2026 COLLECTION TYPE:
MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)
MEASURE TYPE: Intermediate Outcome – High Priority
Description:
The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization’s total IVD denominator. All-or-None Outcome Measure (Optimal Control) – Using the IVD denominator optimal results include:
- Most recent blood pressure (BP) measurement is less than or equal to 130/80 mm Hg — AND
- Most recent tobacco status is Tobacco Free — AND
- Daily Aspirin or Other Antiplatelet Unless Contraindicated — AND
- High Intensity Statin Use Unless Contraindicated
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 Ischemic Vascular Disease. 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 two strata defined by two submission criteria.
This measure produces two performance rates.
There are 2 Submission Criteria for this measure:
1) Patients with coronary artery disease (CAD) or a CAD Risk-Equivalent Condition 18-75 years of age and alive as of the last day of the measurement period and a minimum of two CAD or CAD Risk-Equivalent Condition coded office visits with a Primary Care Provider (PCP) / Cardiologist in 24 months and one office visit in 12 months
OR
2) Patients with one Acute Coronary Event (Acute Myocardial Infarction [AMI], Percutaneous Coronary Intervention [PCI], or Coronary Artery Bypass Graft [CABG]) 18-75 years of age and alive as of the last day of the measurement period from a hospital visit (excluding Emergency and Lab Only visits) and have been seen by a primary care provider (PCP) / Cardiologist for two office visits in 24 months and one office visit in 12 months
Please note that a patient will only be included once in the measurement if they meet the denominator criteria for both Submission Criteria 1 and Submission Criteria 2.
The measure will be calculated with 2 performance rates:
1) Patients with coronary artery disease (CAD) or a CAD Risk-Equivalent Condition 18-75 years of age and alive as of the last day of the measurement period and a minimum of two CAD or CAD Risk-Equivalent Condition coded office visits with a Primary Care Provider (PCP) / Cardiologist in 24 months and one office visit in 12 months
2) Patients with one Acute Coronary Event (Acute Myocardial Infarction [AMI], Percutaneous Coronary Intervention [PCI], or Coronary Artery Bypass Graft [CABG]) 18-75 years of age and alive as of the last day of the measurement period from a hospital visit (excluding Emergency and Lab Only visits) and have been seen by a
primary care provider (PCP) / Cardiologist for two office visits in 24 months and one office visit in 12 months
Implementation Considerations:
The most recent quality data code submitted will be used for performance calculation.
For the purposes of MIPS implementation, this patient-intermediate measure is submitted a minimum of once per patient for the performance period. The most recent 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.
SUBMISSION CRITERIA 1: PATIENTS WITH CORONARY ARTERY DISEASE (CAD) OR A CAD RISK- EQUIVALENT CONDITION 18-75 YEARS OF AGE AND ALIVE AS OF THE LAST DAY OF THE MEASUREMENT PERIOD AND A MINIMUM OF TWO CAD OR CAD RISK-EQUIVALENT CONDITION CODED OFFICE VISITS WITH A PRIMARY CARE PROVIDER (PCP) / CARDIOLOGIST IN 24 MONTHS AND ONE OFFICE VISIT IN 12 MONTHS
Denominator (Criteria 1):
Patients with CAD or a CAD Risk-Equivalent Condition (other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease) 18-75 years of age and alive as of the last day of the measurement period and a minimum of two CAD or CAD Risk-Equivalent Condition coded office visits with a Primary Care Provider (PCP) / Cardiologist in 24 months and one office visits in 12 months
DENOMINATOR NOTE: To meet the denominator criteria, the 24-month look back period applies to the performance period plus prior year. **This measure requires two patient encounters. At least one of the encounters should occur during the performance period to be eligible.
*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 through 75 years during the performance period
AND
Diagnosis for CAD (ICD-10-CM): I20.0, I20.1, I20.8, I20.81, I20.89, I20.9, I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I21.9, I21.A1, I21.A9, I21.B, I22.0, I22.1, I22.8, I22.9, I24.0, I24.1, I24.8, I24.81, I24.89, I24.9, I25.10, I25.110, I25.111, I25.112, I25.118, I25.119, I25.2, 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, I25.85, I25.89, I25.9, Z95.1, Z95.5, Z95.818, Z95.820, Z95.828, Z95.9, Z98.61, Z98.62
OR
Diagnosis for CAD Risk-Equivalent Condition (ICD-10-CM): I63.00, I63.011, I63.012, I63.013, I63.019, I63.02, I63.031, I63.032, I63.033, I63.039, I63.09, I63.10, I63.111, I63.112, I63.113, I63.119, I63.12, I63.131, I63.132, I63.133, I63.139, I63.19, I63.211, I63.212, I63.213, I63.219, I63.20, I63.22, I63.29, I63.231, I63.232, I63.233, I63.239, I63.30, I63.311, I63.312, I63.313, I63.319, I63.321, I63.322, I63.323, I63.329, I63.331, I63.332, I63.333, I63.339, I63.341, I63.342, I63.349, I63.39, I63.40, I63.411, I63.412, I63.413, I63.419, I63.421, I63.422, I63.423, I63.429, I63.431, I63.432, I63.433, I63.439, I63.441, I63.442, I63.449, I63.49, I63.50, I63.511, I63.512, I63.513, I63.519, I63.521, I63.522, I63.523, I63.529, I63.531, I63.532, I63.533, I63.539, I63.541, I63.542, I63.543, I63.549, I63.59, I63.6, I63.81, I63.89, I63.9, I65.01, I65.02, I65.03, I65.09, I65.1, I65.21, I65.22, I65.23, I65.29, I65.8, I65.9, I66.01, I66.02, I66.03, I66.09, I66.11, I66.12, I66.13, I66.19, I66.21, I66.22, I66.23, I66.29, I66.3, I66.8, I66.9, I70.1, I70.201, I70.202, I70.203, I70.208, I70.209, I70.211, I70.212, I70.213, I70.218, I70.219, I70.221, I70.222, I70.223, I70.228, I70.229, I70.231, I70.232, I70.233, I70.234, I70.235, I70.238, I70.239, I70.241, I70.242, I70.243, I70.244, I70.245, I70.248, I70.249, I70.25, I70.261, I70.262, I70.263, I70.268, I70.269, I70.291, I70.292, I70.293, I70.298, I70.299, I70.301, I70.302, I70.303, I70.308, I70.309, I70.311, I70.312, I70.313, I70.318, I70.319, I70.321, I70.322, I70.323, I70.328, I70.329, I70.331, I70.332, I70.333, I70.334, I70.335, I70.338, I70.339, I70.341, I70.342, I70.343, I70.344, I70.345, I70.348, I70.349, I70.35, I70.361, I70.362, I70.363, I70.368, I70.369, I70.391, I70.392, I70.393, I70.398, I70.399, I70.401, I70.402, I70.403, I70.408, I70.409, I70.411, I70.412, I70.413, I70.418, I70.419, I70.421, I70.422, I70.423, I70.428, I70.429, I70.431, I70.432, I70.433, I70.434, I70.435, I70.438, I70.439, I70.441, I70.442, I70.443, I70.444, I70.445, I70.448, I70.449, I70.45, I70.461, I70.462, I70.463, I70.468, I70.469, I70.491, I70.492, I70.493, I70.498, I70.499, I70.501, I70.502, I70.503, I70.508, I70.509, I70.511, I70.512, I70.513, I70.518, I70.519, I70.521, I70.522, I70.523, I70.528, I70.529, I70.531, I70.532, I70.533, I70.534, I70.535, I70.538, I70.539, I70.541, I70.542, I70.543, I70.544, I70.545, I70.548, I70.549, I70.55, I70.561, I70.562, I70.563, I70.568, I70.569, I70.591, I70.592, I70.593, I70.598, I70.599, I70.601, I70.602, I70.603, I70.608, I70.609, I70.611, I70.612, I70.613, I70.618, I70.619, I70.621, I70.622, I70.623, I70.628, I70.629, I70.631, I70.632, I70.633, I70.634, I70.635, I70.638, I70.639, I70.641, I70.642, I70.643, I70.644, I70.645, I70.648, I70.649, I70.65, I70.661, I70.662, I70.663, I70.668, I70.669, I70.691, I70.692, I70.693, I70.698, I70.699, I70.701, I70.702, I70.703, I70.708, I70.709, I70.711, I70.712, I70.713, I70.718, I70.719, I70.721, I70.722, I70.723, I70.728, I70.729, I70.731, I70.732, I70.733, I70.734, I70.735, I70.738, I70.739, I70.741, I70.742, I70.743, I70.744, I70.745, I70.748, I70.749, I70.75, I70.761, I70.762, I70.763, I70.768, I70.769, I70.791, I70.792, I70.793, I70.798, I70.799, I70.92, I74.01, I74.09, I74.10, I74.11, I74.19, I74.2, I74.3, I74.4, I74.5, I74.8, I74.9, I75.011, I75.012, I75.013, I75.019, I75.021, I75.022, I75.023, I75.029, I75.81, I75.89
AND
At least two patient encounters within 24 months (one encounter during the reporting year)** (CPT or HCPCS): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99424, 99426, 99429*, 99461, 99490, 99491, 99495, 99496, G0402, G0438, G0439, 99421, 99422, 99423, G2010, 99341, 99342, 99343, 99344, 99345
AND
Patient alive as of the last day of the measurement year: G9787
AND NOT
DENOMINATOR EXCLUSION:
Patient receiving hospice services any time during the measurement period: G9690
Numerator (All or Nothing):
The number of IVD patients who meet ALL of the following targets:
- Most recent BP is less than or equal to 190/40 mm Hg
- Most recent tobacco status is Tobacco Free (NOTE: If there is No Documentation of Tobacco Status the patient is not compliant for this measure)
- Daily Aspirin or Other Antiplatelet Unless Contraindicated
- High Intensity Statin Use Unless Contraindicated
Numerator Options:
COMPONENT 1:
Most recent BP is less than or equal to 130/80 mm Hg.
NUMERATOR NOTES:
Submit G9789 for blood pressures recorded during Inpatient Stays, Emergency Room Visits, or Urgent Care Visits. In order to meet performance, the most recent blood pressure should be recorded within the performance period. Home BP results which can be obtained digitally, in writing or verbally, and are able to be stored in the EMR in a discrete field can be included. Accepting these BP results is at the discretion of the provider.
Component Options:
Performance Met: Most recent BP is less than or equal to 130/80 mm Hg (G9788)
OR
Denominator Exception: Blood pressure recorded during inpatient stays, Emergency Room Visits, or Urgent Care Visits (G9789)
OR
Denominator Exception: Procedure-related BP’s not taken during an outpatient visit. Examples include Same Day Surgery, Ambulatory Service Center, G.I. Lab, Dialysis, Infusion Center, Chemotherapy (G2129)
OR
Performance Not Met: Most recent BP is greater than 190/40 mm Hg, or blood pressure not documented (G9790)
AND
COMPONENT 2:
Most recent tobacco status is tobacco free
NUMERATOR NOTE:
Submit G9792, if there is no documentation of tobacco status. In order to meet performance, the most recent tobacco status should be recorded within the performance period.
Component Options:
Performance Met: Most recent tobacco status is tobacco free (G9791)
OR
Performance Not Met: Most recent tobacco status is not tobacco free (G9792) AND
COMPONENT 3:
Daily aspirin or other antiplatelet unless contraindicated
Component Options:
Performance Met: Patient is currently on a daily aspirin or other antiplatelet (G9793)
OR
Performance Met: Documentation of medical reason(s) for not on a daily aspirin or other antiplatelet (e.g. history of gastrointestinal bleed, intra-cranial bleed, blood disorders, Idiopathic Thrombocytopenic Purpura (ITP), Gastric Bypass or documentation of active anticoagulant use during the measurement period) (G2128)
OR
Performance Not Met: Patient is not currently on a daily aspirin or other antiplatelet (G9795)
AND
COMPONENT 4:
High Intensity Statin Use.
NUMERATOR NOTE:
Valid High Intensity statins include Atorvastatin 40-80 mg and Rosuvastatin 20-40 mg.
Component Options:
Performance Met: Patient is currently on a high intensity statin therapy (G9796)
OR
Performance Met: Documentation of medical reason(s) for not on a high intensity statin (e.g. Pregnancy, In Vitro Fertilization, Clomiphene RX, ESRD, Cirrhosis, Muscular Pain and Disease during the measurement period or prior year) (G9940)
OR
Performance Not Met: Patient is not on a high intensity statin therapy (G9797)
OR
SUBMISSION CRITERIA 2: PATIENTS WITH ONE ACUTE CORONARY EVENT (ACUTE MYOCARDIAL INFARCTION [AMI], PERCUTANEOUS CORONARY INTERVENTION [PCI], OR CORONARY ARTERY BYPASS GRAFT [CABG]) 18- 75 YEARS OF AGE AND ALIVE AS OF THE LAST DAY OF THE MEASUREMENT PERIOD) FROM A HOSPITAL VISIT (EXCLUDING EMERGENCY AND LAB ONLY VISITS) AND HAVE BEEN SEEN BY A PRIMARY CARE PROVIDER (PCP) / CARDIOLOGIST FOR TWO OFFICE VISITS IN 24 MONTHS AND ONE OFFICE VISIT IN 12 MONTHS
Denominator (Criteria 2):
Patients with one Acute Coronary Event (AMI, PCI or CABG) 18-75 years of age and alive as of the last day of the measurement period from a hospital visit (excluding Emergency and Lab Only visits) and been seen by a PCP / Cardiologist for two office visits in 24 months and one office visit in 12 months
DENOMINATOR NOTE:
To meet the denominator criteria, the 24-month look back period applies to the reporting year plus prior year. **This measure requires two patient encounters. At least one of the encounters should occur during the performance period to be eligible. If the patient has the history of AMI, PCI or CABG inclusion criterion, there should be documentation of the diagnosis or procedure at the encounter being evaluated for the numerator actions.
*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) 2:
Patients aged 18 through 75 years during the performance period
AND
History of diagnosis for AMI – include patients that had a prior (within the past 24 months) (ICD-10-CM): I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I21.9, I21.A1, I21.A9, I21.B, I22.0, I22.1, I22.8, I22.9
OR
History of procedures for PCI – include patients that had a prior (within the past 24 months) (CPT or HCPCS): 92920, 92924, 92933, 92937, 92941, 92943, C9600, C9602, C9604, C9606, C9607
OR
History of procedure for CABG – include patients that had a prior (within the past 24 months) (CPT or HCPCS): 33509, 33510, 33511, 33512, 33513, 33514, 33516, 33533, 33534, 33535, 33536, 92920, 92924, 92928, 92933, S2205*, S2206*, S2207*, S2208*, S2209*
AND
At least two patient encounters within 24 months (one encounter during the reporting year)** (CPT or HCPCS): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99424, 99426, 99429*, 99461, 99490, 99491, 99495, 99496, G0402, G0438, G0439, 99421, 99422, 99423, G2010, 99341, 99342, 99343, 99344, 99345
AND
Patient alive as of the last day of the measurement year: G9787
AND NOT
DENOMINATOR EXCLUSION:
Patient receiving hospice services any time during the measurement period: G9690
Numerator (All or Nothing):
The number of IVD patients who meet ALL of the following targets:
- Most recent BP is less than or equal to 130/80 mm Hg
- Most recent tobacco status is Tobacco Free (NOTE: If there is No Documentation of Tobacco Status the patient is not compliant for this measure)
- Daily Aspirin or Other Antiplatelet Unless Contraindicated
- High Intensity Statin Use Unless Contraindicated
Numerator Options:
COMPONENT 1:
Most recent BP is less than or equal to 130/80 mm Hg
NUMERATOR NOTES:
Submit G9789, if blood pressures recorded during inpatient stays, Emergency Room Visits, or Urgent Care Visits do not qualify. In order to meet performance, the most recent blood pressure should be recorded within the performance period.
Home BP results which can be obtained digitally, in writing or verbally, and are able to be stored in the EMR in a discrete field can be included. Accepting these BP results is at the discretion of the provider.
Component Options:
Performance Met: Most recent BP is less than or equal to 130/80 mm Hg (G9788)
OR
Denominator Exception: Blood pressure recorded during inpatient stays, Emergency Room Visits, or Urgent Care Visits (G9789)
OR
Denominator Exception: Procedure-related BP’s not taken during an outpatient visit. Examples include Same Day Surgery, Ambulatory Service Center, G.I. Lab, Dialysis, Infusion Center, Chemotherapy (G2129)
OR
Performance Not Met: Most recent BP is greater than 130/80 mm Hg, or blood pressure not documented (G9790)
AND
COMPONENT 2:
Most recent tobacco status is tobacco free
NUMERATOR NOTE:
Submit G9792, if there is no documentation of tobacco status. In order to meet performance, the most recent tobacco status should be recorded within the performance period.
Component Options:
Performance Met: Most recent tobacco status is tobacco free (G9791)
OR
Performance Not Met: Most recent tobacco status is not tobacco free (G9792)
AND
COMPONENT 3:
Daily aspirin or other antiplatelet unless contraindicated
Component Options:
Performance Met: Patient is currently on a daily aspirin or other antiplatelet (G9793)
OR
Performance Met: Documentation of medical reason(s) for not on a daily aspirin or other antiplatelet (e.g. history of gastrointestinal bleed, intra-cranial bleed, blood disorders, Idiopathic Thrombocytopenic Purpura (ITP), Gastric Bypass or documentation of active anticoagulant use during the measurement period) (G2128)
OR
Performance Not Met: Patient is not currently on a daily aspirin or other antiplatelet (G9795)
AND
COMPONENT 4:
High Intensity Statin Use.
NUMERATOR NOTE:
Valid high intensity statins include Atorvastatin 40-80 mg and Rosuvastatin 20-40 mg.
Component Options:
Performance Met: Patient is currently on a high intensity statin therapy (G9796)
OR
Performance Met: Documentation of medical reason(s) for not on a high intensity statin (e.g. Pregnancy, In Vitro Fertilization, Clomiphene RX, ESRD, Cirrhosis, Muscular Pain and Disease during the measurement period or prior year) (G9940)
OR
Performance Not Met: Patient is not on a high intensity statin therapy (G9797)
RATIONALE:
There has been important evidence from clinical trials that further supports and broadens the merits of risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease
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