| Confirm Diagnosis of Coronary Artery
Disease (CAD) |
Instruction: Determine if the patient has a documented history
of CAD at any time in the patient’s history up through
the last day of the measurement period. |
AMI, angina, arteriosclerotic cardiovascular disease, arteriosclerotic
heart disease, ASCVD, ASHD, atherectomy, atherosclerotic cardiovascular disease,
atherosclerotic heart disease, CABG, CAD, cardiovascular (heart) disease, CHD, chronic
myocardial ischemia, chronic stable angina, coronary arterio–sclerosis, coronary
artery bypass graft, coronary artery disease, coronary disease, coronary endarteritis,
coronary heart disease, coronary insufficiency, coronary vascular disease, CVD,
ischemic heart disease, MI, myocardial infarction (current or history), PCI, percutaneous
transluminal coronary angio–plasty, post cardiac/coronary injury, PTCA, rotablator,
S/P MI, status–post myocardial infarction, stent (coronary), unstable angina
|
Chest pain, unspecified Chest wall pain |
| [CADCONFIRMED] |
Yes (1): Select this option if
the patient has a documented history of CAD anywhere in the office/clinic record.
No/No reason documented (0): Select this option
if the patient has no documented history of CAD anywhere in the office/clinic record.
If “No” – STOP ABSTRACTION
Medical record not found (2):
Select this option if you are unable to find the patient’s medical record.
|
| Antiplatelet Therapy |
Instruction: Determine if the patient was prescribed antiplatelet
therapy (aspirin, clopidogrel or a combination of aspirin and dipyridamole) at any time during the measurement period. |
See drug list of aspirin and aspirin containing
medications in Table 1 and clopidogrel
medications in Table 2. |
None |
| [CADANTIPLATDRUG]
|
Yes (1): Select this
option if the patient was prescribed antiplatelet therapy.
No/No reason documented (0): Select this option
if the patient was not prescribed antiplatelet therapy or no reason was documented
in the office/clinic record. |
Not prescribed for medical reasons (3):
Select this option if the patient was not prescribed antiplatelet therapy for medical
reasons.
Not prescribed for patient reasons (4): Select
this option if the patient was not prescribed antiplatelet therapy for patient reasons.
Not prescribed for system reasons (5): Select this
option if the patient was not prescribed antiplatelet therapy for system reasons.
|
Not prescribed for medical reasons (3) may include: active
bleeding in the previous six months which required hospitalization(s) or transfusion(s),
adverse effect, allergy or intolerance, anaphylactic shock, angioneurotic edema
due to aspirin, bleeding disorder, other reason documented by the practitioner for
not prescribing aspirin or clopidogrel therapy |
| Drug Therapy for Lowering LDL Cholesterol
|
Instruction: Determine if the patient was prescribed drug therapy
for lowering LDL Cholesterol at any time during the measurement
period. |
See drug list of lipid–lowering medications
in Table 3. |
None |
| [CADLDLCDRUG] |
Yes (1): Select this
option if the patient was prescribed drug therapy for lowering LDL Cholesterol.
No/No reason documented (0): Select this option
if the patient was not prescribed drug therapy for lowering LDL Cholesterol or no
reason was documented in the office/clinic record. |
Not prescribed for medical reasons (3):
Select this option if the patient was not prescribed drug therapy for lowering LDL
Cholesterol for medical reasons.
Not prescribed for patient reasons (4): Select
this option if the patient was not prescribed drug therapy for lowering LDL Cholesterol
for patient reasons.
Not prescribed for system reasons (5): Select this
option if the patient was not prescribed drug therapy for lowering LDL Cholesterol
for system reasons. |
Not prescribed for medical reasons (3) may include: LDL–C
< 130, adverse effect, anaphylactic shock, angioneurotic edema, other reason documented
by the practitioner for not prescribing lipid–lowering therapy |
| Myocardial Infarction
(MI) |
Instruction: Determine if the patient has
a documented history of an MI at any time in the patient’s
history up through the last day of the measurement period. |
MI, AMI, cardiac infarction, coronary artery embolism, coronary artery
occlusion, coronary artery rupture, coronary artery thrombosis, infarction of heart,
infarction of myocardium, infarction of ventricle, anterolateral infarction, anterior
infarction, anteroapical infarction, anteroseptal infarction, inferolateral infarction,
inferoposterior infarction, inferior infarction, diaphragmatic wall infarction,
lateral infarction, apical–lateral infarction, basal–lateral infarction,
high lateral infarction, posterolateral infarction, posterior infarction, posterobasal
infarction, subendocardial infarction, nontransmural infarction, infarction of atrium,
infarction of papillary muscle, infarction of septum, thrombotic coronary artery,
non–Q–wave MI, transmural myocardial infarction,
ST wave elevation MI, STEMI, non elevated ST wave MI, NSTEMI |
None |
| [CADMI] |
Yes (1): Select this option if
the patient has a documented history of an MI.
No/No reason documented (0): Select this option
if the patient does not have a documented history of an MI. |
| Beta–Blocker Therapy–Prior
MI |
Instruction: Determine if the patient was prescribed beta–blocker
therapy at any time during the measurement period.
|
See drug list of beta–blocker medications
in Table 4. |
None |
| [CADBBLOCKDRUG]
|
Yes (1): Select this
option if the patient was prescribed beta–blocker therapy.
No/No reason documented (0): Select this option
if the patient was not prescribed beta–blocker therapy or no reason was documented
in the office/clinic record. |
Not prescribed for medical reasons (3):
Select this option if the patient was not prescribed beta–blocker therapy
for medical reasons.
Not prescribed for patient reasons (4): Select
this option if the patient was not prescribed beta–blocker therapy for patient
reasons.
Not prescribed for system reasons (5): Select this
option if the patient was not prescribed beta–blocker therapy for system reasons.
|
Not prescribed for medical reasons (3) may include: adverse
reaction to beta–blockers, asthma, documentation of bradycardia < 50 bpm (without
beta–blocker therapy), exercise induced bronchospasm, history of Class IV
(congestive) heart failure, history of second or third–degree atrioventricular
(AV) block without permanent pacemaker, hypotension, orthostatic hypotension, sick
sinus syndrome, SSS, other reason documented by the practitioner for not prescribing
beta–blocker therapy |
| Lipid Profile |
Instruction: Determine if a lipid profile was performed during the measurement period.
Note: The default setting for this element is
Claim Not Found.
|
Cholesterol analysis, cholesterol panel, cholesterol profile, fasting
lipids, lipid analysis, lipid panel, lipids, lipoprotein analysis |
None |
| [CADLIPID] |
Yes (1): Select this option if
a lipid profile was performed.
No/No reason documented (0): Select this option
if a lipid profile was not performed.
Claim Not Found (2):
Select this option if you are not abstracting records for this claims–based
measure.
Note: A lipid profile consists of all of the following components:
- Total cholesterol
- High–density lipoprotein cholesterol (HDL–C)
- Low–density lipoprotein cholesterol (LDL–C)
- Triglycerides
If LDL–C could not be calculated due to high triglycerides,
count as complete lipid profile. Use the following priority ranking:
- Lab report draw date
- Lab report date
- Flow sheet documentation
- Practitioner notes
- Other documentation
|
| LDL Cholesterol Test |
Instruction: Determine if the patient had one or more LDL–C
tests during the measurement period.
|
Cholesterol analysis, cholesterol panel, cholesterol profile, fasting
lipids, LDL:HDL, LDL:HDL ratio, lipid analysis, lipid panel, lipid profile, lipids,
lipoprotein analysis, low density lipoprotein (LDL), LDL–Cholesterol, LDL–C
|
None |
| [CADLDLCTEST] |
Yes (1): Select this
option if the patient had one or more LDL–C tests. |
| [CADLDLCDATE] |
* Record the most recent date the blood was drawn for LDL–C in MM/DD/YYYY
format
|
| [CADLDLCVALUE] |
* Record the most recent LDL–C value [if laboratory unable to calculate
LDL–C value due to high triglycerides, record 0 (zero). If the test result
is labeled ‘unreliable’ and a result is provided, also record 0 (zero)]
Note: A calculated LDL may be used for LDL–C screening and control indicators.
|
| [CADLDLCTEST] |
No/No reason documented (0): Select
this option if the patient did not have one or more LDL–C tests.
Use the following priority ranking:
- Lab report draw date
- Lab report date
- Flow sheet documentation
- Practitioner notes
- Other documentation
|
| Diabetes |
Instruction: Determine if the patient has
diabetes.
|
See drug list of insulin preparations in
Table 5 and oral hypoglycemic/antihyperglycemic medications in
Table 6.
Diabetes mellitus, diabetes, Type II diabetes, IDDM, insulin dependent diabetes
mellitus, NIDDM, non–insulin dependent diabetes mellitus, Type I diabetes
|
None |
| [CADDIABETES] |
Yes (1): Select this option if
the patient has diabetes.
No/No reason documented (0): Select this option
if the patient does not have diabetes. |
| Left Ventricular Systolic Dysfunction
(LVSD) |
THIS ELEMENT IS SYNCRONIZED WITH THE LEFT VENTRICULAR SYSTOLIC
DYSFUNCTION (LVSD) ELEMENT IN HF
Instructions: Determine if the patient has LVSD (use most
recent result). LVSD is present when left ventricular ejection
fraction (LVEF) is less than 40% or documented as moderate to severe. |
Moderate or severe LVSD
(see synonyms below) |
None |
| [HFCADLVSD] |
Yes (1): Select this option if
the patient has LVSD.
No/No reason documented (0): Select this option
if the patient does not have LVSD.
Note: If multiple diagnostic studies were performed on the same
day to measure ejection fraction, use the following hierarchy to determine if LVSD
is present:
- cardiac catheterization
- echocardiogram
- MUGA or other cardiac scan
|
LVSD Synonyms – (moderate or severe)
Contractility described as:
- abnormal
- compromised
- decreased
- depressed
- impaired
- low
- poor
- reduced
- very low
Ejection fraction (EF) described as:
- abnormal
- compromised
- decreased
- depressed
- impaired
- low
- poor
- reduced
- very low
Hypokinesis described as:
- diffuse
- generalized
- global
|
Left ventricular dysfunction (LVD) described as:
- marked
- moderate
- moderate–severe
- severe
- significant
- substantial
- the severity is not specified
- very severe
Left ventricular ejection fraction (LVEF) described as:
- abnormal
- compromised
- decreased
- depressed
- impaired
- low
- poor
- reduced
- very low
Left ventricular function (LVF) described as:
- abnormal
- compromised
- decreased
- depressed
- impaired
- low
- poor
- reduced
|
Left ventricular systolic dysfunction (LVSD) described as:
- marked
- moderate
- moderate-severe
- severe
- significant
- substantial
- the severity is not specified
- very severe
Systolic dysfunction described as:
- marked
- moderate
- moderate-severe
- severe
- significant
- substantial
- the severity is not specified
- very severe
Systolic function described as:
- abnormal
- compromised
- decreased
- depressed
- impaired
- low
- poor
- reduced
- very low
|
|
| ACE Inhibitor or ARB Therapy
|
Instruction: Determine if the patient was prescribed ACE Inhibitor
or ARB therapy at any time during the measurement period.
|
See drug list of ACE Inhibitor medications in Table 7 and ARBs in
Table 8. |
None |
| [CADACEARBDRUG]
|
Yes (1): Select this
option if the patient was prescribed ACE Inhibitor or ARB therapy.
No/No reason documented (0): Select this option
if the patient was not prescribed ACE Inhibitor or ARB therapy or no reason was
documented in the office/clinic record. |
Not prescribed for medical reasons (3):
Select this option if the patient was not prescribed ACE Inhibitor and ARB therapy
for medical reasons.
Not prescribed for patient reasons (4): Select
this option if the patient was not prescribed ACE Inhibitor and ARB therapy for
patient reasons.
Not prescribed for system reasons (5): Select this
option if the patient was not prescribed ACE Inhibitor and ARB therapy for system
reasons. |
Not prescribed for medical reasons (3) may include: acute
renal failure, adverse reaction to ACE (angiotensin-converting enzyme) inhibitor
and ARB (angiotensin receptor blocker), allergy/intolerance to ACE inhibitor and
ARB, angioedema , anuria, ARF, bilateral renal artery stenosis, BRAS, chronic renal
failure, CRF, hypertrophic obstructive cardiomyopathy,mitral insufficiency, mitral
stenosis, moderate or severe aortic stenosis, pregnancy, RAS, renal artery stenosis,
renal failure, rheumatic aortic stenosis, rheumatic aortic valve obstruction, subaortic
stenosis, chronic kidney disease, CKD, end stage renal disease,
ESRD, hypertensive chronic kidney disease, hypertensive heart and chronic kidney
disease, dialysis, pregnancy, other reason documented by the practitioner
for not prescribing ACE Inhibitor and not prescribing ARB therapy |
|