Medicare Shared Savings Program Accountable Care Organization (ACO) Measures Deep Dive Series

Transcription

1 Medicare Shared Savings Program Accountable Care Organization (ACO) Measures Deep Dive Series At Risk Population: Measure 33 Coronary Artery Disease (CAD-7): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy Diabetes or Left Ventricular Systolic Dysfunction (LVEF <40%) ACO_QRM33PPTv7_0616_IA Approved 1

2 Measure 33: ACE Inhibitor or ARB Therapy Diabetes or LVEF <40% Objectives: Understand acceptable documentation required to successfully satisfy the Coronary Artery Disease (CAD) measure Understand the following: Appropriate age parameters Acceptable medications Three acceptable exceptions 2

3 Measure 33: ACE Inhibitor or ARB Therapy Diabetes or LVEF <40% Measure Description: Percentage of beneficiaries aged 18 years and older with a diagnosis of CAD seen within a 12 month period who also have diabetes, or a current or prior LVSD (Left Ventricular Ejection Fraction (LVEF) 40% or documented as moderate or severe) who were prescribed an ACE inhibitor or ARB therapy. Note: LVSD is defined as the beneficiary ever having LVEF 40% or having an LVSD documented as moderate or severely depressed. Beneficiary can have either Diabetes or LVSD, does not need both diagnoses. 3

4 Measure 33: Measure Qualification Determine if the patient is qualified for the measure. There are no acceptable exclusions provided for this measure. The measure qualification answer is Yes or Not Confirmed - Diagnosis unless prior approval is received to select: No Other CMS Approved Reason This answer is only acceptable with approval from the Centers for Medicare & Medicaid Services (CMS) 4

5 Measure 33: ACE Inhibitor or ARB Therapy Diabetes or LVEF <40% 1. Does patient have an active diagnosis of CAD or history of cardiac surgery? Yes The patient has an active diagnosis of CAD or history of cardiac surgery documented at any time up through the last day of the measurement period Not Confirmed - Diagnosis No documentation to indicate the patient has a confirmed diagnosis of CAD 2. Does patient have diabetes? 5 Yes Documentation that patient has diabetes No No documentation that patient has diabetes

6 Measure 33: ACE Inhibitor or ARB Therapy Diabetes or LVEF <40% 3. Does patient have LVSD (ever having a LVEF < 40% or documented as moderately or severely depressed)? Yes Documentation that a patient has ever had a LVEF < 40% or a documented LVSD as moderate or severe Documentation of moderate or severe LVSD equates to a LVEF < 40% No No documentation of LVSD (LVEF < 40%) or moderate or severe LVSD 6 Note: If multiple diagnostic studies were performed on the same day to measure ejection fraction, use the following hierarchy to determine if LVSD is present: cardiac catheterization echocardiogram MUGA or other cardiac scan

7 Measure 33: ACE Inhibitor or ARB Therapy Diabetes or LVEF <40% 4. Was patient prescribed an ACE inhibitor or ARB therapy in 2016? Yes ACE inhibitor prescription or ARB therapy is required if a patient has a diagnosis of diabetes or a current or prior LVSD Documentation that a patient was prescribed an approved ACE inhibitor or ARB therapy at anytime during 2016 No Documentation that a patient was not prescribed an ACE inhibitor or ARB therapy at anytime during See additional responses (next page)

8 Measure 33: ACE Inhibitor or ARB Therapy Diabetes or LVEF <40% 4. (Continued) Was patient prescribed an ACE inhibitor or ARB therapy in 2016? Exceptions: No - Medical Reasons Documentation that indicates the patient was not prescribed an ACE inhibitor or ARB therapy for medical reasons (e.g., allergy, intolerance, or other medical reasons) No - Patient Reasons Documentation that indicates patient was not prescribed an ACE inhibitor or ARB therapy for patient reasons (e.g., patient declined or other patient reasons) No - System Reasons Documentation that indicates patient was not prescribed an ACE inhibitor or ARB therapy for system reasons (e.g., lack of drug availability or other reasons attributable to the healthcare system) 8

9 Measure 33: ACE Inhibitor or ARB Therapy Medications Diabetes or LVEF <40% Approved ACE/ARBs Sample List ACCUPRIL ACCURETIC ACEON ALTACE ATACAND ATACAND HCT AVALIDE AVAPRO AZOR BENICAR BENICAR HCT CAPOTEN CAPOZIDE COZAAR DIOVAN DIOVAN HCT EXFORGE EXFORGE HCT HYZAAR Brand Name Generic Name QUINAPRIL QUINAPRIL/HCTZ PERINDOPRIL ERBUMINE RAMIPRIL CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL/HCTZ IRBESARTAN/HCTZ IRBESARTAN AMLODIPINE/OLMESARTAN MEDOXOMIL OLMESARTAN MEDOXOMIL OLMESARTAN MEDOXOMIL/HCTZ CAPTOPRIL CAPTOPRIL/HCTZ LOSARTAN POTASSIUM VALSARTAN VALSARTAN/HCTZ AMLODIPINE/VALSARTAN AMLODIPINE/VALSARTAN/HCTZ LOSARTAN POTASSIUM/HCTZ 9 Continued (see next page)

10 Measure 33: ACE Inhibitor or ARB Therapy Medications Diabetes or LVEF <40% 10 Approved ACE/ARBs Sample List Brand Name Generic Name LEXXEL ENALAPRIL MALEATE/FELODIPINE ER LOTENSIN BENAZEPRIL or BENAZEPRIL HCL LOTENSIN HCT BENAZEPRIL HCL/HCTZ LOTREL AMLODIPINE/BENAZEPRIL HCL MAVIK TRANDOLAPRIL MICARDIS TELMISARTAN MICARDIS HCT TELMISARTAN/HCTZ MONOPRIL FOSINOPRIL SODIUM MONOPRIL HCT FOSINOPRIL SODIUM/HCTZ PRINIVIL or ZESTRIL LISINOPRIL PRINIZIDE/ZESTORETIC LISINOPRIL/HCTZ TARKA TRANDOLAPRIL/VERAPAMIL HCL ER TECZEM TEVETEN TEVETEN HCT TRIBENZOR TWYNSTA UNIRETIC UNIVASC VALTURNA VASERETIC VASOTEC DILTIAZEM HCL / ENALAPRIL EXTENDED RELEASE EPROSARTAN Please refer to slide 13 for the supporting EPROSARTAN/HCTZ documents link for a complete list of approved ACE Inhibitors and ARB therapies. AMLODIPINE/OLMESARTAN MEDOXOMIL/HCTZ AMLODIPINE/TELMISARTAN MOEXIPRIL HCL/HCTZ MOEXIPRIL HCL ALISKIREN/VALSARTAN ENALAPRIL MALEATE/ HCTZ ENALAPRIL MALEATE

11 Measure 33: Quick Tips The diagnosis of diabetes would need to be documented in the medical record. There is not a specific timeframe/limitation for the diagnosis of DM for CAD. Accepted ACE inhibitors and ARB therapies are listed in the CAD Drug Codes tab available in the 2016_GPROWebInterface_MeasuresDocumentation supporting document. Refer to the 2016_GPROWebInterface_MeasuresDocumentation link on the Resources page. This list may not be all inclusive. Acceptable exceptions must be documented annually in the medical record. If multiple diagnostic studies are presented on the same day to measure ejection fraction, use the following order to determine if LVSD is present: 1. Cardiac catheterization 2. Echocardiogram 3. MUGA or other cardiac scan 11

12 Measure 33: Denominator & Numerator Inclusion in the Denominator: Beneficiary is qualified for the sample Not Qualified = Hospice, Death, Moved Out of Country, Medicare Not Primary Medical record is available Age, diagnosis and timeframe qualifications met (see pages 3, 5 and 6) Beneficiary is qualified for the measure (see page 4) Not excluded per measure exceptions (see page 8) Inclusion in the Numerator: Prescription of an ACE inhibitor or ARB therapy at anytime during 2016 (see page 7) 12

13 Disclaimer: This presentation was current at the time it was published. The CMS Programs are subject to policy changes. Links to the resource documents have been provided in the following page(s) within this document for your reference. Review the link(s) for specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. 13

14 Resources: Instruments/PQRS/GPRO_Web_Interface.html Instruments/PQRS/Downloads/2016_GPROWebInterface_MeasuresDo cumentation_ zip Payment/sharedsavingsprogram/Quality-Measures-Standards.html Instruments/PQRS/Downloads/QA_2015DataCollection_Final_psg.pdf 14