CMS135v9 – Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40%.

– DENOMINATOR EXCEPTIONS

• Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., hypotensive patients who are at immediate risk of cardiogenic shock, hospitalized patients who have experienced marked azotemia, allergy, intolerance, other medical reasons).
• Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., patient declined, other patient reasons).
• Documentation of system reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., other system reasons).

– NUMERATOR

Patients who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.

For Denominator 1:

Patients satisfying all of the following conditions are included in denominator 1:

• Patients aged 18 years or older at the start of the measurement period with two or more qualifying encounters during the measurement period and a heart failure outpatient encounter. To record an encounter, navigate to Patient > Provider Note > eSuperbill. Under the ‘Procedure- CPTs’ heading, enter the encounter code.

Heart failure should be diagnosed during the outpatient encounter. To document the heart failure diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.

• Patients with moderate or severe LVSD findings before the end of heart failure outpatient encounter. Ejection Fraction diagnostic study should be performed or a diagnosis for either ‘Moderate or Severe LVSD’ or ‘Left Ventricular Systolic Dysfunction’ should exist. To document ‘Ejection Fraction’ diagnostic study performed, use the workflow Patient > Clinical > Orders & Results > Radiology. Click ‘+ Order’ and add the radiology order details. Then hover over ‘Sign’ and click ‘Queue’.

Mark the radiology order as completed by clicking the ‘Mark As Completed’ button.

Note:

For LOINC Codes Based Labs: Please ensure that the test code is mapped to a LOINC Code from the Settings. To map a LOINC with the radiology test code, navigate to Settings > EHR > Radiology. Select the radiology test and navigate to the ‘Code’ tab. Then, click on a code. Under the ‘Result Codes and LOINCS’ heading, add a Code, LOINC and Description and click on the ‘Add’ button.

Once done, click on ‘Save’.  

For CPT Codes Based Labs: When a CPT code is added to a test order, please ensure that the CPT code is present in the ‘Procedures’.  

Moreover, the CPT code should be mapped to a LOINC Code from the Settings. To map a LOINC with the CPT code, navigate to Settings > Billing > Procedure. Select the CPT code and navigate to the ‘Edit Procedure’ tab. Under the ‘Procedure Components’ heading, add a Code, LOINC and Description and click on the ‘Add’ button.

Once done, click on ‘Save’.  

To document the LVSD diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’.

For Denominator 2:

Patients satisfying all of the following conditions are included in denominator 2:

• Patients aged 18 years or older at the start of the measurement period with heart failure inpatient encounter during the measurement period. To record an encounter, navigate to Patient > Provider Note > eSuperbill. Under the ‘Procedure- CPTs’ heading, enter the encounter code.
  • Heart failure should be diagnosed during the inpatient encounter. To document the heart failure diagnosis, use the workflow Patient > Provider Note > Diagnoses.
• Patients with moderate or severe LVSD findings before the end of heart failure inpatient encounter. Ejection Fraction diagnostic study should be performed or a diagnosis for either ‘Moderate or Severe LVSD’ or ‘Left Ventricular Systolic Dysfunction’ should exist. To document ‘Ejection Fraction’ diagnostic study performed, use the workflow Patient > Clinical > Orders & Results > Radiology. Click ‘+ Order’ and add the radiology order details. Then hover over ‘Sign’ and click ‘Queue’. Mark the radiology order as completed by clicking the ‘Mark As Completed’ button.
  • To document the LVSD diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’.

For Numerator 1:

Include patients fulfilling any of the following criteria in Numerator 1:

• Patients having ACEI, ARB, or ARNI therapy ordered and heart failure outpatient encounter with moderate or severe LVSD. ACEI, ARB, or ARNI therapy should be ordered during heart failure outpatient encounter with moderate or severe LVSD. To document a ACEI, ARB, or ARNI therapy ordered, navigate to Patient > Provider Note > Prescription. Click ‘Add’ and search for the prescription. Enter the medication details and click ‘Save’.

• • To record an outpatient encounter, navigate to Patient > Provider Note > eSuperbill.
  • To document ‘Ejection Fraction’ diagnostic study performed, use the workflow Patient > Clinical > Orders & Results > Radiology.
  • Moreover, diagnoses for heart failure and LVSD and can be recorded via Patient > Provider Note > Diagnoses.

• Patients currently taking ACEI, ARB, or ARNI therapy and having heart failure outpatient encounter with moderate or severe LVSD. ACEI, ARB, or ARNI therapy should begin after the heart failure outpatient encounter with moderate or severe LVSD. To document ACEI, ARB, or ARNI therapy, navigate to Patient > Provider Note > Medications. Click ‘Add’ and search for the medication. Enter the medication details and click ‘Save’.

• • To record an outpatient encounter, navigate to Patient > Provider Note > eSuperbill.
  • To document ‘Ejection Fraction’ diagnostic study performed, use the workflow Patient > Clinical > Orders & Results > Radiology.
  • Moreover, diagnoses for heart failure and LVSD and can be recorded via Patient > Provider Note > Diagnoses.

For Numerator 2:

Include patients fulfilling the following criteria:

• Patients having ACEI, ARB, or ARNI therapy at hospital discharge and heart failure inpatient encounter with moderate or severe LVSD. ACEI, ARB, or ARNI therapy should be performed during heart failure inpatient encounter with moderate or severe LVSD. To document ACEI, ARB, or ARNI therapy at hospital discharge, navigate to Patient > Provider Note > Prescription. Click ‘Add’ and search for the medication. Enter the medication details and click ‘Save’.
  • To record an inpatient encounter, navigate to Patient > Provider Note > eSuperbill.
  • To document ‘Ejection Fraction’ diagnostic study performed, use the workflow Patient > Clinical > Orders & Results > Radiology.
  • Moreover, diagnoses for heart failure and LVSD and can be recorded via Patient > Provider Note > Diagnoses.

• Patients currently taking ACEI, ARB, or ARNI therapy and having heart failure inpatient encounter with moderate or severe LVSD. ACEI, ARB, or ARNI therapy should begin after the heart failure inpatient encounter with moderate or severe LVSD. To document ACEI, ARB, or ARNI therapy, navigate to Patient > Provider Note > Medications. Click ‘Add’ and search for the medication. Enter the medication details and click ‘Save’.
  • To record an inpatient encounter, navigate to Patient > Provider Note > eSuperbill.
  • To document ‘Ejection Fraction’ diagnostic study performed, use the workflow Patient > Clinical > Orders & Results > Radiology.
  • Moreover, diagnoses for heart failure and LVSD and can be recorded via Patient > Provider Note > Diagnoses.

For Denominator Exceptions 1:

Denominator exceptions 1 for this measure include:

• Patients diagnosed with ‘Pregnancy’ or ‘Renal Failure Due to ACEI’ during heart failure outpatient encounter with moderate or severe LVSD.
  • Diagnosis of pregnancy, renal failure due to ACEI, and LVSD can be recorded via Patient > Provider Note > Diagnoses.
  • To record an outpatient encounter, navigate to Patient > Provider Note > eSuperbill.
  • To document ‘Ejection Fraction’ diagnostic study performed, use the workflow Patient > Clinical > Orders & Results > Radiology.
• Patients diagnosed with allergy or intolerance to ACEI or ARB therapy. The diagnosis should be documented after heart failure outpatient encounter with moderate or severe LVSD. Diagnosis for allergy or intolerance to ACEI or ARB therapy can be recorded via Patient > Provider Note > Diagnoses.
• Patients with allergy or intolerance to ACEI, ARB or ARNI therapy after heart failure outpatient encounter with moderate or severe LVSD.
  • To document allergy or intolerance to ACEI, ARB or ARNI therapy, use the workflow Patient > Clinical > Allergies. Click ‘+Allergen’ and search for an allergen. Add the allergen details and click ‘Save’.

• Patients with medication not ordered during heart failure outpatient encounter with moderate or severe LVSD. To record medication not ordered, use the workflow Patient > Provider Note > Medications. Click ‘Medications’ and mark the ‘Patient Refused to Provide Current Medication Details’ checkbox. 

For Denominator Exceptions 2:

Denominator exceptions 2 for this measure include:

• Patients diagnosed with ‘Pregnancy’ or ‘Renal Failure Due to ACEI’ during heart failure inpatient encounter with moderate or severe LVSD.
  • Diagnosis of pregnancy, renal failure due to ACEI, and LVSD can be recorded via Patient > Provider Note > Diagnoses.
  • To record an inpatient encounter, navigate to Patient > Provider Note > eSuperbill.
  • To document ‘Ejection Fraction’ diagnostic study performed, use the workflow Patient > Clinical > Orders & Results > Radiology.
• Patients diagnosed with allergy or intolerance to ACEI or ARB therapy. The diagnosis should be documented after heart failure inpatient encounter with moderate or severe LVSD. Diagnosis for allergy or intolerance to ACEI or ARB therapy can be recorded via Patient > Provider Note > Diagnoses.
• Patients with allergy or intolerance to ACEI, ARB or ARNI therapy after heart failure inpatient encounter with moderate or severe LVSD.
  • To document allergy or intolerance to ACEI, ARB or ARNI therapy, use the workflow Patient > Clinical > Allergies. Click ‘+Allergen’ and search for an allergen. Add the allergen details and click ‘Save’.
• Patients with medication not ordered during heart failure inpatient encounter with moderate or severe LVSD. To record medication not ordered, use the workflow Patient > Provider Note > Medications. Click ‘Medications’ and mark the ‘Patient Refused to Provide Current Medication Details’ checkbox.