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Coding claims to exclude patients not eligible for statin use
May 4, 2022

This article is for cardiologists, endocrinologists, primary care providers, and their billing staff

  Common exclusions

Patients are excluded from the statin therapy quality measures if they:

  • Are in hospice
  • Are pregnant or breastfeeding
  • Have cirrhosis
  • Are being treated with in vitro fertilization (IVF)
  • Have end stage renal disease (ESRD) or are being treated with dialysis
  • Have myalgia, myositis, myopathy, or rhabdomyolysis diagnoses

Statin therapy quality measures assess patients diagnosed with diabetes or atherosclerotic cardiovascular disease (ASCVD) who receive and adhere to statin therapy. As you know, statin therapy can help prevent cardiovascular events, but some patients may not be clinically appropriate to receive statin therapy.

We review claims data to determine which patients to include or exclude from quality measures, based on their diagnosis. When you code your claims using the most current ICD-10-CM diagnosis code, we’ll automatically exclude ineligible patients from this quality measure.

The diagnosis code you use helps identify ineligible patients

Use the codes below to document patient conditions that prevent them from taking a statin.

For patients with this condition Use the appropriate code
Cirrhosis K70.30, K70.31, K71.7, K74.3, K74.4, K74.5, K74.60, K74.69
Dialysis procedure G0257
End stage renal disease N18.6
Hospice care G9473-G9479
IVF procedure S4015, S4016, S4018, S4020, S4021
Myalgia M79.1-M79.18
Myositis M60.80-M60.819, M60.821-M60.829, M60.831-M60.839, M60.841-M60.849, M60.851-M60.859, M60.861-M60.869, M60.871-M60.879, M60.88-M60.9
Myopathy G72.0, G72.2, G72.9
Rhabdomyolysis M62.82
Pregnancy G9778

Please note that there are many codes that may exclude members from statin quality measures; the list above is a sample of diagnosis and procedure codes that may be used.

We also understand that there are patients with mild myalgias of unclear relationship to statins, and for whom statins are critical therapy. If you have worked through a careful continuation plan with your patient, they may also be excluded from the HEDIS quality measures.

Using these codes will exclude members from the HEDIS measure’s eligible population and help to determine possible gaps in care.

Thank you

As always, thank you for the care you provide to our members.