SOAPware Learning CenterClinical Quality Measures User Guide (for 2011) Additional Measures (Choose 3 Additional Measures)NQF 0075 (Additional): Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control

NQF 0075 (Additional): Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control

Measure: NQF 0075 (Additional Measure)

Measure Title:  Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control

Measurement Description: The percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from January 1–November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year and who had a complete lipid profile performed during the measurement year and whose LDL-C  was <100 mg/dL.

*REQUIRED FOR MEANINGFUL USE (MU): Click here to view the Meaningful Use Criteria.

Quality Measure Documentation Workflow

Quality Measure Documentation Workflow

In Order for the Clinical Quality Measure report to generate, the following must be documented in the relevant patient's chart:

1. Patients must be 18 years of age or older and have at least one face-to-face encounter with the provider during the reporting period.

2. Patients must have documentation of a diagnosis of Ischemic Vascular Disease (IVD) during the measurement year and the year prior to the measurement year. Inserting the shortcut code "PQRIivd" in the encounter Plan field will allow the user to select from a group of specific SMARText custom codes that can be used to document for this measure.  Patients must have the custom SMARText code of 0068b, 0068c, 0075a or 0075b entered into the encounter Plan field to document "Patient had MI, CABG or PTCA last calendar year, or IVD in past 2 years".

3. Patients must also have documentation that they have had a complete lipid profile performed during the measurement year.  Inserting the shortcut code "PQRIivd" in the encounter Plan field will allow the user to select from a group of specific SMARText custom codes that can be used to document for this measure.  

  • Patients must have the custom SMARText code of 0075b entered into the encounter Plan field to document "LDL <100 (or lipid goals reached), had either MI, CABG or PTCA last calendar year or IVD past 2 years".  
  • Or SMARText code 0075a should be entered into the encounter Plan field to document "LDL >100 (or appropriate lipid testing) performed in reporting period.  Had either MI, CABG or PTCA last calendar year or IVD past 2 years."

 

Measurement Calculation Details

Eligible Providers will be required to report two population criteria for this Clinical Quality Measure.

Population Criteria #1: Laboratory test performed: LDL test

Numerator Calculation:

The Numerator for this measurement is calculated based on the following:

1. The number of patients in the denominator that have the appropriate Custom ID item in the Plan field:

  • 0075a: LDL >100 (or appropriate lipid testing) performed in reporting period.  Had either MI, CABG or PTCA last calendar year or IVD past 2 years
  • 0075b: LDL <100 (or lipid goals reached), had either MI, CABG, or PTCA last calendar year or IVD past 2 years

The following codes will not increase the numerator:

  • 0068a: Pt had no MI, CABG or PTCA last calendar year, or IVD in past 2 years
  • 0068b: Antithrombotic Tx, Pt had either MI, CABG or PTCA last calendar year, or IVD in past 2 years
  • 0068c: PT had MI, CABG or PTCA last calendar year, or IVD in past 2 years
  • 0073b: BP <140/90, Pt had either MI, CABG or PTCA last calendar year, or IVD in past 2 years

Denominator:

The Denominator for this measurement is calculated based on the following:

1.  The number of patients 18 years of age or older with at least one face-to-face encounter within the reporting period;

2.  AND have one of the following SMARText custom codes in the encounter Plan field:

  • 0075a: LDL >100 (or appropriate lipid testing) performed in reporting period.  Had either MI, CABG or PTCA last calendar year or IVD past 2 years
  • 0075b:  LDL <100 (or lipid goals reached), had either MI, CABG, or PTCA last calendar year or IVD past 2 years
  • 0068b: Antithrombotic Tx, Pt had either MI, CABG or PTCA last calendar year, or IVD in past 2 years
  • 0068c: Pt had MI, CABG or PTCA last calendar year, or IVD in past 2 years

The following codes will not increase the denominator:

  • 0068a: Pt had no MI, CABG or PTCA last calendar year, or IVD in past 2 years
  • 0073b: BP <140/90, Pt had either MI, CABG or PTCA last calendar year, or IVD in past 2 years

Population Criteria #2: Laboratory test performed: LDL test with most Recent value <100mg/dL

Numerator Calculation:

The Numerator for this measurement is calculated based on the following:

1. The number of patients in the denominator that have the appropriate Custom ID item in the Plan field:

  • 0075b: LDL <100 (or lipid goals reached), had either MI, CABG, or PTCA last calendar year or IVD past 2 years

The following codes will not increase the numerator:

  • 0068a: Pt had no MI, CABG or PTCA last calendar year, or IVD in past 2 years
  • 0068b: Antithrombotic Tx, Pt had either MI, CABG or PTCA last calendar year, or IVD in past 2 years
  • 0068c: PT had MI, CABG or PTCA last calendar year, or IVD in past 2 years
  • 0073b: BP <140/90, Pt had either MI, CABG or PTCA last calendar year, or IVD in past 2 years
  • 0075a: LDL >100 (or appropriate lipid testing) performed in reporting period.  Had either MI, CABG or PTCA last calendar year or IVD past 2 years

Denominator:

The Denominator for this measurement is calculated based on the following:

1.  The number of patients 18 years of age or older with at least one face-to-face encounter within the reporting period;

2.  AND have one of the following SMARText custom codes in the encounter Plan field:

  • 0075a: LDL >100 (or appropriate lipid testing) performed in reporting period.  Had either MI, CABG or PTCA last calendar year or IVD past 2 years
  • 0075b:  LDL <100 (or lipid goals reached), had either MI, CABG, or PTCA last calendar year or IVD past 2 years
  • 0068b: Antithrombotic Tx, Pt had either MI, CABG or PTCA last calendar year, or IVD in past 2 years
  • 0068c: Pt had MI, CABG or PTCA last calendar year, or IVD in past 2 years

The following codes will not increase the denominator:

  • 0068a: Pt had no MI, CABG or PTCA last calendar year, or IVD in past 2 years
  • 0073b: BP <140/90, Pt had either MI, CABG or PTCA last calendar year, or IVD in past 2 years

Report Clinical Quality Measures to CMS/States

All of the items in the above steps need to be documented as structured data (as detailed above) in order to allow the user to capture the numerator, denominator and percentage for this quality measure.

For more information on how to export the numerator, denominator, and percentage for each Clinical Quality measure, Click Here.

For more information on reporting clinical quality measures, Click Here.