2017 MIPS Measure #438: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Valid Data Submission Method(s) Measure Type High Priority Measure? NQS Domain Specialty Measure Sets
CMS Web Interface, Registry Process No Effective Clinical Care Internal Medicine, Cardiology, General Practice/Family Medicine

Measure Description

Percentage of the following patients-all considered at high risk of cardiovascular events-who were prescribed or were on statin therapy during the measurement period: Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR Adults aged >=21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL

Instruction

This measure is to be reported once per performance period for patients seen during the performance period. This measure may be reported by eligible clinicians who provide the services in the measure-specific denominator coding.

Denominator

THERE ARE THREE REPORTING CRITERIA FOR THIS MEASURE**:
1) Patients aged ≥ 21 years at the beginning of the measurement period with clinical ASCVD diagnosis

OR

2) Patients aged ≥ 21 years at the beginning of the measurement period who have ever had a fasting or direct laboratory result of LDL-C ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia

OR

3) Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with an LDL-C result of 70–189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period

**All patients who meet one or more of the following criteria indicated above would be considered at high risk for cardiovascular events under the ACC/AHA guidelines. When reporting this measure determine if the patient meets denominator eligibility in order of each risk category.

DENOMINATOR (REPORTING CRITERIA 1):
Patients aged ≥21 years at the beginning of the measurement period with clinical ASCVD diagnosis

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

Lipoprotein Density Cholesterol (LDL-C) result – A fasting or direct LDL-C laboratory test performed and test result documented in the medical record

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 registry-based measures.

Denominator Criteria: (Eligible Cases):
Patients aged ≥ 21 years at the beginning of the measurement period
AND
Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, G0438, G0439
WITHOUT
Telehealth Modifier: GQ, GT
AND
Previously diagnosed or have an active diagnosis of Clinical ASCVD: G9662
AND NOT
DENOMINATOR EXCLUSIONS:
Patients who have a diagnosis of pregnancy: G9778
OR
Patients who are breastfeeding: G9779
OR
Patients who have a diagnosis of rhabdomyolysis: G9780

 

–OR–

 

DENOMINATOR (REPORTING CRITERIA 2):
Patients aged ≥21 years at the beginning of the measurement period who have ever had a fasting or direct laboratory result of LDL-C ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia

Definition:
Lipoprotein Density Cholesterol (LDL-C) result – A fasting or direct LDL-C laboratory test performed and test result documented in the medical record

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 registry-based measures.

Denominator Criteria: (Eligible Cases):
Patient aged ≥21 years at the beginning of the measurement period
AND
Patient encounter during the performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212,99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, G0438, G0439
WITHOUT
Telehealth Modifier: GQ, GT
AND
Any fasting or direct LDL-C laboratory test result ≥ 190 mg/dL: G9663
OR
History of or active diagnosis of familial or pure hypercholesterolemia: G9782
AND NOT
DENOMINATOR EXCLUSIONS:
Patients who have a diagnosis of pregnancy: G9778
OR
Patients who are breastfeeding: G9779
OR
Patients who have a diagnosis of rhabdomyolysis:
G9780

 

–OR–

 

DENOMINATOR (REPORTING CRITERIA 3):
Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with a LDL-C result of 70–189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period

Definition:
Lipoprotein Density Cholesterol (LDL-C) result – A fasting or direct LDL-C laboratory test performed and test result documented in the medical record

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 registry-based measures.

Denominator Criteria: (Eligible Cases):
Patients aged 40 through 75 years at the beginning of the measurement period
AND
Type 1 or Type 2 diabetes diagnosis (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.3211, E10.3212, E10.3213, E10.3219, E10.329, E10.3291, E10.3292, E10.3293, E10.3299, E10.331, E10.3311, E10.3312, E10.3313, E10.3319, E10.339, E10.3391, E10.3392, E10.3393, E10.3399, E10.341, E10.3411, E10.3412, E10.3413, E10.3419, E10.349, E10.3491, E10.3492, E10.3493, E10.3499, E10.351, 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, E10.359, 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, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.3211, E11.3212, E11.3213, E11.3219, E11.329, E11.3291, E11.3292, E11.3293, E11.3299, E11.331, E11.3311, E11.3312, E11.3313, E11.3319, E11.339, E11.3391, E11.3392, E11.3393, E11.3399, E11.341, E11.3411, E11.3412, E11.3413, E11.3419, E11.349, E11.3491, E11.3492, E11.3493, E11.3499, E11.351, 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, E11.359, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, 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, E13.321, E13.3211, E13.3212, E13.3213, E13.3219, E13.329, E13.3291, E13.3292, E13.3293, E13.3299 E13.331, E13.3311, E13.3312, E13.3313, E13.3319, E13.339, E13.3391, E13.3392, E13.3393, E13.3399, E13.341, E13.3411, E13.3412, E13.3413, E13.3419, E13.349, E13.3491, E13.3492, E13.3493, E13.3499, E13.351, 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, E13.359, 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): 99201, 99202, 99203, 99204, 99205, 99212,99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, G0438, G0439
WITHOUT
Telehealth Modifier: GQ, GT
AND
The highest fasting or direct LDL-C laboratory test result of 70 –189 mg/dL in the measurement period or two years prior to the beginning of the measurement period: G9666
AND NOT
DENOMINATOR EXCLUSIONS:
Patients who have a diagnosis of pregnancy: G9778
OR
Patients who are breastfeeding: G9779
OR
Patients who have a diagnosis of rhabdomyolysis: G9780

Numerator

THERE ARE THREE REPORTING CRITERIA FOR THIS MEASURE**:
1) Patients aged ≥ 21 years at the beginning of the measurement period with clinical ASCVD diagnosis

OR

2) Patients aged ≥ 21 years at the beginning of the measurement period who have ever had a fasting or direct laboratory result of LDL-C ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia

OR

3) Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with an LDL-C result of 70–189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period

**All patients who meet one or more of the following criteria indicated above would be considered at high risk for cardiovascular events under the ACC/AHA guidelines. When reporting this measure determine if the patient meets denominator eligibility in order of each risk category.

NUMERATOR (REPORTING CRITERIA 1):
Patients who are actively using or who receive an order (prescription) for statin therapy at any point during the measurement period

Definitions:
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.
Sample list of statin medications (list is NOT inclusive of all agents) is included in the clinical recommendations
Active Liver or Hepatic Disease or Insufficiency – The following codes are included in the Denominator Exception (G9667) to define liver disease: B15.0, B15.9, B16.0, B16.1, B16.2, B16.9, B18.0, B18.1, B19.10, B19.11, B17.0, B17.2, B17.8, B17.10, B17.11, B18.2, B18.8, B18.9, B19.0, B19.20, B19.21, K70.0, K70.9, K70.30, K70.31, K70.40, K70.41, K71.3, K71.4, K71.9, K71.10, K71.11, K71.50, K71.51, K72.00, K72.01, K72.10, K72.11, K72.90, K72.91, K73.0, K73.2, K73.8, K73.9, K74.0, K74.1, K74.2, K74.3, K74.4, K74.5, K74.60, K74.69, K75.4, K76.0, K76.2, K76.3, K76.7, K76.9, K76.89, O98.419, Z22.51

NUMERATOR NOTE: In order to meet the measure, current statin therapy use must be documented in the patient’s current medication list or ordered during the measurement 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; 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.

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 receive an order (prescription) for statin therapy (e.g., patient with adverse effect, allergy or intolerance to statin medication therapy, patients who are receiving palliative care, patients with active liver disease or hepatic disease or insufficiency, and patients with end stage renal disease (ESRD) (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–

 

NUMERATOR (REPORTING CRITERIA 2):
Patients who are actively using or who receive an order (prescription) for statin therapy at any point during the measurement period

Definitions:
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.
Sample list of statin medications (list is NOT inclusive of all agents) is included in the clinical recommendations
Active Liver or Hepatic Disease or Insufficiency –
The following codes are included in the Denominator Exception (G9667) to define liver disease: B15.0, B15.9, B16.0, B16.1, B16.2, B16.9, B18.0, B18.1, B19.10, B19.11, B17.0, B17.2, B17.8, B17.10, B17.11, B18.2, B18.8, B18.9, B19.0, B19.20, B19.21, K70.0, K70.9, K70.30, K70.31, K70.40, K70.41, K71.3, K71.4, K71.9, K71.10, K71.11, K71.50, K71.51, K72.00, K72.01, K72.10, K72.11, K72.90, K72.91, K73.0, K73.2, K73.8, K73.9, K74.0, K74.1, K74.2, K74.3, K74.4, K74.5, K74.60, K74.69, K75.4, K76.0, K76.2, K76.3, K76.7, K76.9, K76.89, O98.419, Z22.51

NUMERATOR NOTE: In order to meet the measure, current statin therapy use must be documented in the patient’s current medication list or ordered during the measurement 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; 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.

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 receive an order (prescription) for statin therapy (e.g., patient with adverse effect, allergy or intolerance to statin medication therapy, patients who are receiving palliative care, patients with active liver disease or hepatic disease or insufficiency, and patients with end stage renal disease (ESRD) (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–

 

NUMERATOR (REPORTING CRITERIA 3):
Patients who are actively using or who receive an order (prescription) for statin therapy at any point during the measurement period

Definitions:
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.
Sample list of statin medications (list is NOT inclusive of all agents) is included in the clinical recommendations
Active Liver or Hepatic Disease or Insufficiency – The following codes are included in the Denominator Exception (G9667) to define liver disease: B15.0, B15.9, B16.0, B16.1, B16.2, B16.9, B18.0, B18.1, B19.10, B19.11, B17.0, B17.2, B17.8, B17.10, B17.11, B18.2, B18.8, B18.9, B19.0, B19.20, B19.21, K70.0, K70.9, K70.30, K70.31, K70.40, K70.41, K71.3, K71.4, K71.9, K71.10, K71.11, K71.50, K71.51, K72.00, K72.01, K72.10, K72.11, K72.90, K72.91, K73.0, K73.2, K73.8, K73.9, K74.0, K74.1, K74.2, K74.3, K74.4, K74.5, K74.60, K74.69, K75.4, K76.0, K76.2, K76.3, K76.7, K76.9, K76.89, O98.419, Z22.51

NUMERATOR NOTE: In order to meet the measure, current statin therapy use must be documented in the patient’s current medication list or ordered during the measurement 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; 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.

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 receive an order (prescription) for statin therapy (e.g., patient with adverse effect, allergy or intolerance to statin medication therapy, patients who are receiving palliative care, patients with active liver disease or hepatic disease or insufficiency, patients with end stage renal disease (ESRD) (G9781)
OR
Denominator Exception: Documentation of patients with diabetes who have a most recent fasting or direct LDL- C laboratory test result < 70 mg/dL and are not taking statin therapy (G9783)
OR
Performance Not Met: Patients who are not currently statin therapy users or did not receive an order (prescription) for statin therapy (G9665)

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