MedicalCodify.com
Search Term or Code: Advanced Search 
Geek Mode

Measure: CMS135

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

Measure Versions

eMeasure Code Measure Year Full Version Number Title
CMS135v12 2024 12.1.000 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
CMS135v11 2023 11 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
CMS135v10 2022 10.1.000 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
CMS135v9 2021 9.2.000 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
CMS135v8 2020 8.2.000 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
CMS135v7 2019 7.1.000 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
CMS135v6 2018 6.0.000 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
CMS135v5 2017 5.2.000 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Description

Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) <=40% who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period

Guidance

This eCQM is to be reported as patient-based. To satisfy this measure, it must be reported for all heart failure patients at least once during the measurement period. The requirement of two or more visits is used to establish that the eligible professional or eligible clinician has an existing relationship with the patient. A range value should satisfy the logic requirement for 'Ejection Fraction' as long as the ranged observation value clearly meets the less than or equal to 40% threshold noted in the denominator logic. A range that is greater than 40% would not meet the measure requirement. In order for the Ejection Fraction result pathway to be recognized as below 40%, the result must be reported as a number with unit of %. A text string of "below 40%" or "ejection fraction between 35 and 40%" will not be recognized through electronic data capture. Although, this criteria can also be met using the Diagnosis pathway if specified as "Moderate or Severe." Eligible clinicians who have given a prescription for or whose patient is already taking an Angiotensin-Converting Enzyme Inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB) would meet performance for this measure. Other combination therapies that consist of an ACEI plus diuretic, ARB + neprilysin inhibitor (ARNI), ARB plus diuretic, ACEI plus calcium channel blocker, ARB plus calcium channel blocker, or ARB plus calcium channel blocker plus diuretic would also meet performance for this measure. This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Patient Group Definitions

Group Description Instructions Links
Initial PopulationAll patients aged 18 years and older with two qualifying encounters during the measurement period and a diagnosis of heart failureWebchart Instructions
DenominatorEquals Initial Population with a current or prior LVEF <= 40%Webchart Instructions
Denominator ExclusionsPatients with a history of heart transplant or with a Left Ventricular Assist Device (LVAD) prior to the end of the outpatient encounter with Moderate or Severe LVSDWebchart Instructions
NumeratorPatients who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement periodWebchart Instructions
Numerator ExclusionsNot ApplicableWebchart Instructions
Denominator ExceptionsDocumentation of medical reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., pregnancy, renal failure due to ACEI, 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).Webchart Instructions

Details

Full eMeasure Code eMeasure Identifier Measure Year Version NQF # GUID
CMS135v12 2024 12.1.000 0081e 430ffc53-4122-4421-88cc-2edd8117bb3c
Steward Developer Endorsed By
American Medical Association (AMA) American Heart Association National Quality Forum
Scoring Method Measure Type Stratification Risk Adjustment
Proportion PROCESS None None

Rate Aggregation 

None

Improvement Notation

Higher score indicates better quality

Rationale

Use of ACE inhibitor, ARB, or ARNI therapy has been associated with improved outcomes in patients with reduced LVEF. Long-term therapy with ARBs have also been shown to reduce morbidity and mortality, especially in ACE inhibitor–intolerant patients. More recently, ARNI therapy has also been shown to more significantly improve outcomes, such that the newest guidelines recommend replacement of ACE inhibitors or ARBs with ARNI therapy in eligible patients. However, despite the benefits of these drugs, use of ACE inhibitor, ARB, or ARNI remains suboptimal.

Clinical Recommendation Statement 

In patients with Heart Failure with Reduced Ejection Fraction (HFrEF) and New York Heart Association (NYHA) class II to III symptoms, the use of ARNI is recommended to reduce morbidity and mortality (Class I, Level of Evidence A) (ACC/AHA/HFSA, 2022). 

In patients with previous or current symptoms of chronic HFrEF, the use of ACEi is beneficial to reduce morbidity and mortality when the use of ARNI is not feasible (Class I, Level of Evidence A) (ACC/AHA/HFSA, 2022). 

In patients with previous or current symptoms of chronic HFrEF who are intolerant to ACEi because of cough or angioedema and when the use of ARNI is not feasible, the use of ARB is recommended to reduce morbidity and mortality. (Class I, Level of Evidence A) (ACC/AHA/HFSA, 2022). 

In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEi or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality (Class I, Level of Evidence B-R) (ACC/AHA/HFSA, 2022). 

ARNI should not be administered concomitantly with ACEi or within 36 hours of the last dose of an ACEi (Class II: Harm, Level of Evidence B-R) (ACC/AHA/HFSA, 2022). 

ARNI should not be administered to patients with any history of angioedema (Class III: Harm, Level of Evidence C-LD) (ACC/AHA/HFSA, 2022). 

ACEi should not be administered to patients with any history of angioedema (Class III: Harm, Level of Evidence C-LD) (ACC/AHA/HFSA, 2022).

Drugs Commonly Used for Stage C HFrEF (abbreviated to align with focus of measure to include only ACE inhibitors, ARB and ARNI therapy)

Drug                       Initial Daily Dose(s)                           Target Dose(s)        Mean Doses Achieved in 
                                                                                                                        Clinical Trials
ACEi 
   Captopril              6.25 mg 3 times                               50 mg 3 times              122.7 mg total daily
   Enalapril               2.5 mg twice                                    10 to 20 mg twice        16.6 mg total daily
   Fosinopril             5 to 10 mg once                               40 mg once                  N/A
   Lisinopril              2.5 to 5 mg once                              20 to 40 mg once         32.5 to 35.0 mg total daily
   Perindopril           2 mg once                                        8 to 16 mg once           N/A
   Quinapril              5 mg twice                                       20 mg twice                  N/A
   Ramipril               1.25 to 2.5 mg once                         10 mg once                  N/A
   Trandolapril          1 mg once                                        4 mg once                   N/A
ARB
   Candesartan         4 to 8 mg once                                32 mg once                  24 mg total daily
   Losartan               25 to 50 mg once                             50 to 150 mg once      129 mg total daily
   Valsartan              20 to 40 mg twice                            160 mg twice                254 mg total daily
ARNI
   Sacubitril-             49/51 mg twice                                97/103 mg twice         182/193 mg 
   valsartan              (sacubitril/valsartan)                        (sacubitril/valsartan)    (sacubitril/valsartan) total
                                (therapy may be initiated                                                     daily
                                at 24/26 mg twice)

Definition

Prescribed - prescription given to the patient for ACE inhibitor or ARB or ARNI therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB or ARNI therapy as documented in current medication list. LVEF <=40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction (LVSD). The LVSD 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 LVSD or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD can be used to identify patients.

Transmission Format

TBD

Applicable Value Sets

Category Value Set OID
Allergy/Intolerance ACE Inhibitor or ARB Ingredient 2.16.840.1.113883.3.526.3.1489
Diagnosis Allergy to ACE Inhibitor or ARB 2.16.840.1.113883.3.526.3.1211
Diagnosis Heart Failure 2.16.840.1.113883.3.526.3.376
Diagnosis Heart Transplant Related Diagnoses 2.16.840.1.113762.1.4.1178.56
Diagnosis Intolerance to ACE Inhibitor or ARB 2.16.840.1.113883.3.526.3.1212
Diagnosis Left Ventricular Assist Device Related Diagnoses 2.16.840.1.113762.1.4.1178.58
Diagnosis Moderate or Severe LVSD 2.16.840.1.113883.3.526.3.1090
Diagnosis Pregnancy 2.16.840.1.113883.3.526.3.378
Diagnostic Study, Performed Ejection Fraction 2.16.840.1.113883.3.526.3.1134
Encounter, Performed Care Services in Long-Term Residential Facility 2.16.840.1.113883.3.464.1003.101.12.1014
Encounter, Performed Home Healthcare Services 2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed Nursing Facility Visit 2.16.840.1.113883.3.464.1003.101.12.1012
Encounter, Performed Office Visit 2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed Outpatient Consultation 2.16.840.1.113883.3.464.1003.101.12.1008
Encounter, Performed Patient Provider Interaction 2.16.840.1.113883.3.526.3.1012
Medication, Active ACE Inhibitor or ARB 2.16.840.1.113883.3.526.3.1139
Medication, Not Ordered ACE Inhibitor or ARB 2.16.840.1.113883.3.526.3.1139
Medication, Order ACE Inhibitor or ARB 2.16.840.1.113883.3.526.3.1139
Patient Characteristic Ethnicity Ethnicity 2.16.840.1.114222.4.11.837
Patient Characteristic Payer Payer 2.16.840.1.114222.4.11.3591
Patient Characteristic Race Race 2.16.840.1.114222.4.11.836
Patient Characteristic Sex ONC Administrative Sex 2.16.840.1.113762.1.4.1
Procedure, Performed Heart Transplant 2.16.840.1.113762.1.4.1178.33
Procedure, Performed Left Ventricular Assist Device Placement 2.16.840.1.113762.1.4.1178.61

References 

CITATIONHeidenreich, P.A., Bozkurt, B, Aguilar, D., ... Allen, L. A. (2022). 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145(18), e895-e1032. doi: 10.1161/CIR.0000000000001063

Disclaimer

The Measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications. The Measure, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measure require a license agreement between the user and the American College of Cardiology (ACC) or the American Heart Association (AHA). Neither the ACC, nor AHA, nor their members shall be responsible for any use of the Measure. ACC and AHA encourage use of the Measure by other health care professionals, where appropriate. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The ACC and AHA and their members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) is copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2022 World Health Organization. All Rights Reserved. The American Medical Association’s and the PCPI(R) Foundation’s significant past efforts and contributions to the performance measure are gratefully acknowledged. Due to technical limitations, registered trademarks are indicated by (R) or [R].

Copyright 

Copyright 2023 American College of Cardiology and American Heart Association. All Rights Reserved.

Source: https://ecqi.healthit.gov/ecqm/measures/cmsv1