Features Navigation

(800) 825-0224 Live Demo
 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
243 0643 Process Yes Communication and Care Coordination Registry

Measure Description

Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program

Instructions

This measure is to be submitted a minimum of once per performance period for all patients seen during the performance period who had a qualifying diagnosis within the previous 12 months and who have not already participated in an outpatient CR program. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE:

Definitions:

Referral – A referral is defined as an official communication between the health care provider and the patient to recommend and carry out a referral order to an outpatient CR program. This includes the provision of all necessary information to the patient that will allow the patient to enroll in an outpatient CR program. This also includes a written or electronic communication between the healthcare provider or healthcare system and the cardiac rehabilitation program that includes the patient’s enrollment information for the program. A hospital discharge summary or office note may potentially be formatted to include the necessary patient information to communicate to the CR program (the patient’s cardiovascular history, testing, and treatments, for instance). According to standards of practice for cardiac rehabilitation programs, care coordination communications are sent to the referring provider, including any issues regarding treatment changes, adverse treatment responses, or new non-emergency condition (new symptoms, patient care questions, etc.) that need attention by the referring provider. These communications also include a progress report once the patient has completed the program. All communications must maintain an appropriate level of confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act (HIPAA).

NOTE: A patient with a qualifying diagnosis should have a referral to CR within the subsequent 12 months.In the event that the patient has a second (recurrent) qualifying event before the original 12 month “referral” period has ended, a new 12 month “referral” period for CR referral starts at the time of the second qualifying event, since the patient again becomes eligible for CR at that time.

Measure Submission

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

Numerator

Patients who have had a qualifying event/diagnosis within the previous 12 months, who have been referred to an outpatient cardiac rehabilitation/secondary prevention (CR) program

Definition

Numerator Instructions: CR programs may include a traditional CR program based on face-to-face interactions and training sessions or other options that include home-based approaches. If alternative CR approaches are used, they should be designed to meet appropriate safety standards

Numerator Quality-Data Coding Options

Performance Met:

Referral to an outpatient cardiac rehabilitation/secondary prevention program. Referred to an outpatient cardiac rehabilitation program (4500F)

Denominator Exception:

Documentation of medical reason(s) for not referring to an outpatient CR program (4500F with 1P)

OR

Documentation of system reason(s) for not referring to an outpatient CR program (4500F with 3P)

OR

Previous cardiac rehabilitation for qualifying cardiac event completed (4510F)

Performance Not Met:

Patient not referred to outpatient CR/secondary prevention program, reason not otherwise specified(4500F with 8P)

NUMERATOR NOTE: No data related

Denominator

All patients age ≥ 18 years evaluated in the outpatient setting during the reporting period who have a qualifying event/diagnosis [who within the previous 12 months have had a chronic stable angina, an acute myocardial infarction (AMI) or have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation] who do not meet any of the denominator exceptions (medical factors, health care system factors, previous cardiac rehabilitation for qualifying cardiac event completed)

Denominator Instructions: Chronic Stable Angina, Coronary Artery Bypass Graft, Percutaneous Coronary Intervention, Cardiac Valve surgery, Cardiac Transplant or Acute Myocardial Infarction are all considered qualifying events. In order to meet the criteria for inclusion of the measure, the qualifying event must have occurred or been performed within 12 months of date of encounter.

Option 1Physical Therapy Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0438, G0439

WITHOUT

Telehealth Modifier: GQ, GT, 95, POS 02

AND

Diagnosis for Chronic Stable Angina (ICD-10-CM): I20.1, I20.8, I20.9

OR

Diagnosis of Acute Myocardial Infarction (ICD-10-CM): 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, I25.2

OR

Coronary Artery Bypass Graft Surgery (CPT): 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33530, 33533, 33534, 33535, 33536, 33572, 33999, 35500, 35600, 35682, 35683

OR

Percutaneous Coronary Intervention (CPT): 92920, 92924, 92928, 92933, 92937, 92941, 92943

OR

Cardiac Valve Surgery (CPT): 33361, 33362, 33363, 33364, 33365, 33390, 33391, 33404, 33405, 33406,
33410, 33411, 33412, 33413, 33414, 33415, 33416, 33417, 33418, 33419, 33420, 33422, 33425, 33426,
33427, 33430, 33460, 33463, 33464, 33465, 33468, 33470, 33471, 33474, 33475, 33476, 33477, 33478,
33496, 33600,33602

OR

Cardiac Transplantation (CPT): 33935, 33945

AND

Qualifying cardiac event/diagnosis in previous 12 months: 1460F

Experience AdvancedMD Software in a Live Demo.

Schedule a short and personalized overview, guided by a live expert.

“The doctor who is not using AdvancedMD right now, is wasting his time.”

Armando Diez
Owner – Florida Pro Health

“Everybody still does basically the same thing; they just do it in a different and better way that’s more efficient.”

Steve Wampler, MD
Greenhill Family Clinic

Read the story  ›

“Our workflow has diminished as far as the redundancies, having to do the back-and-click here or check on this and check on that—it’s all right there!”

Johnette Lamborne
Office manager

“The nice thing about AdvancedMD is claims are cleared before they are forwarded to various insurance companies. We know very, very quickly if we have some defective portion on our claim.”

Dwight Romriell, DMD

Read the story  ›