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  2. CQM-6879

Traditional MIPS eCQM--Statins for the Prevention and Tx of CV Disease--Risk Stratification 4

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
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    • Amanda Fredricksen
    • Mayo Clinic
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      Thank you for your questions about CMS347v7 (Statin Therapy for the Prevention and Treatment of Cardiovascular Disease). The measure developer recommends using risk calculators derived from the Pooled Cohort Equations. There are two LOINC codes currently used to capture 10-year ASCVD risk. One is 79423-0 and reflects use of the 2013 ACC-AHA Pooled Cohort by Goff. The other is 99055-6, which captures 10-year ASCVD risk, though does not specify a particular ASCVD risk estimator to use. The calculation can be performed using the following formula:

      (Numerator 1 + Numerator 2 + Numerator 3 + Numerator 4)/ [(Denominator 1 - Denominator Exclusions 1- Denominator Exceptions 1) + (Denominator 2 - Denominator Exclusions 2 - Denominator Exceptions 2) + (Denominator 3 - Denominator Exclusions 3 - Denominator Exceptions 3) + (Denominator 4 - Denominator Exclusions 4 - Denominator Exceptions 4)].

      Alternatively, we recommend that you use the on-line versions. The 10-year ASCVD risk score (quantitative result, i.e., result.value, “%”) must be documented in a structured field and cannot be mapped to LOINC code 79423-0.

      We are unable to provide specific guidance related to the mapping of codes. As such, we recommend you consult with your EHR vendor and clinical partners. If mapping is conducted, you should maintain documentation in case of a CMS audit.

      Regarding your question about whether organizations can submit this measure even if the ASCVD risk is not documented in a discrete EHR field and does not use either of the ASCVD risk assessment options, the four measure populations are mutually exclusive. Therefore, assuming no ASCVD risk estimates are available for patients in the EHR, a Mayo Clinic Enterprise location score would be based on the first three populations.

      Specific to your question of whether a zero denominator for this stratification would be concerning to CMS, we are unable to respond to questions specific to reporting/performance. Please contact the Quality Payment Program Help Desk E-mail: QPP@cms.hhs.gov and Phone: (866) 288-8292 TTY: (877) 715-6222.

      You are correct that reporting is voluntary. Please consult with your organization’s leadership regarding future participation in reporting this measure.
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      Thank you for your questions about CMS347v7 (Statin Therapy for the Prevention and Treatment of Cardiovascular Disease). The measure developer recommends using risk calculators derived from the Pooled Cohort Equations. There are two LOINC codes currently used to capture 10-year ASCVD risk. One is 79423-0 and reflects use of the 2013 ACC-AHA Pooled Cohort by Goff. The other is 99055-6, which captures 10-year ASCVD risk, though does not specify a particular ASCVD risk estimator to use. The calculation can be performed using the following formula: (Numerator 1 + Numerator 2 + Numerator 3 + Numerator 4)/ [(Denominator 1 - Denominator Exclusions 1- Denominator Exceptions 1) + (Denominator 2 - Denominator Exclusions 2 - Denominator Exceptions 2) + (Denominator 3 - Denominator Exclusions 3 - Denominator Exceptions 3) + (Denominator 4 - Denominator Exclusions 4 - Denominator Exceptions 4)]. Alternatively, we recommend that you use the on-line versions. The 10-year ASCVD risk score (quantitative result, i.e., result.value, “%”) must be documented in a structured field and cannot be mapped to LOINC code 79423-0. We are unable to provide specific guidance related to the mapping of codes. As such, we recommend you consult with your EHR vendor and clinical partners. If mapping is conducted, you should maintain documentation in case of a CMS audit. Regarding your question about whether organizations can submit this measure even if the ASCVD risk is not documented in a discrete EHR field and does not use either of the ASCVD risk assessment options, the four measure populations are mutually exclusive. Therefore, assuming no ASCVD risk estimates are available for patients in the EHR, a Mayo Clinic Enterprise location score would be based on the first three populations. Specific to your question of whether a zero denominator for this stratification would be concerning to CMS, we are unable to respond to questions specific to reporting/performance. Please contact the Quality Payment Program Help Desk E-mail: QPP@cms.hhs.gov and Phone: (866) 288-8292 TTY: (877) 715-6222. You are correct that reporting is voluntary. Please consult with your organization’s leadership regarding future participation in reporting this measure.
    • CMS0347v7

      This ticket is in regard to a number of the Mayo Clinic Enterprise locations including but not limited to MAYO CLINIC Rochester TIN xxxxx1702, MAYO CLINIC ARIZONA xxxxx0150, MAYO CLINIC JACKSONVILLE xxxxx7028, and MAYO CLINIC HEALTH SYSTEM SOUTHWEST MINNESOTA REGION xxxxx6756. The measure steward (CMS) introduced a fourth stratification for 2024 for the CMS 347 Statins for the Prevention and Treatment of Cardiovascular Disease measure: patients aged 40 to 75 with a 10-year ASCVD risk score greater than or equal to 20%. Mayo Clinic as an Enterprise uses its own version of the ASCVD Risk Calculator, which is titled Mayo Clinic Cardiovascular Risk Calculator. If a provider launches this calculator from within the patient's EHR, the provider is taken to a Mayo Clinic intranet site and some of the inputs will prepopulate with information if documented in the patient's chart. There is no EHR integration with this scoring tool. The provider would need to copy and paste the information and results into the patient's EHR so results are not captured discretely. Currently, Mayo Clinic as an Enterprise has two issues: we are not using one of the two ASCVD risk assessment options (2013 ACC/AHA ASCVD Risk Estimator) and ACC Risk Estimator Plus) and results are not captured discretely in the EHR. This is a measure we have historically submitted over the last several years this measure has been available. As this measure is used in the MIPS program where scores are used for payment determination, can organizations still submit this measure even if the ASCVD risk is not documented in a discrete EHR field and does not use one of the two ASCVD risk assessment options? If so, would a zero denominator for this stratification be concerning to CMS and how would we map the internal Mayo Clinic-developed ASCVD risk assessment if we did develop a discrete field mid-year within our EHR? Should we avoid this measure and choose another since the measure is voluntary?

            edave Mathematica EC eCQM Team
            m076050 Amanda Fredricksen
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