Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD in the Outpatient Setting (v2019A)

Specifications Manual for Joint Commission National Quality Measures (v2019A)

Home » Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD in the Outpatient Setting

Release Notes:
Data Element
Version 2019A

Name:

Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD in the Outpatient Setting

Collected For:

ACHFOP-01

Definition:

Reasons for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD in the outpatient setting:

Beta-blocker allergy
Second or third-degree heart block on ECG and does not have a pacemaker
Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist

Bisoprolol, carvedilol, and sustained-release metoprolol succinate are agents which block beta-adrenergic receptors, thereby decreasing the rate and force of heart contractions, and reducing blood pressure. Over time beta-blockers improve the heart's pumping ability.

Question:

Is there documentation of a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD in the outpatient setting?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is documentation of a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD in the outpatient setting.

N (No) There is no documentation of a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD in the outpatient setting, or unable to determine from medical record documentation.

Notes for Abstraction:

A beta-blocker “allergy” or “sensitivity” documented counts as an allergy regardless of what type of reaction might be noted (e.g., “Allergies: Beta-blockers — Impotence” — select “Yes”).
Documentation of an allergy/sensitivity to one particular beta-blocker is acceptable to take as an allergy to the entire class of beta-blockers (e.g., “Allergic to Toprol-XL”).
When conflicting information is documented in a medical record, select “Yes”.
When determining whether there is second or third-degree heart block on ECG in the outpatient setting AND does not have pacemaker:
- Consider this true if (1) there are findings of second or third-degree heart block on the ECG AND this same ECG does NOT show pacemaker findings, OR (2) There is documentation of a finding of second or third-degree heart block (not specifically referenced as an ECG finding) without mention of the presence of pacemaker findings (e.g., “Second-degree heart block” per ER report).
- Disregard pacemaker findings if documentation suggests the patient has a non-functioning pacemaker.
- Second or third-degree heart block and pacemaker ECG findings can be taken from unsigned ECG reports. Physician/APN/PA documentation is not required.
- Second or third-degree heart block findings and pacemaker findings from telemetry and rhythm strips are acceptable.
- In cases where ECG findings of second- or third-degree heart block are referenced and documentation does not address the presence or absence of pacemaker findings, infer no pacemaker findings. E.g., “ECG on arrival showed second-degree heart block” per H&P.
When determining whether there is a reason documented by a physician/APN/PA or pharmacist for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate in the outpatient setting:
- Reasons must be explicitly documented (e.g., “COPD - No BBs”, “HR running in 50s. Hold off on beta-blocker therapy”) or clearly implied (e.g., “Severe hypotension with beta-blockers in past,” “BBs contraindicated,” “Pt. refusing all medications,” “Supportive care only — no medications,” “BBs not indicated,” beta-blocker on pre-printed order form is crossed out, “No beta-blockers” [no reason given]). If reasons are not mentioned in the context of beta-blockers, do not make inferences (e.g., Do not assume that bisoprolol, carvedilol, or sustained-release metoprolol succinate is not being prescribed because of the patient's history of Peripheral Vascular Disease alone).
  - Discontinuation of bisoprolol, carvedilol, or sustained-release metoprolol succinate documented in combination with the start of a another one of these beta-blockers (i.e., switch from bisoprolol to carvedilol) does not count as a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate in the outpatient setting. Examples:
    - “Stop carvedilol” and “Start Coreg 12.5 mg po bid” in same physician order
    - “Change metoprolol to Coreg” in progress note
  - Discontinuation of bisoprolol, carvedilol, or sustained-release metoprolol succinate at a particular dose documented in combination with the start of a different dose of that beta-blocker (i.e., change in dosage) does not count as a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate in the outpatient setting. Examples:
    - “Stop metoprolol succinate 25 mg po” and “Start metoprolol succinate 50 mg po” in same physician order
    - “Increase bisoprolol 5 mg to 10 mg” in progress note
- “Reason documentation which refers to a more general medication class is not acceptable (e.g., “Hold all BP meds”).
- Deferral from one physician/APN/PA or pharmacist to another does NOT count as a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate in the outpatient setting unless the problem underlying the deferral is also noted. Examples:
  - “Consulting cardiologist to evaluate pt. for beta-blocker treatment” - select “No”.
  - “Pt. hypotensive. Start Coreg if OK with cardiology.” - select "Yes”.
- If there is documentation of a plan to initiate/restart bisoprolol, carvedilol, or sustained-release metoprolol succinate, and the reason/problem underlying the delay in starting/restarting the beta-blocker is also noted, this constitutes a “clearly implied” reason for not prescribing a beta-blocker in the outpatient setting.
  - Acceptable examples (select “Yes”):
    - “BPs running low. May start Zebeta as outpatient.”
    - "Add Toprol-XL if HR stabilizes"
  - Unacceptable examples (select “No”):
    - “Consider starting Coreg next appointment .”
    - “May add beta-blockers when pt. can tolerate”

Suggested Data Sources:

Consultation notes
Emergency department record
History and physical
Progress notes
Physician orders
Discharge summary
Transfer sheet
Outpatient medical record

Additional Notes:

Guidelines for Abstraction:

Inclusion

Exclusion

2nd/3rd degree heart block (HB) Note: The following inclusive terms may stand alone or be modified by “variable” or “intermittent.”

Atrioventricular (AV) block described as 2 to 1, 3 to 1, second-degree, or third-degree
Atrioventicular (AV) dissociation
Heart block (HB) described as 2 to 1, 3 to 1, complete (CHB), high degree, high grade, second-degree, or third-degree
Mobitz Type 1 or 2
Wenckebach

Pacemaker findings

Paced rhythm
Paced spikes
Pacing described as atrial, AV, dual chamber, or ventricular

Beta-blocker allergy

Allergy to beta-blocker eye drops (e.g., Cosopt)
Beta-blocker allergy described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table

2nd/3rd degree heart block (HB)

2nd/3rd degree heart block (HB), or any of the other 2nd/3rd degree heart block inclusion terms, described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table
Atrial flutter
Atrioventricular (AV) block or conduction block, type/degree not specified
First-degree atrioventricular (AV) block
First-degree heart block (HB)
Heart block, type/degree not specified
Intraventricular conduction delay (IVCD)

Specifications Manual for Joint Commission National Quality Measures (v2019A)
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19)

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.