CMS347v3 – Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

All patients aged 21 years and older at the beginning of the measurement period with a patient encounter during the measurement period

All patients who meet one or more of the following criteria (considered at “high risk” for cardiovascular events, under ACC/AHA guidelines):

• Patients aged >= 21 years at the beginning of the measurement period with clinical ASCVD diagnosis

 Patients who are actively using or who receive an order (prescription) for statin therapy at any point during the measurement period

All patients aged 21 years and older at the beginning of the measurement period with a patient encounter during the measurement period

Patients who meet one or more of the following criteria (considered at “high risk” for cardiovascular events, under ACC/AHA guidelines):

• Patients aged >= 21 years at the beginning of the measurement period who have ever had a fasting or direct laboratory result of LDL-C >=190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia

Patients who are actively using or who receive an order (prescription) for statin therapy at any point during the measurement period

All patients aged 21 years and older at the beginning of the measurement period with a patient encounter during the measurement period

All patients who meet one or more of the following criteria (considered at “high risk” for cardiovascular events, under ACC/AHA guidelines):

• Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with an LDL-C result of 70-189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period

Patients who are actively using or who receive an order (prescription) for statin therapy at any point during the measurement period

• Patients who have a diagnosis of pregnancy
• Patients who are breastfeeding
• Patients who have a diagnosis of rhabdomyolysis

– DENOMINATOR EXCEPTIONS:

• Patients with adverse effect, allergy, or intolerance to statin medication
• Patients who are receiving palliative care
• Patients with active liver disease or hepatic disease or insufficiency
• Patients with end-stage renal disease (ESRD)
• Patients with diabetes who have the most recent fasting or direct LDL-C laboratory test result < 70 mg/dL and are not taking statin therapy

For Initial Population:

All patients aged 21 years and older at the beginning of the measurement period with a patient encounter during the measurement period are included in Initial population.

The documentation of the first encounter takes place when one visit code gets attached with the patient’s eSuperbill/ charge. Follow the workflow to record an encounter, Patient > Provider Notes > eSuperbill

For Denominator – 1:

All patients who meet one or more of the following criteria (considered at “high risk” for cardiovascular events, under ACC/AHA guidelines) are included in denominator 1.

1) Patients aged >= 21 years at the beginning of the measurement period with clinical ASCVD diagnosis. To document these, navigate to:

• ASCVD Diagnosis Before End of Measurement Period ( Patient > Provider Notes > Diagnosis )
• ASCVD Procedure Before End of Measurement Period ( Patient > Provider Notes > Clinical > Order and Results > Procedures)

For Denominator – 2: 

Patients who meet one or more of the following criteria (considered at “high risk” for cardiovascular events, under ACC/AHA guidelines) are included in denominator 2

• Patients aged >= 21 years at the beginning of the measurement period and
• Ever had a fasting or Direct laboratory result of LDL-C >=190 mg/dL (Patient > Clinical > Order and Results > Lab ) or
• Previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia.

For Denominator – 3:

All patients who meet one or more of the following criteria (considered at “high risk” for cardiovascular events, under ACC/AHA guidelines) are included in denominator – 3

• Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes

• With an LDL-C result of 70-189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period (Patient > Clinical > Order and Results > Lab )

For Numerator:

Patients who are actively using or who receive an order (prescription) for statin therapy at any point during the measurement period. To document the following, navigate to

• Statin Ordered During Measurement Period (Patient > Provider Note > Prescribe)
• Statin Therapy Starts Before End of Measurement Period (Patient > Provider Note > Medication)

For Denominator Exceptions:

Patients with adverse effect, allergy, or intolerance to statin medication
Patients who are receiving palliative care
Patients with active liver disease or hepatic disease or insufficiency
Patients with end-stage renal disease (ESRD)
Patients with diabetes who have the most recent fasting or direct LDL-C laboratory test result < 70 mg/dL and are not taking statin therapy.

To record the following encounters, navigate to the evaluations tab

For Denominator Exclusions: 

Patient fulfilling following criteria are excluded from denominator:

• Patients who have a diagnosis of pregnancy
• Patients who are breastfeeding
• Patients who have a diagnosis of rhabdomyolysis.

To document diagnosis, navigate to diagnosis.