Measure #5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
2009 PQRI REPORTING OPTIONS: CLAIMS-BASED, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure and LVSD who were prescribed ACE inhibitor or ARB therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all heart failure patients seen during the reporting period. This measure is intended to reflect the quality of services provided for patients with heart failure and decreased left ventricular systolic function. The left ventricular systolic dysfunction may be determined by quantitative or qualitative assessment, which may be current or historical. Examples of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a numerical value of left ventricular systolic dysfunction or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. The most recent ejection fraction study should be used. This measure may be reported by clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure's denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes, and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier. The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
NUMERATOR:
Patients who were prescribed ACE inhibitor or ARB therapy
ORDefinition:
Prescribed – Includes patients who are currently receiving medication(s) that follow the treatment plan recommended at an encounter during the reporting period, even if the prescription for that medication was ordered prior to the encounter.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on the claim form in order to properly report this measure. The "correct combination" of codes may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
ACE Inhibitor or ARB Therapy Prescribed(Two CPT II codes [4009F & 3021F] are required on the claim form to submit this numerator option)
CPT II 4009F: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy prescribed
AND
CPT II 3021F: Left ventricular ejection fraction (LVEF) <40% or documentation of moderately or severely depressed left ventricular systolic function
ACE Inhibitor or ARB Therapy not Prescribed for Medical, Patient, or System Reasons
(Two CPT II codes [4009F-xP & 3021F] are required on the claim form to submit this numerator option)
Append a modifier (1P, 2P or 3P) to CPT Category II code 4009F to report documented circumstances that appropriately exclude patients from the denominator.
4009F with 1P: Documentation of medical reason(s) for not prescribing angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy
4009F with 2P: Documentation of patient reason(s) for not prescribing angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy
4009F with 3P: Documentation of system reason(s) for not prescribing angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy
AND
CPT II 3021F: Left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely depressed left ventricular systolic function
OR
If patient is not eligible for this measure because LVEF ≥ 40% or LVEF not performed or documented, report:
Left Ventricular Ejection Fraction (LVEF) ≥ 40%
(One CPT II code [3022F] is required on the claim form to submit this numerator option)
CPT II 3022F: Left ventricular ejection fraction (LVEF) ≥ 40% or documentation as normal or mildly depressed left ventricular systolic function
OR
Left Ventricular Ejection Fraction (LVEF) not Performed or Documented
(One CPT II code [3021F-8P] is required on the claim form to submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 3021F to report circumstances when the patient is not eligible for the measure.
3021F with 8P: Left ventricular ejection fraction (LVEF) was not performed or documented
OR
ACE Inhibitor or ARB Therapy not Prescribed, Reason not Specified
(Two CPT II codes [4009F-8P & 3021F] are required on the claim form to submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 4009F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.
4009F with 8P: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy was not prescribed, reason not otherwise specified
AND
CPT II 3021F: Left ventricular ejection fraction < 40% or documentation of moderately or severely depressed left ventricular systolic function
DENOMINATOR:
Heart failure patients aged 18 years and older with LVEF < 40% or with moderately or severely depressed left ventricular systolic function
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for heart failure (line-item ICD-9-CM): 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9
AND
Patient encounter during reporting period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 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
RATIONALE:
In the absence of contraindications, ACE Inhibitors or ARBs are recommended for all patients with symptoms of heart failure and reduced left ventricular systolic function, as measured by left ventricular ejection fraction (LVEF). Both drugs have been shown to decrease mortality and hospitalizations.
CLINICAL RECOMMENDATION STATEMENTS:
Angiotensin converting enzyme inhibitors are recommended for all patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated. (Class I Recommendation, Level of Evidence: A)(ACC/AHA)
Angiotensin II receptor blockers approved for the treatment of HF are recommended in patients with current or prior symptoms of HF and reduced LVEF who are ACEI-intolerant. (Class I Recommendation, Level of Evidence: A) (ACC/AHA)
Angiotensin II receptor blockers are reasonable to use as alternatives to ACEIs as first-line therapy for patients with mild to moderate HF and reduced LVEF, especially for patients already taking ARBs for other indications. (Class IIa Recommendation, Level of Evidence: A) (ACC/AHA)
