2026 COLLECTION TYPE:
MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)
Description:
Percentage of the following patients – all considered at high risk of cardiovascular events – who were prescribed or were on statin therapy during the performance period:
• All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR
• Patients aged 20 to 75 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR
• Patients aged 40 to 75 years with a diagnosis of diabetes; OR
• Patients aged 40 to 75 with a 10-year ASCVD risk score of ≥ 20 percent
Instructions:
Reporting Frequency:
This measure is to be submitted 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 at high risk for cardiovascular events. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions as defined by the numerator based on the services provided and the measure-specific denominator coding.
Measure Strata and Performance Rates:
This measure contains four strata defined by four submission criteria.
This measure produces a single performance rate.
There are 4 Submission Criteria for this measure**:
1) All patients who were previously diagnosed with or currently have a diagnosis of clinical ASCVD, including an ASCVD procedure
Or
2) Patients aged 20 to 75 years at the beginning of the performance period who have ever had a laboratory result of LDL-C ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia
Or
3) Patients aged 40 to 75 years at the beginning of the performance period with Type 1 or Type 2 diabetes
Or
4) Patients aged 40 to 75 years at the beginning of the performance period with a 10-year ASCVD risk score of ≥ 20 percent
**All patients who meet one or more of the following criteria indicated above would be considered at high risk for cardiovascular events under the American College of Cardiology (ACC)/American Heart Association (AHA)/Multi-society (MS) guidelines.
The measure will be calculated with 1 performance rate:
Percentage of patients at high risk of cardiovascular events who are actively using or receive an order (prescription) for statin therapy at any time during the performance period.
Implementation Considerations:
For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient for the performance period. The most advantageous quality data code will be used if the measure is submitted more than once. There is only one performance rate calculated for this measure. Patients can only be counted once and cannot be in more than one submission criteria. When submitting this measure, determine if the patient meets denominator eligibility in order of each risk category defined in the denominator submission criteria. For example, first evaluate if the patient meets denominator Submission Criteria 1. If no, then evaluate if the patient meets denominator Submission Criteria 2. If yes, then the patient will be in Submission Criteria 2 and is not eligible for denominator Submission Criteria 3 and 4.
In order to meet the measure, current statin therapy use must be documented in the patient’s current medication list or ordered during the performance period. Only statin therapy meets the measure Numerator criteria (NOT other cholesterol lowering medications). Prescription or order does NOT need to be linked to an encounter or visit; it may be called to the pharmacy. Statin medication “samples” provided to patients can be documented as “current statin therapy” if documented in the medication list in health/medical record.
Patients who meet the denominator criteria for inclusion but are not prescribed or using statin therapy will NOT meet performance for this measure. Adherence to statin therapy is not calculated in this measure. It may not be appropriate to prescribe statin therapy for some patients (see exceptions and exclusions for the complete list). Intensity of statin therapy in primary and secondary prevention:
The expert panel of the 2018 ACC/AHA/MS Guidelines [1] defines recommended intensity of statin therapy on the basis of the average expected LDL-C response to specific statin and dose. Although intensity of statin therapy is important in managing cholesterol, this measure assesses prescription of ANY statin therapy, irrespective of intensity. Assessment of appropriate intensity and dosage documentation added too much complexity to allow inclusion of statin therapy intensity in the measure at this time.
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 WHO WERE PREVIOUSLY DIAGNOSED WITH OR CURRENTLY HAVE A DIAGNOSIS OF CLINICAL ASCVD, INCLUDING AN ASCVD PROCEDURE
Denominator (Criteria 1):
All patients who were previously diagnosed with or currently have a diagnosis of clinical ASCVD, including an ASCVD procedure
Definitions:
Clinical Atherosclerotic Cardiovascular Disease (ASCVD) includes –
• Acute Coronary Syndromes
• History of Myocardial Infarction
• Stable or Unstable Angina
• Coronary or other Arterial Revascularization
• Stroke or Transient Ischemic Attack (TIA)
• Peripheral Arterial Disease of Atherosclerotic Origin
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):
All patients, regardless of age
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*, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99429*, G0438, G0439
Or
Previously diagnosed or have a diagnosis of clinical ASCVD, including ASCVD procedure: G9662
And Not
DENOMINATOR EXCLUSION:
Patients who are breastfeeding at any time during the performance period: G9779
Or
Patients who have a diagnosis of rhabdomyolysis at any time during the performance period: G9780
Numerator (Criteria 1):
Patients who are actively using or who receive an order (prescription) for statin therapy at any time during the performance period.
Definition:
Statin therapy – Administration of one or more of a group of medications that are used to lower plasma lipoprotein levels in the treatment of hyperlipoproteinemia.
Table 1 – Statin Medication Therapy List (NOTE: List does NOT include dosage):
| Generic Name | Brand or Trade Name | Medication Type, If Applicable |
| Atorvastatin | Lipitor | Statin |
| Fluvastatin | Lescol XL or Lescol | Statin |
| Lovastatin (Mevinolin) | Mevacor or Altoprev | Statin |
| Pitavastatin | Livalo or Zypitamag or Nikita | Statin |
| Pravastatin Sodium | Pravachol | Statin |
| Rosuvastatin Calcium | Crestor | Statin |
| Simvastatin | Zocor | Statin |
| Amlodipine Besylate/Atorvastatin | Caduet | Fixed Dose Combination |
| Ezetimibe/Simvastatin | Vytorin | Fixed Dose Combination |
| FEzetimibe / Rosuvastatin | Roszet | Fixed Dose Combination |
Statin-Associated Muscle Symptoms (SAMS) – The 2018 ACC/AHA/MS Guideline (Grundy et al., 2019) includes the following SAMS: myalgias, myositis, myopathy, or statin-associated autoimmune myopathy. Patients who experience significant or repeated statin-associated muscle symptoms may prefer not to take or continue statin therapy and therefore may be removed from the denominator.
NUMERATOR NOTE:
Denominator Exceptions should be active during the performance period.
Coding References:
The Denominator Exception for Medical Reasons [G9781] is defined by the following coding only:
• Active Liver or Hepatic Disease or Insufficiency
B15.0, B15.9, B16.0, B16.1, B16.2, B16.9, B17.0, B17.10, B17.11, B17.2, B17.8, B17.9, B18.0, B18.1, B18.2, B18.8, B18.9, B19.0, B19.10, B19.11, B19.20, B19.21, B19.9, K70.0, K70.10, K70.11, K70.2, K70.30, K70.31, K70.40, K70.41, K70.9, K71.0, K71.10, K71.11, K71.2, K71.3, K71.4, K71.50, K71.51, K71.6, K71.7, K71.8, K71.9, K72.00, K72.01, K72.10, K72.11, K72.90, K72.91, K73.0, K73.1, K73.2, K73.8, K73.9, K74.00, K74.01, K74.02, K74.1, K74.2, K74.3, K74.4, K74.5, K74.60, K74.69, K75.4, O98.411, O98.412, O98.413, O98.419
• End Stage Renal Disease
N18.6
• SAMS
G72.0, G72.9, M60.9, M79.10.
Numerator Options:
Performance Met: Patients who are currently statin therapy users or received an order (prescription) for statin therapy (G9664)
Or
Denominator Exception: Documentation of medical reason(s) for not currently being a statin therapy user or receiving an order (prescription) for statin therapy (e.g., patients with statin-associated muscle symptoms or an allergy to statin medication therapy, patients who are receiving palliative or hospice care, patients with active liver disease or hepatic disease or insufficiency, patients with end stage renal disease [ESRD], or other medical reasons) (G9781)
Or
Performance Not Met: Patients who are not currently statin therapy users or did not receive an order (prescription) for statin therapy (G9665)
Or
SUBMISSION CRITERIA 2: PATIENTS AGED 20 TO 75 YEARS AT THE BEGINNING OF THE PERFORMANCE PERIOD WHO HAVE EVER HAD A LABORATORY RESULT OF LDL-C ≥ 190 MG/DL OR WERE PREVIOUSLY DIAGNOSED WITH OR CURRENTLY HAVE AN ACTIVE DIAGNOSIS OF FAMILIAL HYPERCHOLESTEROLEMIA
Denominator (Criteria 2):
Patients aged 20 to 75 years at the beginning of the performance period who have ever had a laboratory result of LDL-C ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia.
DENOMINATOR NOTE:
*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B PFS. These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patient aged 20 to 75 years at the beginning of the performance period
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*, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99429*, G0438, G0439
And
Any LDL-C laboratory result ≥ 190 mg/dL: G9663
Or
History of or active diagnosis of familial hypercholesterolemia: G9782
And Not
DENOMINATOR EXCLUSION:
Patients who are breastfeeding at any time during the performance period: G9779
Or
Patients who have a diagnosis of rhabdomyolysis at any time during the performance period: G9780
Numerator (Criteria 2):
Patients who are actively using or who receive an order (prescription) for statin therapy at any time during the performance period.
Definition:
Statin therapy – Administration of one or more of a group of medications that are used to lower plasma lipoprotein levels in the treatment of hyperlipoproteinemia.
Table 1 – Statin Medication Therapy List (NOTE: List does NOT include dosage):
| Generic Name | Brand or Trade Name | Medication Type, If Applicable |
| Atorvastatin | Lipitor | Statin |
| Fluvastatin | Lescol XL or Lescol | Statin |
| Lovastatin (Mevinolin) | Mevacor or Altoprev | Statin |
| Pitavastatin | Livalo or Zypitamag or Nikita | Statin |
| Pravastatin Sodium | Pravachol | Statin |
| Rosuvastatin Calcium | Crestor | Statin |
| Simvastatin | Zocor | Statin |
| Amlodipine Besylate/Atorvastatin | Caduet | Fixed Dose Combination |
| Ezetimibe/Simvastatin | Vytorin | Fixed Dose Combination |
| FEzetimibe / Rosuvastatin | Roszet | Fixed Dose Combination |
Statin-Associated Muscle Symptoms (SAMS) – The 2018 ACC/AHA/MS Guideline (Grundy et al., 2019) includes the following SAMS: myalgias, myositis, myopathy, or statin-associated autoimmune myopathy. Patients who experience significant or repeated statin-associated muscle symptoms may prefer not to take or continue statin therapy and therefore may be removed from the denominator.
NUMERATOR NOTE:
Denominator Exceptions should be active during the performance period
Coding References:
The Denominator Exception for Medical Reasons [G9781] is defined by the following coding only:
• Active Liver or Hepatic Disease or Insufficiency
B15.0, B15.9, B16.0, B16.1, B16.2, B16.9, B17.0, B17.10, B17.11, B17.2, B17.8, B17.9, B18.0, B18.1, B18.2, B18.8, B18.9, B19.0, B19.10, B19.11, B19.20, B19.21, B19.9, K70.0, K70.10, K70.11, K70.2, K70.30, K70.31, K70.40, K70.41, K70.9, K71.0, K71.10, K71.11, K71.2, K71.3, K71.4, K71.50, K71.51, K71.6, K71.7, K71.8, K71.9, K72.00, K72.01, K72.10, K72.11, K72.90, K72.91, K73.0, K73.1, K73.2, K73.8, K73.9, K74.00, K74.01, K74.02, K74.1, K74.2, K74.3, K74.4, K74.5, K74.60, K74.69, K75.4, O98.411, O98.412, O98.413, O98.419
• End Stage Renal Disease
N18.6
• SAMS
G72.0, G72.9, M60.9, M79.10.
Numerator Options:
Performance Met: Patients who are currently statin therapy users or received an order (prescription) for statin therapy (G9664)
Or
Denominator Exception: Documentation of medical reason(s) for not currently being a statin therapy user or receiving an order (prescription) for statin therapy (e.g., patients with statin-associated muscle symptoms or an allergy to statin medication therapy, patients who are receiving palliative or hospice care, patients with active liver disease or hepatic disease or insufficiency, patients with end stage renal disease [ESRD], or other medical reasons) (G9781)
Or
Performance Not Met: Patients who are not currently statin therapy users or did not receive an order (prescription) for statin therapy (G9665)
Or
SUBMISSION CRITERIA 3: PATIENTS AGED 40 TO 75 YEARS AT THE BEGINNING OF THE PERFORMANCE PERIOD WITH TYPE 1 OR TYPE 2 DIABETES
Denominator (Criteria 3):
Patients aged 40 to 75 years at the beginning of the performance period with Type 1 or Type 2 diabetes.
DENOMINATOR NOTE:
*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):
Patients aged 40 to 75 years at the beginning of the performance period
And
Type 1 or Type 2 diabetes diagnosis (ICD-10-CM): E10.A0, E10.A1, E10.A2, E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.36, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01,E11.10, E11.11, E11.21, E11.22, E11.29, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, , E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319, E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.36, E13.37X1, E13.37X2, E13.37X3, E13.37X9, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83
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*, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99429*, G0438, G0439
And Not
DENOMINATOR EXCLUSION:
Patients who are breastfeeding at any time during the performance period: G9779
Or
Patients who have a diagnosis of rhabdomyolysis at any time during the performance period: G9780
Numerator (Criteria 3):
Patients who are actively using or who receive an order (prescription) for statin therapy at any time during the performance period.
Definition:
Statin therapy – Administration of one or more of a group of medications that are used to lower plasma lipoprotein levels in the treatment of hyperlipoproteinemia.
Table 1 – Statin Medication Therapy List (NOTE: List does NOT include dosage):
| Generic Name | Brand or Trade Name | Medication Type, If Applicable |
| Atorvastatin | Lipitor | Statin |
| Fluvastatin | Lescol XL or Lescol | Statin |
| Lovastatin (Mevinolin) | Mevacor or Altoprev | Statin |
| Pitavastatin | Livalo or Zypitamag or Nikita | Statin |
| Pravastatin Sodium | Pravachol | Statin |
| Rosuvastatin Calcium | Crestor | Statin |
| Simvastatin | Zocor | Statin |
| Amlodipine Besylate/Atorvastatin | Caduet | Fixed Dose Combination |
| Ezetimibe/Simvastatin | Vytorin | Fixed Dose Combination |
| FEzetimibe / Rosuvastatin | Roszet | Fixed Dose Combination |
Statin-Associated Muscle Symptoms (SAMS) – The 2018 ACC/AHA/MS Guideline (Grundy et al., 2019) includes the following SAMS: myalgias, myositis, myopathy, or statin-associated autoimmune myopathy. Patients who experience significant or repeated statin-associated muscle symptoms may prefer not to take or continue statin therapy and therefore may be removed from the denominator.
NUMERATOR NOTE:
Denominator Exceptions should be active during the performance period.
Coding References:
The Denominator Exception for Medical Reasons [G9781] is defined by the following coding only:
• Active Liver or Hepatic Disease or Insufficiency
B15.0, B15.9, B16.0, B16.1, B16.2, B16.9, B17.0, B17.10, B17.11, B17.2, B17.8, B17.9, B18.0, B18.1, B18.2, B18.8, B18.9, B19.0, B19.10, B19.11, B19.20, B19.21, B19.9, K70.0, K70.10, K70.11, K70.2, K70.30, K70.31, K70.40, K70.41, K70.9, K71.0, K71.10, K71.11, K71.2, K71.3, K71.4, K71.50, K71.51, K71.6, K71.7, K71.8, K71.9, K72.00, K72.01, K72.10, K72.11, K72.90, K72.91, K73.0, K73.1, K73.2, K73.8, K73.9, K74.00, K74.01, K74.02, K74.1, K74.2, K74.3, K74.4, K74.5, K74.60, K74.69, K75.4, O98.411, O98.412, O98.413, O98.419
• End Stage Renal Disease
N18.6
• SAMS
G72.0, G72.9, M60.9, M79.10.
Numerator Options:
Performance Met: Patients who are currently statin therapy users or received an order (prescription) for statin therapy (G9664)
Or
Denominator Exception: Documentation of medical reason(s) for not currently being a statin therapy user or receiving an order (prescription) for statin therapy (e.g., patients with statin-associated muscle symptoms or an allergy to statin medication therapy, patients who are receiving palliative or hospice care, patients with active liver disease or hepatic disease or insufficiency, patients with end stage renal disease [ESRD], or other medical reasons) (G9781)
Or
Performance Not Met: Patients who are not currently statin therapy users or did not receive an order (prescription) for statin therapy (G9665)
Or
SUBMISSION CRITERIA 4: PATIENTS AGED 40 TO 75 YEARS AT THE BEGINNING OF THE PERFORMANCE PERIOD WITH A 10-YEAR ASCVD RISK SCORE OF ≥ 20 PERCENT
Denominator (Criteria 4):
Patients aged 40 to 75 years at the beginning of the performance period with a 10-year ASCVD risk score of ≥ 20 percent during the performance period.
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. The 10-year ASCVD risk score is calculated using the Pooled Cohort Equations: 1) the 2013 ACC/AHA ASCVD Risk Estimator OR 2) the ACC Risk Estimator Plus. If your EHR does not have either of these risk calculators, we recommend that you use the on-line versions.
The 10-year ASCVD risk assessment must be performed during the performance period.
Denominator Criteria (Eligible Cases):
Patients aged 40 to 75 years at the beginning of the performance period
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*, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99429*, G0438, G0439
And
Calculated 10-year ASCVD risk score of ≥ 20 percent during the performance period: M1364
And Not
DENOMINATOR EXCLUSION:
Patients who are breastfeeding at any time during the performance period: G9779
Or
Patients who have a diagnosis of rhabdomyolysis at any time during the performance period: G9780
Numerator (Criteria 4):
Patients who are actively using or who receive an order (prescription) for statin therapy at any time during the performance period
Definition:
Statin therapy – Administration of one or more of a group of medications that are used to lower plasma lipoprotein levels in the treatment of hyperlipoproteinemia.
Table 1 – Statin Medication Therapy List (NOTE: List does NOT include dosage):
| Generic Name | Brand or Trade Name | Medication Type, If Applicable |
| Atorvastatin | Lipitor | Statin |
| Fluvastatin | Lescol XL or Lescol | Statin |
| Lovastatin (Mevinolin) | Mevacor or Altoprev | Statin |
| Pitavastatin | Livalo or Zypitamag or Nikita | Statin |
| Pravastatin Sodium | Pravachol | Statin |
| Rosuvastatin Calcium | Crestor | Statin |
| Simvastatin | Zocor | Statin |
| Amlodipine Besylate/Atorvastatin | Caduet | Fixed Dose Combination |
| Ezetimibe/Simvastatin | Vytorin | Fixed Dose Combination |
| FEzetimibe / Rosuvastatin | Roszet | Fixed Dose Combination |
Statin-Associated Muscle Symptoms (SAMS) – The 2018 ACC/AHA/MS Guideline (Grundy et al., 2019) includes the following SAMS: myalgias, myositis, myopathy, or statin-associated autoimmune myopathy. Patients who experience significant or repeated statin-associated muscle symptoms may prefer not to take or continue statin therapy and therefore may be removed from the denominator.
NUMERATOR NOTE:
Denominator Exceptions should be active during the performance period.
Coding References:
The Denominator Exception for Medical Reasons [G9781] is defined by the following coding only:
• Active Liver or Hepatic Disease or Insufficiency
B15.0, B15.9, B16.0, B16.1, B16.2, B16.9, B17.0, B17.10, B17.11, B17.2, B17.8, B17.9, B18.0, B18.1, B18.2, B18.8, B18.9, B19.0, B19.10, B19.11, B19.20, B19.21, B19.9, K70.0, K70.10, K70.11, K70.2, K70.30, K70.31, K70.40, K70.41, K70.9, K71.0, K71.10, K71.11, K71.2, K71.3, K71.4, K71.50, K71.51, K71.6, K71.7, K71.8, K71.9, K72.00, K72.01, K72.10, K72.11, K72.90, K72.91, K73.0, K73.1, K73.2, K73.8, K73.9, K74.00, K74.01, K74.02, K74.1, K74.2, K74.3, K74.4, K74.5, K74.60, K74.69, K75.4, O98.411, O98.412, O98.413, O98.419
• End Stage Renal Disease
N18.6
• SAMS
G72.0, G72.9, M60.9, M79.10.
Numerator Options:
Performance Met: Patients who are currently statin therapy users or received an order (prescription) for statin therapy (G9664)
Or
Denominator Exception: Documentation of medical reason(s) for not currently being a statin therapy user or receiving an order (prescription) for statin therapy (e.g., patients with statin-associated muscle symptoms or an allergy to statin medication therapy, patients who are receiving palliative or hospice care, patients with active liver disease or hepatic disease or insufficiency, patients with end stage renal disease [ESRD], or other medical reasons) (G9781)
Or
Performance Not Met: Patients who are not currently statin therapy users or did not receive an order (prescription) for statin therapy (G9665)
Or
SUBMISSION CRITERIA 4: PATIENTS AGED 40 TO 75 YEARS AT THE BEGINNING OF THE PERFORMANCE PERIOD WITH A 10-YEAR ASCVD RISK SCORE OF ≥ 20 PERCENT
Rationale:
“Cardiovascular disease (CVD) is the leading cause of death in the United States, causing approximately 1 of every 3 deaths in the United States in 2015. In 2015, stroke caused approximately 1 of every 19 deaths in the United States and the estimated annual costs for CVD and stroke were $329.7 billion, including $199.2 billion in direct costs (hospital services, physicians and other professionals, prescribed medications, home health care, and other medical durables) and $130.5 billion in indirect costs from lost future productivity (cardiovascular and stroke premature deaths). CVD costs more than any other diagnostic group” [1]. Data collected between 2011 and 2014 indicate that more than 94.6 million U.S. adults, 20 years or older had total cholesterol levels equal to 200 mg/dL or more, while almost 28.5 million had levels 240 mg/dL or more [1]. Elevated blood cholesterol is a major risk factor for CVD and statin therapy has been associated with a reduced risk of CVD. Numerous randomized trials have demonstrated that treatment with a statin reduces LDL-C and reduces the risk of major cardiovascular events by approximately 20 percent [2].
In 2018, updated guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults were published [3]. This guideline was published by an Expert Panel, which synthesized evidence from randomized controlled trials to identify people most likely to benefit from cholesterol- lowering therapy. The ACC/AHA/MS Guideline recommendations are intended to provide a strong evidence-based foundation for the treatment of blood cholesterol for the primary and secondary prevention and treatment of ASCVD in patients of all ages. The document concludes the addition of statin therapy reduces the risk of ASCVD among high-risk individuals, defined as follows: individuals with clinical ASCVD, with LDL-C ≥ 190 mg/dL, with diabetes, or individuals with ≥ 20 percent risk of ASCVD as determined via use of an ASCVD risk estimator derived from the Pooled Cohort Equations [3].
One study surveying U.S. cardiology, primary care, and endocrinology practices found that 1 in 4 guideline-eligible patients were not on a statin and less than half were on the recommended statin intensity. Untreated and undertreated patients had significantly higher LDL-C levels than those receiving guideline-directed statin treatment [4]. In a follow-up study authored by Nanna et al., the same clinics were divided into tertiles based on the percentage of patients with guideline-recommended statin use. The researchers found that patients in the high-tertile clinics were more likely to achieve target LDL-C levels than patients at the low- or mid-tertile clinics, and this held true when patients were stratified by primary and secondary prevention [5]. Research also indicates that certain populations are far less likely to receive guideline-recommended statin therapy than others. A retrospective study of the National Health and Nutrition Examination Survey found that Black and Hispanic race or ethnicity, low income, lack of health insurance coverage, poor health care access, young age, and female gender are predictors of lower statin utilization [6]. In particular, there is extensive evidence that women are far less likely than men to be prescribed guidelinerecommended statin therapy [7, 8], despite research showing that female patients with cardiovascular disease derive the same or greater benefit from statin therapy as male patients with cardiovascular disease [9]. The Statin Safety Expert Panel that participated in a National Lipid Association (NLA) Statin Safety Task Force meeting in October 2013 reaffirms the general safety of statin therapy. The panel members concluded that for most patients requiring statin therapy, the potential benefits of statin therapy outweigh the potential risks. In general terms, the benefits of statins to prevent non-fatal myocardial infarction, revascularization, stroke, and CVD mortality, far outweighs any potential harm related to the drug [10].
Stay updated with the latest news regarding MACRA and MIPS
The Healthmonix Advisor is a free news source that connects you to the latest in the value-based care industry!