CONARY ARTERY DISEASE (CAD) MEASURES GROUP OVERVIEW 2014 PQRS OPTIONS F MEASURES GROUPS: 2014 PQRS MEASURES IN CONARY ARTERY DISEASE (CAD) MEASURES GROUP: #6. Coronary Artery Disease (CAD): Antiplatelet Therapy #197. Coronary Artery Disease (CAD): Lipid Control #226. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention #242. Coronary Artery Disease (CAD): Symptom Management INSTRUCTIONS F REPTING: It is not necessary to submit the measures group-specific intent G-code for registry-based submissions. However, the measures group specific intent G-code has been created for registry only measure groups for use by registries that utilize claims data. G8489: I intend to report the Coronary Artery Disease (CAD) Measures Group Report the patient sample method: 20 Patient Sample Method: 20 unique patients (a majority of which must be Medicare Part B FFS [fee for service] patients) meeting patient sample criteria for the measures group during the reporting period (January 1 through December 31, 2014 July 1 through December 31, 2014). Patient sample criteria for the CAD Measures Group are patients aged 18 years and older with a specific diagnosis of CAD accompanied by a specific patient encounter: One of the following diagnosis codes indicating coronary artery disease: ICD-9-CM [for use 1/1/2014 9/30/2014]: 410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20, 410.21, 410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42, 410.50, 410.51, 410.52, 410.60, 410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81, 410.82, 410.90, 410.91, 410.92, 411.0, 411.1, 411.81, 411.89, 412, 413.0, 413.1, 413.9, 414.00, 414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07, 414.2, 414.3, 414.8, 414.9, V45.81, V45.82 ICD-10-CM [for use 10/1/2014-12/31/2014]: I20.0, I20.1, I20.8, I20.9, I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I22.0, I22.1, I22.2, I22.8, I22.9, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.2, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750, I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.83, I25.89, I25.9, Z95.1, Z95.5, Z98.61 Accompanied by: One of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 Report a numerator option on all applicable measures within the CAD Measures Group for each patient within the eligible professional s patient sample. Instructions for qualifying numerator option reporting for each of the measures within the Coronary Artery Disease (CAD) Measures Group are displayed on the next several pages. The following composite Quality Data Code (QDC) has been created for registries that utilize claims data. This QDC may be reported in lieu of individual QDCs when all quality clinical actions for all applicable measures within the group have been performed. Page 114 of 342
Composite QDC G8498: All quality actions for the applicable measures in the Coronary Artery Disease (CAD) Measures Group have been performed for this patient To report satisfactorily for the CAD Measures Group it requires all applicable measures for each patient within the eligible professional s patient sample to be reported a minimum of once during the reporting period. Measure #242 is represented differently from the corresponding individual measure. Therefore the individual measures are specified and analyzed in a slightly different manner than the same measures contained within the measures group. Use the measure specifications as defined within the measures group for reporting purposes in order to satisfactorily report the measures group. Measures groups containing a measure with a 0% performance rate will not be counted as satisfactorily reporting the measures group. The recommended clinical quality action must be performed on at least one patient for each measure within the measures group reported by the eligible professional. Performance exclusion quality-data codes are not counted in the performance denominator. If the eligible professional submits all performance exclusion quality-data codes, the performance rate would be 0/0 and would be considered satisfactorily reporting. NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures groups option. Page 115 of 342
Measure #6 (NQF 0067): Coronary Artery Disease (CAD): Antiplatelet Therapy DESCRIPTION: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who were prescribed aspirin or clopidogrel NUMERAT: Patients who were prescribed aspirin or clopidogrel Definition: Prescribed May include prescription given to the patient for aspirin or clopidogrel at one or more visits in the measurement period patient already taking aspirin or clopidogrel as documented in current medication list. Numerator Options: Aspirin or clopidogrel prescribed (4086F) Documentation of medical reason(s) for not prescribing aspirin or clopidogrel (eg, allergy, intolerance, receiving other thienopyridine therapy, receiving warfarin therapy, bleeding coagulation disorders, other medical reasons) (4086F with 1P) Documentation of patient reason(s) for not prescribing aspirin or clopidogrel (eg, patient declined, other patient reasons) (4086F with 2P) Documentation of system reason(s) for not prescribing aspirin or clopidogrel (eg, lack of drug availability, other reasons attributable to the health care system) (4086F with 3P) Aspirin or clopidogrel was not prescribed, reason not otherwise specified (4086F with 8P) Page 116 of 342
Measure #197 (NQF 0074): Coronary Artery Disease (CAD): Lipid Control DESCRIPTION: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who have a LDL-C result < 100 mg/dl patients who have a LDL-C result 100 mg/dl and have a documented plan of care to achieve LDL-C < 100 mg/dl, including at a minimum the prescription of a statin NUMERAT: Patients who have a LDL-C result < 100 mg/dl patients who have a LDL-C result 100 mg/dl and have a documented plan of care to achieve LDL-C < 100 mg/dl, including at a minimum the prescription of a statin Numerator Instructions: The first numerator option can be reported for patients who have a documented LDL-C < 100 mg/dl at any time during the measurement period (if more than one result, report most current). All patients that meet denominator criteria without an LDL-C result will NOT meet performance for the measure. Definitions: Documented plan of care - Includes the prescription of a statin and may also include: documentation of discussion of lifestyle modifications (diet, exercise) or scheduled re-assessment of LDL-C. Prescribed - May include prescription given to the patient for a statin at one or more visits within the measurement period patient already taking a statin as documented in current medication list. Numerator Options: Most current LDL-C < 100 mg/dl (G8736) Most current LDL-C 100 mg/dl (G8737) Statin therapy prescribed or currently being taken (4013F) Plan of care to achieve lipid control documented (0556F) Most current LDL-C 100 mg/dl (G8737) Plan of care to achieve lipid control documented (0556F) Documentation of medical reason(s) for statin therapy not prescribed or currently being taken (eg, allergy, intolerance to statin medication(s), other medical reasons) (4013F with 1P) Documentation of patient reason(s) for statin therapy not prescribed or currently being taken (eg, patient declined, other patient reasons) (4013F with 2P) Documentation of system reason(s) for statin therapy not prescribed or currently being taken (eg, financial reasons, other system reasons) (4013F with 3P) Most current LDL-C 100 mg/dl (G8737) Statin therapy not prescribed or currently being taken, reason not otherwise specified (4013F with 8P) Page 117 of 342
Most current LDL-C 100 mg/dl (G8737) Plan of care to achieve lipid control not documented (0556F with 8P) LDL-C result not present or not within 12 months prior (G8943) Page 118 of 342
Measure #226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention DESCRIPTION: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months who received cessation counseling intervention if identified as a tobacco user NUMERAT: Patients who were screened for tobacco use at least once within 24 months who received tobacco cessation counseling intervention if identified as a tobacco user Definitions: Tobacco Use Includes use of any type of tobacco. Cessation Counseling Intervention Includes brief counseling (3 minutes or less), and/or pharmacotherapy. NUMERAT NOTE: In the event that a patient is screened for tobacco use and identified as a user but did not receive tobacco cessation counseling report 4004F with 8P. Numerator Options: Patient screened for tobacco use received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user (4004F) Current tobacco non-user (1036F) Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason) (4004F with 1P) Tobacco screening tobacco cessation intervention not performed, reason not otherwise specified (4004F with 8P) Page 119 of 342
Measure #242: Coronary Artery Disease (CAD): Symptom Management DESCRIPTION: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period with results of an evaluation of level of activity and an assessment of whether anginal symptoms are present or absent with appropriate management of anginal symptoms within a 12 month period NUMERAT: Patients with appropriate management of anginal symptoms within a 12 month period NUMERAT NOTE: The reporting numerator options contained within this specification are represented differently than the corresponding individual measure. Reference this specification only in order to satisfactorily report the measures group. Numerator Instruction: Patients with an evaluation of level of activity and an assessment of whether anginal symptoms are present or absent are included within this measure Evaluation of level of activity and evaluation of presence or absence of angina symptoms should include: Documentation of Canadian Cardiovascular Society (CCS) Angina Class Completion of a disease-specific questionnaire (e.g., Seattle Angina Questionnaire or other validated questionnaire) to quantify angina and level of activity Definitions: Canadian Cardiovascular Society (CCS) Angina Classification: Class 0: Asymptomatic Class 1: Angina with strenuous exercise Class 2: Angina with moderate exertion Class 3: Angina with mild exertion 1. Walking 1-2 level blocks at normal pace 2. Climbing 1 flight of stairs at normal pace Class 4: Angina at any level of physical exertion Appropriate Management of Anginal Symptoms Includes the Following: 1. Absence of anginal symptoms as determined by evaluation of level of activity and symptoms. 2. Presence of anginal symptoms as determined by evaluation of level of activity and symptoms and a plan of care is documented to achieve control of anginal symptoms. Documented plan of care may include: 2 or more anti-anginal medications prescribed, ** Referral for consideration for coronary revascularization, Referral for additional evaluation or treatment of anginal symptoms **Prescribed may include prescription given to the patient for anti-anginal medication at one or more visits in the measurement period patient already taking 2 or more anti-anginal medications as documented in current medication list. Numerator Options: Severity of angina assessed by level of activity (1010F) Angina present (1011F) Page 120 of 342
Plan of care to manage anginal symptoms documented (0557F) Severity of angina assessed by level of activity (1010F) Angina absent (1012F) Severity of angina assessed by level of activity (1010F) Angina present (1011F) Documentation of medical reason(s) for not providing any specified element of plan of care to achieve control of anginal symptoms (eg, allergy, intolerance, other medical reasons) (0557F with 1P) Documentation of patient reason(s) for not providing any specified element of plan of care to achieve control of anginal symptoms (eg, patient declined, other patient reasons) (0557F with 2P) Documentation of system reason(s) for not providing any specified element of plan of care to achieve control of anginal symptoms (eg, financial reasons, other reasons attributable to the health care system) (0557F with 3P) Severity of angina assessed by level of activity (1010F) Angina present (1011F) Plan of care to achieve control of angina symptoms was not performed, reason not otherwise specified (0557F with 8P) Severity of angina not assessed, reason not otherwise specified (1010F with 8P) Page 121 of 342
CONARY ARTERY DISEASE (CAD) MEASURES GROUP RATIONALE CLINICAL RECOMMENDATION STATEMENTS Measure #6 - Coronary Artery Disease (CAD): Antiplatelet Therapy RATIONALE: Use of antiplatelet therapy has shown to reduce the occurrence of vascular events in patients with coronary artery disease, including myocardial infarction and death. CLINICAL RECOMMENDATION STATEMENTS: The following evidence statements are quoted verbatim from the referenced clinical guidelines. Aspirin should be started at 75 to 162 mg per day and continued indefinitely in all patients unless contraindicated. (Class I Recommendation, Level A Evidence) (ACC/AHA, 2007) Clopidogrel when aspirin is absolutely contraindicated. (Class IIa Recommendation; Level of Evidence B) (ACC/AHA, 2002) Measure #197 - Coronary Artery Disease (CAD): Lipid Control RATIONALE: Managing LDL-C to less than 100 mg/dl through use of statins reduces risk of cardiovascular events. CLINICAL RECOMMENDATION STATEMENTS: The following evidence statements are quoted verbatim from the referenced clinical guidelines: Recommended lipid management includes assessment of a fasting lipid profile (Class I Recommendation, Level A Evidence). (ACC/AHA, 2007) a. LDL-C should be less than 100 mg/dl (Class I Recommendation, Level A Evidence) b. Reduction of LDL-C to less than 70 mg/dl or high-dose statin therapy is reasonable (Class IIa Recommendation, Level A Evidence). c. If baseline LDL-C is greater than or equal to 100 mg/dl, LDL-lowering medications are used in high-risk or moderately high-risk persons, it is recommended that intensity of the therapy be sufficient to achieve a 30% to 40% reduction in LDL-C levels (Class I Recommendation, Level A Evidence). d. If on-treatment LDL-C is greater than or equal to 100 mg/dl, LDL-lowering therapy should be intensified (Class I Recommendation, Level A Evidence). e. If baseline LDL-C is 70 to 100 mg/dl, it is reasonable to treat LDL-C to less than 70 mg/dl (Class IIa Recommendation, Level B Evidence). Statins should be considered as first-line drugs when LDL-lowering drugs are indicated to achieve LDL treatment goals. (The Third Report of the National Cholesterol Education Program [NCEP] Adult Treatment Panel III [ATPII], 2002) Measure #226 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention RATIONALE: This measure is intended to promote adult tobacco screening and tobacco cessation interventions for those who use tobacco products. There is good evidence that tobacco screening and brief cessation intervention (including counseling and/or pharmacotherapy) is successful in helping tobacco users quit. Tobacco users who are able to stop smoking lower their risk for heart disease, lung disease, and stroke. CLINICAL RECOMMENDATION STATEMENTS: The following evidence statements are quoted verbatim from the referenced clinical guidelines: Page 122 of 342
All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status or the use of other reminder systems such as chart stickers or computer prompts, significantly increase rates of clinician intervention. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008) All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008) Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates. Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008) The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008) Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008) The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. (A Recommendation) (U.S. Preventive Services Task Force, 2009) Measure #242 - Coronary Artery Disease (CAD): Symptom Management RATIONALE: In order to effectively manage the symptoms of a patient with chronic stable coronary artery disease, an assessment of those symptoms needs to be performed. This assessment is the basis of any treatment modification that needs to be made. Effective management of the symptoms associated with chronic stable coronary artery disease (eg, chest pain, shortness of breath) through medication management or referral for consideration of revascularization or other additional treatment. This may lead to improved patient quality of life, an important patient-centered outcome. CLINICAL RECOMMENDATION STATEMENTS: The following evidence statements are quoted verbatim from the referenced clinical guidelines: The treatment of chronic stable angina has two complementary objectives: to reduce the risk of mortality and morbid events and to reduce symptoms. From the patient s perspective, it is often the latter that is of greater concern. The cardinal symptom of [coronary artery disease (CAD)] is anginal chest pain or equivalent symptoms, such as exertional dyspnea. Often the patient suffers not only from discomfort of the symptom itself but also from accompanying limitations on activities and the associated anxiety that the symptoms may produce. (ACC/AHA, 2002)Beta-blockers as initial therapy in the absence of contraindications in patients with prior MI or without prior MI. (Class I Recommendation; Level of Evidence A [with prior MI]) (Class I Recommendation; Level of Evidence B [without prior MI] (ACC/AHA, 2002) Sublingual nitroglycerin or nitroglycerin spray for the immediate relief of angina. (Class I Recommendation; Level of Evidence B) (ACC/AHA, 2002) Page 123 of 342
Calcium antagonists* or long-acting nitrates as initial therapy for reduction of symptoms when beta-blockers are contraindicated. (Class I Recommendation; Level of Evidence B) (ACC/AHA, 2002) Calcium antagonists* or long-acting nitrates in combination with beta-blockers when initial treatment with betablockers is not successful. (Class I Recommendation; Level of Evidence B) (ACC/AHA, 2002) Calcium antagonists* and long-acting nitrates as a substitute for beta-blockers if initial treatment with beta-blockers leads to unacceptable side effects. (Class I Recommendation; Level of Evidence C) (ACC/AHA, 2002) *Short-acting, dihydropyridine calcium antagonists should be avoided. Page 124 of 342