2013 physician quality reporting (pqrs) claims/registry measure specification manual

Measure #6 (NQF 0067): Coronary Artery Disease (CAD): Antiplatelet Therapy

2013 PQRS OPTIONS FOR INDIVIDUAL MEASURES:
CLAIMS, REGISTRY

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 INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with CAD seen during the
reporting period. This measure may be reported by clinicians who perform the quality actions described in the measure for the primary management of patients with CAD based on the services provided and the measure-specific Measure Reporting via Claims:
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 OR the CPT Category II code with the modifier. The modifiers al owed for this
measure are: 1P- medical reasons, 2P- patient reasons, 3P- system reasons, 8P- reason not otherwise specified. Al measure-specific coding should be reported on the claim(s) representing the eligible encounter.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The numerator options as described in the quality-data codes are used to report the The quality-data codes listed do not need to be submit ed for registry-based submissions; however, these codes may be submit ed for those registries that utilize claims data.
DENOMINATOR:
Al patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter Diagnosis for coronary artery disease (ICD-9-CM): 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 Diagnosis for coronary artery disease (ICD-10-CM) [REFERENCE ONLY/Not Reportable]: 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, I25.82, I25.83, I25.89, I25.9, Z95.1, Z95.5, Z98.61 CPT only copyright 2012 American Medical Association. Al rights reserved. Patient encounter during the reporting period (CPT): 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
NUMERATOR:
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 OR patient already taking aspirin or clopidogrel as documented in current
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Aspirin or Clopidogrel Prescribed
CPT II 4086F: Aspirin or clopidogrel prescribed
Aspirin or Clopidogrel not Prescribed for Medical, Patient, or System Reasons
Append a modifier (1P, 2P or 3P) to Category II code 4086F to report documented circumstances that
appropriately exclude patients from the denominator. 4086F with 1P: Documentation of medical reason(s) for not prescribing Aspirin or clopidogrel (eg, al ergy,
intolerance, receiving other thienopyridine therapy, receiving warfarin therapy, bleeding coagulation disorders, other medical reasons) 4086F with 2P: Documentation of patient reason(s) for not prescribing Aspirin or clopidogrel (eg, patient
4086F with 3P: Documentation of system reason(s) for not prescribing Aspirin or clopidogrel (eg, lack of
drug availability, other reasons at ributable to the health care system) Aspirin or Clopidogrel was not Prescribed, Reason not Otherwise Specified
Append a reporting modifier (8P) to CPT Category II code 4086F to report circumstances when the action
described in the numerator is not performed and the reason is not otherwise specified. 4086F with 8P: Aspirin or clopidogrel was not prescribed, reason not otherwise specified
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 fol owing 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 al 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, CPT only copyright 2012 American Medical Association. Al rights reserved.

Source: http://www.qhs.org/janda/files/home/1357707090_Claims%20and%20Registry%206.pdf