Clinical Quality Measure
CMS182v3 (NQF 0075) - Additional Measure

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

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 angioplasty (PTCA) from January1-November1 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 <100 mg/dL.

NQS DOMAIN:   Clinical Process/Effectiveness

Description and Implementation within the EMR software

There is 1 denominator having 2 numerators in this measure and this translates to 2 sets in total.

Denominator: All patients 18 years or older with at least 1 encounter during the meaningful-use reporting period AND the year prior having one of the following ICD-10 codes selected in ASSESSMENT/DIAGNOSIS section on the ENCOUNTER form:
I20.0, I20.1, I20.8, I20.9, I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I22.0, I22.1, I22.2, I22.8, I22.9, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750, I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.89, I25.9, I63.00, I63.011, I63.012, I63.019, I63.02, I63.031, I63.032, I63.039, I63.09, I63.10, I63.111, I63.112, I63.119, I63.12, I63.131, I63.132, I63.139, I63.19, I63.20, I63.211, I63.212, I63.219, I63.22, I63.231, I63.232, I63.239, I63.29, I63.30, I63.311, I63.312, I63.319, I63.321, I63.322, I63.329, I63.331, I63.332, I63.339, I63.341, I63.342, I63.349, I63.39, I63.40, I63.411, I63.412, I63.419, I63.421, I63.422, I63.429, I63.431, I63.432, I63.439, I63.441, I63.442, I63.449, I63.49, I63.50, I63.511, I63.512, I63.519, I63.521, I63.522, I63.529, I63.531, I63.532, I63.539, I63.541, I63.542, I63.549, I63.59, I63.6, I63.8, I63.9, I65.01, I65.02, I65.03, I65.09, I65.1, I65.21, I65.22, I65.23, I65.29, I65.8, I65.9, I66.01, I66.02, I66.03, I66.09, I66.11, I66.12, I66.13, I66.19, I66.21, I66.22, I66.23, I66.29, I66.3, I66.8, I66.9, I70.1, I70.201, I70.202, I70.203, I70.208, I70.209, I70.211, I70.212, I70.213, I70.218, I70.219, I70.221, I70.222, I70.223, I70.228, I70.229, I70.231, I70.232, I70.233, I70.234, I70.235, I70.238, I70.239, I70.241, I70.242, I70.243, I70.244, I70.245, I70.248, I70.249, I70.25, I70.261, I70.262, I70.263, I70.268, I70.269, I70.291, I70.292, I70.293, I70.298, I70.299, I70.92, I74.11, I74.2, I74.3, I74.4, I74.5, I74.8, I74.9, I75.011, I75.012, I75.013, I75.019, I75.021, I75.022, I75.023, I75.029, I75.81, I75.89

Numerator 1: Patients in the above mentioned list who had a complete lipid profile during the reporting period. UniCharts searches for the test names "Total Cholesterol" (or LOINC codes 14647-2, 2093-3), "HDL-C" (or LOINC codes 14646-4, 18263-4, 2085-9), "Triglycerides" (or LOINC codes 12951-0, 14927-8, 2571-8, 47210-0) and "LDL-C" (or LOINC codes 12773-8, 13457-7, 18261-8, 18262-6, 2089-1, 22748-8, 39469-2, 49132-4, 55440-2) at an internal database table to determine if the complete lipid profile was performed. This internal database table is the place where discrete lab data is stored after extraction from imported HL7 laboratory results.

Numerator 2: Patients in the above mentioned list whose last LDL-C reading within the reporting period was less than 100 mg/dL. LDL-C is identified either by the lab name LDL-C, LDLC, LDL-Cholesterol or LDL Cholesterol, or alternatively by one of the following LOINC codes 12773-8, 13457-7, 18261-8, 18262-6, 2089-1, 22748-8, 39469-2, 49132-4, 55440-2

Exceptions: None

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