURE TYPE:

Process

‌DESCRIPTION:

Percentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribed an FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period.

‌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 atrial fibrillation (AF) or atrial flutter. 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 (QDC) 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 aged 18 years and older with AF or atrial flutter who do not have a documented CHA2DS2-VASc risk score of 0 or 1 for men; or 0, 1, or 2 for women.

Definitions:

Comfort Care Only – Refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort. It includes attention to the psychological and spiritual needs of the patient and support for both the dying patient and the patient’s family. Comfort Measures Only is commonly referred to as “”comfort care” by the general public. It may be completed in an inpatient, outpatient, or home environment. Comfort Measures Only includes hospice, palliative and supportive treatment for patients who are suffering from a terminal illness—e.g., AIDS, cancer—or who have refused life-sustaining treatment. In order to use G9930, a patient must be on comfort care measures only and not be receiving any other types of care. It is not equivalent to a physician order to withhold emergency resuscitative measures such as Do Not Resuscitate (DNR).

CHA2 DS2-VASc Stroke Risk Assessment – The assessment of patients with AF or atrial flutter, assessment of thromboembolic risk should include:

CHA2 DS2-VASc Criteria Score

Congestive HF 1

Hypertension 1

Age ≥ 75 years 2

Diabetes Mellitus 1

Stroke/Transient Ischemic Attack (TIA)/Thromboembolism (TE) 2

Vascular disease (prior myocardial infarction [MI], peripheral artery 1

disease [PAD], or aortic plaque)

Age 65-74 years 1

Sex category (i.e.; female) 1

DENOMINATOR NOTE:

Denominator Exclusions are determined on the date of the denominator eligible encounter. The intent of the denominator exclusion G9931 is to allow patients with a low risk for a thromboembolic event (i.e., a CHA2DS2-VASc score of 0 or 1 for men; or 0, 1, or 2 for women) to be excluded from the sample. This denominator exclusion serves as documentation that a patient’s risk for a thromboembolic event was appropriately assessed using the CHA2DS2-VASc scoring tool and that the risk was low enough to not warrant anticoagulation treatment. In order to exclude low risk patients, eligible clinicians must use the CHA2DS2-VASc assessment tool to determine a patient’s risk score and must document either the numeric score (i.e., 0 or 1 for men; or 0, 1, or 2 for women) or all the individual risk factors assessed to support an assessment of the CHA2DS2-VASc score.

*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

Diagnosis for atrial fibrillation or atrial flutter on date of encounter (ICD-10-CM): I48.0, I48.3, I48.4, I48.11, I48.19, I48.20, I48.21, I48.91, I48.92

AND

Patient encounter during the 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*, 99315, 99316, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99424, 99426

AND NOT

DENOMINATOR EXCLUSIONS:

Patient with transient or reversible cause of AF (e.g., pneumonia, hyperthyroidism, pregnancy, cardiac surgery): G9929

OR

Patients who are receiving comfort care only: G9930

OR

Documentation of CHA2DS2 -VASc risk score of 0 or 1 for men; or 0, 1, or 2 for women: G9931

OR

Patients with moderate or severe mitral stenosis: G0044

OR

Patients with mechanical prosthetic heart valve: G0043

‌NUMERATOR:

Patients with AF or atrial flutter for whom an FDA-approved oral anticoagulant was prescribed.

Definition:

Prescribed – Also satisfied by documentation in current medication list.

NUMERATOR NOTE:

Denominator Exception(s) are determined on the date of the denominator eligible encounter.

Numerator Options:

Performance Met: FDA-approved oral anticoagulant is prescribed (G8967)

OR

Denominator Exception: Documentation of medical reason(s) for not prescribing an FDA-approved anticoagulant (e.g., present or planned atrial appendage occlusion or ligation or patient being currently enrolled in a clinical trial related to AF/atrial flutter treatment) (G8968)

OR

Denominator Exception: Documentation of patient reason(s) for not prescribing an oral anticoagulant that is FDA approved for the prevention of thromboembolism (e.g., patient preference for not receiving anticoagulation) (G8969)

OR

Performance Not Met: FDA-approved anticoagulant not prescribed, reason not given (G9928)

RATIONALE:

AF, whether paroxysmal, persistent, or permanent and whether symptomatic or silent, significantly increases the risk of thromboembolic ischemic stroke. Nonvalvular atrial fibrillation increases the risk of stroke 5 times, and AF in the setting of mitral stenosis increases the risk of stroke 20 times over that of patients in sinus rhythm.

Thromboembolism occurring with AF is associated with a greater risk of recurrent stroke, more severe disability, and mortality. Silent AF is also associated with ischemic stroke. The appropriate use of antithrombotic therapy and the control of other risk factors, including hypertension and hypercholesterolemia, substantially reduce stroke risk. One meta-analysis has stratified ischemic stroke risk among patients with nonvalvular AF using the following point scoring systems: AF Investigators; CHA2DS2 (congestive heart failure, hypertension, age 75 years, diabetes mellitus, prior stroke or TIA or thromboembolism [doubled]), or CHA2DS2-VASc (congestive heart failure, hypertension, age 75 years [doubled], diabetes mellitus, prior stroke or TIA or thromboembolism [doubled], vascular disease, age 65 to 74 years, sex category).

When compared with the CHA2DS2 score, the CHA2DS2-VASc score for nonvalvular AF has a broader score range (0 to 9) and includes a larger number of risk factors (female sex, 65 to 74 years of age, and vascular disease). The selection of an antithrombotic agent should be based on shared decision making that takes into account risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the INR therapeutic range if the patient has been on warfarin, irrespective of whether the AF pattern is paroxysmal, persistent, or permanent.

The term “nonvalvular AF” was clarified in the 2019 update and does not imply the absence of valvular heart disease. Instead, as used in the 2019 guideline update, nonvalvular AF is “AF in the absence of moderate or severe mitral stenosis or a mechanical heart valve.”