This article is for cardiologists, endocrinologists, primary care providers, and their billing staff
Patients are excluded from the statin therapy quality measures if they:
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.
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|
|End stage renal disease||N18.6|
|IVF procedure||S4015, S4016, S4018, S4020, S4021|
|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|
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.
As always, thank you for the care you provide to our members.