© eClinicalWorks, 2013. All rights reserved
ACCOUNTABLE CARE ORGANIZATION QUICK-REFERENCE SETUP GUIDE
V 9.0
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 2
Contents
CONTENTS
ACO SETUP _______________________________________________________3
Demographics ___________________________________________________________________3
ACO 12_________________________________________________________________________4
ACO 13_________________________________________________________________________6
ACO 14_________________________________________________________________________7
ACO 15_________________________________________________________________________8
ACO 16_________________________________________________________________________9
ACO 17________________________________________________________________________11
ACO 18________________________________________________________________________13
ACO 19________________________________________________________________________16
ACO 20________________________________________________________________________18
ACO 21________________________________________________________________________20
ACO 22________________________________________________________________________25
ACO 23________________________________________________________________________26
ACO 24________________________________________________________________________27
ACO 25________________________________________________________________________28
ACO 26________________________________________________________________________29
ACO 27________________________________________________________________________31
ACO 28________________________________________________________________________32
ACO 29________________________________________________________________________33
ACO 30________________________________________________________________________35
ACO 31________________________________________________________________________36
ACO 32________________________________________________________________________38
ACO 33________________________________________________________________________41
APPENDIX A: NOTICES _______________________________________________43
Trademarks ____________________________________________________________________43
Copyright ______________________________________________________________________43
ACO SETUP
The following information is related to setting up the eClinicalWorks system for reporting on
Accountable Care Organization measures. All possible setup options are presented here, and not all
are required for every measure. For more detailed information on all available methods of satisfying
each measure, refer to the 2013 Accountable Care Organization Users Guide.
DemographicsSome patients do not qualify for the sample data. Structured data must be created in order to indicate
the patient should not be included in the sample data. This is to ensure that they are not counted
against your compliance percentages.
Structured data setup:
Patient Information > Additional Info > Structured tab > Reason patient not qualified for sample
(ACO Reporting): Structured (single select):
In hospice
Moved out of country
HMO Enrollment
Deceased
Patient Information > Additional Info > Structured tab > Date of Ineligibility (ACO Reporting): Date
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 3
ACO Setup ACO 12
ACO 12
ACO Definitions eClinicalWorks Data Points
Denominator All patients aged 65
years and older
discharged from any
inpatient facility (e.g.,
hospital, skilled nursing
facility, or rehabilitation
facility) and seen within
30 days following
discharge in the office
by the physician
providing ongoing care
Setup Requirements:
Structured data in HPI >Interim History > Transition of care
visit from hospital > [questions]:
(Q1) Date of admission to hospital: (Type: Date)
(Q2) Date of receipt of hospital admission report:
(Type: Date)
(Q3) Date of discharge from hospital: (Type: Date)
(Q4) Date of receipt of hospital discharge summary:
(Type: Date)
OR
Structured data in HPI > Interim History > Transition of care
visit from other inpatient facility > [questions]:
(Q1) Type of other inpatient facility other than
hospital: (Type: Structured ‐ single select)
• Rehabilitation Facility
• Skilled Nursing Facility
• Other Inpatient Facility
(Q2) Date of admission to inpatient facility: (Type:
Date)
(Q3) Date of receipt of admission report: (Type: Date)
(Q4) Date of discharge from inpatient facility: (Type:
Date)
(Q5)Date of receipt of discharge summary: (Type:
Date)
Note: The denominator is satisfied by entering information for
either of the structured data options in bold above.
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 4
ACO Setup ACO 12
Numerator Patients who had a
reconciliation of the
discharge medications
with the current
medication list in the
outpatient medical
record documented.
The Medical Record
must indicate that the
clinician is aware of the
inpatient facility
discharge medications
and will either keep the
inpatient facility
discharge medications
or change the inpatient
facility discharge
medications or the
dosage of an inpatient
facility discharge
medication.
Setup Requirements:
Structured data in HPI >Interim History > Transition of care
visit from hospital > [questions]:
(Q5) Discharge medications reviewed and reconciled
from hospital: (Type: Structured ‐ multiselect)
• Medications left unchanged
• Medications changed (e.g., discontinued, changed
or added)
OR
Structured data in HPI > Interim History > Transition of care
visit from other inpatient facility > [questions]:
(Q6) Discharge medications reviewed and reconciled
from inpatient facility: (Type: Structured ‐ multiselect)
• Medications left unchanged
• Medications changed (e.g., discontinued, changed
or added)
CPT* II Code: 1111F ‐ Discharge medications reconciled with
the current medication list in outpatient medical record.
Note: The numerator is satisfied by either recording the
structured data information or the CPT II code.
*. CPT copyright 2012 American Medical Association. All rights reserved.
ACO Definitions eClinicalWorks Data Points
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 5
ACO Setup ACO 13
ACO 13
ACO Definitions eClinicalWorks Data Points
Denominator All patients aged 65
years and older
No eClinicalWorks setup required.
Numerator Patients who were
screened for future fall
risk at least once within
12 months
Setup Requirements:
Structured data in Preventive Medicine > Screening > Fall Risk
Screening > Fall Risk Assessment > (Type: Structured ‐
multiselect):
No falls in the past year
One fall without injury in the past year
Two or more falls with injury in the past year
Two or more falls without injury in the past year
One fall with injury in the past year
Note: Patients are
considered at risk for
future falls if they have
had two or more falls in
the past year or any fall
with injury in the past
year.
CPT* II Codes: 3288F ‐ Fall risk assessment documented
1100F ‐ Patient screened for future fall risk
*. CPT copyright 2012 American Medical Association. All rights reserved.
Note: The numerator is satisfied by either recording the
structured data information or a CPT II code.
Exclusions Documentation of
medical reason(s) for
not screening for future
fall risk (e.g., patient is
not ambulatory)
No eClinicalWorks setup required.
Note: Exclusions only
apply if the patient was
not screened for future
fall risk.
CPT II Code: 3288F‐1P ‐ Risk assessment for falls not completed
for medical reason
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 6
ACO Setup ACO 14
ACO 14
ACO Definitions eClinicalWorks Data Points
Denominator All patients aged six months and
older seen for a visit between
October 1 and March 31
No eClinicalWorks setup required.
Numerator Patients who have received an
influenza immunization or who
reported previous receipt of
influenza immunization
Setup Requirements:
Map the Influenza immunization to the following
CVX codes: 111, 135, 140, 141, 144, 149
Note: Previous receipt is defined as
receipt of the current season’s
influenza immunization from
another provider or from the same
provider prior to the visit to which
the measure is applied (typically,
prior vaccination would include
influenza vaccine given since August
1st).
CPT* Codes: 90653, 90654, 90655, 90656, 90658,
90660, 90661, 90662, 90664, 90666, 90667, 90668,
90672
CPT II Code: 4037F ‐ Influenza immunization
ordered or administered
ICD Codes: V04.81, V06.6
*. CPT copyright 2012 American Medical Association. All rights reserved.
Note: The numerator is satisfied by recording an
immunization, CPT code, CPT II code, or ICD code.
Exclusions Documentation of medical
reason(s), patient reason(s), or
system reason(s) for not receiving
an influenza immunization during
the flu season (e.g., patient allergy,
patient refused, immunization not
available, etc.).
No eClinicalWorks setup required.
Note: Exclusions only apply if the
patient did not receive influenza
immunization during the flu season.
ICD Codes: V15.03
CPT II Codes: 4037F‐1P ‐ Influenza immunization
not ordered or administered, medical reason
4037F‐2P ‐ Influenza immunization not ordered or
administered, patient reason
4037F‐3P ‐ Influenza immunization not ordered or
administered, system reason
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 7
ACO Setup ACO 15
ACO 15
ACO Definitions eClinicalWorks Data Points
Denominator All patients 65 years and
older
No eClinicalWorks setup required.
Numerator Patients who have ever
received a
pneumococcal
vaccination
Setup Requirements:
The Pneumonia vaccination must be mapped to the following
CVX codes: 100, 133, 33
CPT* Codes: 90669, 90670, 90732
CPT II Code: 4040F ‐ Pneumococcal vaccine administered or
previously received
*. CPT copyright 2012 American Medical Association. All rights reserved.
Note: The numerator is satisfied by recording an immunization,
CPT code, or CPT II code.
Exclusions Documentation of
medical reason(s) for
not ever receiving
pneumococcal
vaccination
No eClinicalWorks setup required.
Note: Exclusions only
apply if the patient did
not ever receive a
pneumococcal
immunization.
CPT II Code: 4040F‐1P ‐ Pneumococcal vaccine not
administered or previously received, medical reason
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 8
ACO Setup ACO 16
ACO 16
ACO Definitions eClinicalWorks Data Points
Denominator All patients aged 18 years and older at
the beginning of the measurement
period
No eClinicalWorks setup required.
Numerator Patients with BMI calculated within the
past six months or during the current
visit and a follow‐up plan is
documented within the last six months
or during the current visit if the BMI is
outside of normal parameters
Setup Requirements:
Configure Height, Weight, and BMI fields
from EMR > Vitals > Configure Vitals
(Mandatory) > BMI
Structured data in Preventive Medicine >
Counseling > Provider to provider
communication > Dietary consultation order
provided (Data type: Boolean)
Structured data in Preventive Medicine >
Counseling > Care Goal Follow Up Plan >
BMI management provided (Data type:
Boolean)
Note: Normal parameters are defined
as:
Age 65 and older ‐ BMI > 23 and <
30
Age 18 – 64 BMI > 18.5 and < 25
Follow‐Up BMI Plan:
CPT* Codes: 43644, 43645, 43770, 43771,
43772, 43773, 43774, 43842, 43843, 43845,
43846, 43847, 43848, 97802, 97804, 98960,
98961, 98962, 99078
ICD Codes: V65.3, V65.41
HCPCS Codes: S9449, S9451, S9452, S9470,
G8417, G8418
Medications: Weight loss and weight gain
medications
Note: The numerator is satisfied by recording
vitals and, if applicable, one of the following:
structured data, a CPT code, an ICD code, a
HCPCS code, or a medication.
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ACO Setup ACO 16
Exclusions Documentation of medical, or patient
reason(s) for not having a BMI
measurement performed during the
measurement period (e.g., patient is
receiving palliative care, patient is
pregnant or patient is in an urgent or
emergent medical situation where time
is of the essence and to delay
treatment would jeopardize the
patient’s health status; patient refuses
BMI measurement or if there is any
other reason documented in the
medical record by the provider
explaining why BMI measurement was
not appropriate, etc.)
Setup Requirements:
Structured data in Preventive Medicine >
Counseling > Provider to provider
communication > Palliative Care > (Data Type:
Structured ‐ single select):
Admission by palliative care physician
Admission to palliative care department
Referral by palliative care physician
Referral to palliative care physician
Referral to palliative care service
Note: Exclusions only apply if a
calculated BMI was not documented as
normal or was outside parameters with
a follow‐up not performed during the
reporting period.
ICD Codes: V66.5, Pregnancy Dx
HCPCS Codes: G8422 ‐ Patient not eligible for
BMI calculation
G8938 ‐ BMI is calculated, but patient not
eligible for follow‐up plan
*. CPT copyright 2012 American Medical Association. All rights reserved.
ACO Definitions eClinicalWorks Data Points
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ACO Setup ACO 17
ACO 17
ACO Definitions eClinicalWorks Data Points
Denominator All patients aged 18
years and older
No eClinicalWorks setup required.
Numerator Patients who were
screened for tobacco
use at least once within
24 months and who
received tobacco
cessation counseling
intervention if identified
as a tobacco user
Setup Requirements:
Recording Tobacco Use:
Structured data in Social History > Tobacco Use > Smoking
> are you a: (Data Type: Structured ‐ single select):
Current Smoker
Former Smoker
Non‐Smoker
Current Everyday Smoker
Current Someday Smoker
Smoker current status unknown
Unknown if ever smoked
Structured data in Social History > Tobacco Use > Tobacco
Use Other than smoking > are you an other tobacco user:
(Data Type: Boolean)
AND
Recording Tobacco Cessation Counseling:
Structured data in Preventive Medicine > Counselling >
Smoking > Patient counselled on the dangers of tobacco
use and urged to quit > (Data Type: Date)
Structured data in Preventive Medicine > Counselling >
Communication to patient > Counselled the patient on
pregnancy smoking effects; education provided > (Data
Type: Date)
Structured data in Preventive Medicine > Counselling >
Communication to patient > Counselled the patient on
smoking cessation; education provided > (Data Type: Date)
Structured data in Preventive Medicine > Counselling >
Communication to patient > Counselled the patient on
smoking effects; education provided > (Data Type: Date)
(continued on next page)
Note: Tobacco Use
includes use of any type
of tobacco.
Cessation Counseling
Intervention includes
brief counseling (three
minutes or less) and/or
pharmacotherapy.
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ACO Setup ACO 17
Numerator
(continued)
Structured data in Preventive Medicine > Counselling >
Communication to patient > Counselled the patient on
tobacco use; cessation provided > (Data Type: Date)
Structured data in Preventive Medicine > Counselling >
Communication to patient > Referral given to patient to a
stop‐smoking clinic > (Data Type: Date)
Structured data in Preventive Medicine > Counselling >
Communication to patient > Referral to smoking cessation
advisor was given to patient > (Data Type: Date)
Structured data in Preventive Medicine > Counselling >
Communication to patient > Smoking Cessation Assistance
Provided > (Data Type: Date)
CPT* II Codes: 4004F ‐ Patient screened for tobacco use AND
received tobacco cessation and intervention
Medications: Smoking cessation medications
Note: The numerator is satisfied by recording information for
both structured data options under Recording Tobacco Use
and, if applicable, recording one of the following: a structured
data option under Recording Tobacco Cessation Counseling, a
CPT II code, or a medication.
Exclusions Documentation of
medical reason(s) for
not screening for
tobacco use (e.g.,
limited life expectancy
or other medical
reasons)
No eClinicalWorks setup required.
Note: Exclusions only
apply if the patient was
not screened for
tobacco use during the
reporting period or year
prior.
CPT II Code: 4004F‐1P ‐ Documentation of medical reason(s)
for not screening for tobacco use (e.g., limited life expectancy,
other reason)
*. CPT copyright 2012 American Medical Association. All rights reserved.
ACO Definitions eClinicalWorks Data Points
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ACO Setup ACO 18
ACO 18
ACO Definitions eClinicalWorks Data Points
Denominator All patients aged 12
years and older at the
beginning of the
measurement period
No eClinicalWorks setup required.
Numerator Patients screened for
clinical depression
during the
measurement period
using an age
appropriate
standardized tool and, if
positive, have had a
follow‐up plan
documented on the
date of the positive
screen
Setup Requirements:
Depression Screening Structured Data:
Structured data in HPI > Depression Screening >
Intervention> Depression Screening Findings > (Data Type:
Structured ‐ single select):
Positive
Negative
Depression Screening Intervention Follow‐Up Structured Data:
Structured data in HPI > Depression Screening >
Intervention > Follow‐Up for Depression > (Data type:
Structured ‐ multi‐select):
Case management follow‐up
Completion of mental health crisis plan
Coping support assessment
Coping support management
Crisis intervention with follow‐up
Discharge by mental health primary care worker
Emotional support assessment
Emotional support education
Emotional support management
Implementation of measures to provide psychological
support
Management of mental health treatment
Mental health care assessment
Mental health care education
Mental health care management
Mental health history taking assessment
(continued on next page)
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ACO Setup ACO 18
Numerator
(continued)
Mental health history taking education
Mental health history taking management
Mental health promotion assessment
Mental health promotion education
Mental health promotion management
Mental health screening assessment
Mental health screening education
Mental health screening management
Mental health treatment assessment
Mental health treatment education
Patient follow‐up to return when and if necessary
Psychiatric follow up
Note: A screening is
defined as the
completion of a clinical
or diagnostic tool used
to identify people at risk
of developing or having
a certain disease or
condition, even in the
absence of symptoms.
A Standardized Clinical
Depression Screening
Tool is defined as a
normalized and
validated depression
screening tool
developed for the
patient population
where it is being
utilized.
Depression Screening:
Smart Forms: PHQ2, PHQ9
ICD Code: V79.0
HCPCS Code: S3005
Screen‐and‐Plan Codes: G8510 ‐ Negative screen for
clinical depression, follow‐up not required
G8431 ‐ Positive screen for clinical depression with a
documented follow‐up plan
Positive for Clinical Depression:
Screen‐and‐Plan Code: G8431
Smart Form: PHQ9
Depression Follow‐Up Plan:
Screen‐and‐Plan Code: G8431
Medications:
Medispan ‐ Antidepressant medications
Multum ‐ Miscellaneous Antidepressant medications
Note: The numerator is satisfied by recording Depression
Screening structured data, recording a Smart Form, or an ICD/
HCPCS/Screen‐and‐Plan code under either the Depression
Screening or Positive for Clinical Depression sections, and, if
applicable, recording one of the following: a Depression
Screening Intervention Follow‐Up structured data option or
coding/medication under the Depression Follow‐Up Plan
section
ACO Definitions eClinicalWorks Data Points
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ACO Setup ACO 18
Exclusions Documentation of
medical or patient
reason(s) for not having
a screening for clinical
depression performed
during the reporting
period (e.g., patient is in
an urgent or emergent
medical situation where
time is of the essence
and to delay treatment
would jeopardize the
patient’s health status,
situations where the
patient’s functional
capacity or motivation
to improve may impact
the accuracy of results
of standardized
depression assessment
tools [e.g., certain court
appointed cases or cases
of delirium], or patient
has an active diagnosis
of depression or bipolar
disorder; patient refuses
to participate, etc.)
No eClinicalWorks setup required.
Note: Exclusions only
apply if the patient did
not receive a screening
for clinical depression
using an age
appropriate
standardized tool.
ICD Codes: Depression/Bipolar Dx codes
HCPCS Codes: G8940 ‐ Screening for clinical depression
documented, follow‐up plan not documented, patient not
eligible/appropriate
G8433 ‐ Screening for clinical depression not documented,
patient not eligible/appropriate
ACO Definitions eClinicalWorks Data Points
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ACO Setup ACO 19
ACO 19
ACO Definitions eClinicalWorks Data Points
Denominator All patients aged 50
through 75 years
No eClinicalWorks setup required.
Numerator Patients who had at
least one or more
screenings for colorectal
cancer during or prior to
the reporting period
Setup Requirements:
Map the Colonoscopy diagnostic imaging test to the
community Colonoscopy ID from:
EMR > Community Mapping > DI > Colonoscopy
Note: Patients are
considered to have had
an appropriate
screening for colorectal
cancer if any of the
following are
documented:
Fecal occult blood
test (FOBT) within
the last 12 months
Flexible
sigmoidoscopy
during the reporting
period or the four
years prior to the
reporting period
Colonoscopy during
the reporting
period or the nine
years prior to the
reporting period
CPT* II Code: 3017F ‐ Colorectal cancer screening documented
and reviewed
Flexible Sigmoidoscopy:
CPT Codes: 45330, 45331, 45332, 45333, 45334, 45335,
45337, 45338, 45339, 45340, 45341, 45342, 45345
ICD Code: 45.24
Colonoscopy:
CPT Codes: 44388, 44389, 44390, 44391, 44392, 44393,
44394, 44397, 45355, 45378, 45379, 45380, 45381, 45382,
45383, 45384, 45385, 45386, 45387, 45391, 45392
HCPCS Codes: G0105, G0121
ICD Codes: 45.22, 45.23, 45.25, 45.42, 45.43
Fecal Occult Blood Test:
LOINC Codes: 29771‐3, 2335‐8, 14563‐1, 14564‐9, 14565‐
6, 12503‐9, 12504‐7, 27401‐9, 27925‐7, 27926‐5, 27396‐1
CPT Codes: 82270, 82274
HCPCS Code: G0328
ICD Code: V76.51
Note: The numerator is satisfied by recording a colonoscopy,
flexible sigmoidoscopy, FOBT, CPT code, HCPCS code, ICD code,
or CPT II code.
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 16
ACO Setup ACO 19
Exclusions Documentation of
medical reason(s) for
not performing
colorectal cancer
screening (e.g., total
colectomy or other
medical reason)
No eClinicalWorks setup required.
Note: Exclusions only
apply if the patient was
not screened for
colorectal cancer.
ICD Codes: 45.81, 45.82, 45.83, 153.0, 153.1, 153.2, 153.3,
153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 154.0, 154.1, 197.5,
V10.05, V66.5
CPT Codes: 44150, 44151, 44152, 44153, 44155, 44156, 44157,
44158, 44210, 44211, 44212
CPT II Code: 3017F‐1P ‐ Colorectal cancer screening results not
documented and reviewed, medical reason
*. CPT copyright 2012 American Medical Association. All rights reserved.
ACO Definitions eClinicalWorks Data Points
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ACO Setup ACO 20
ACO 20
ACO Definitions eClinicalWorks Data Points
Denominator All female patients aged
40 through 69 years
No eClinicalWorks setup required.
Numerator Patients who had a
mammogram at least
once within 24 months
Setup Requirements:
Map the Mammogram diagnostic imaging test to the
community Mammogram ID from:
EMR > Community Mapping > DI > Mammogram Screening
EMR > Community Mapping > DI > Mammogram, Diagnostics
EMR > Community Mapping > DI > Mammogram, Uni Left
EMR > Community Mapping > DI > Mammogram, Uni Right
HCPCS Codes: G0202, G0204, G0206
ICD Codes: V76.11, V76.12, 87.36, 87.37
CPT* Codes: 77055, 77056, 77057
CPT II Code: 3014F ‐ Screening mammography results
documented and reviewed
Note: If using an ICD/CPT/HCPCS code to indicate a
mammogram was performed, documentation in the medical
record MUST also include a diagnostic imaging test for a
mammogram with both of the following documented:
The date the breast cancer screening was performed
The result of the findings
Note: The numerator is satisfied by recording a mammogram
diagnostic imaging test, a HCPCS code, an ICD code, a CPT
code, or a CPT II code.
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ACO Setup ACO 20
Exclusions Documentation of
medical reason(s) for
not performing a
mammogram within 24
months (e.g., women
who had a bilateral
mastectomy or two
unilateral mastectomies)
No eClinicalWorks setup required.
Note: Exclusions only
apply if a mammogram
was not performed
within 24 months.
ICD Codes: 85.41, 85.42, 85.43, 85.44, 85.45, 85.46, 85.47,
85.48
CPT Codes: 19303, 19303‐50, 19304, 19304‐50, 19305, 19305‐
50, 19306, 19306‐50, 19307, 19307‐50
CPT II Codes: 3014F‐1P ‐ Screening mammography not
documented and not reviewed, medical reason
*. CPT copyright 2012 American Medical Association. All rights reserved.
ACO Definitions eClinicalWorks Data Points
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ACO Setup ACO 21
ACO 21
ACO Definitions eClinicalWorks Data Points
Denominator All patients aged 18 years and
older at the beginning of the
measurement period
No eClinicalWorks setup required.
Numerator Patients who were screened for
high blood pressure and a
recommended follow‐up plan is
documented as indicated if the
blood pressure is pre‐
hypertensive or hypertensive
Setup Requirements:
Configure the blood pressure vital from: EMR >
Vitals > Configure Vitals (Mandatory) > BP
(1) Structured data in Preventive Medicine >
Counseling > BP Management > Pre‐Hypertensive
BP Follow‐Up Plan (Type: Structured ‐ single select):
Follow‐Up 1 day
Follow‐Up 2‐3 days
Follow‐Up 4‐6 days
Follow‐Up 1 week
Follow‐Up 2 weeks
Follow‐Up 3 weeks
Follow‐Up 1 month
Follow‐Up 6 weeks
Follow‐Up 2 ‐3 months
Follow‐Up 4 ‐6 months
Follow‐Up 6 months
Follow‐Up 7 ‐11 months
Follow‐Up 1 year
(continued on next page)
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ACO Setup ACO 21
Numerator
(continued)
(2) Structured data in Preventive Medicine >
Counseling > BP Management > First Hypertensive
BP Follow‐Up Plan (Type: Structured ‐ single select):
Follow‐Up 1 day
Follow‐Up 2‐3 days
Follow‐Up 4‐6 days
Follow‐Up 1 week
Follow‐Up 2 weeks
Follow‐Up 3 weeks
Follow‐Up 1 month
(3) Structured data in Preventive Medicine >
Counseling > BP Management > Referral to
alternative/primary care provider > (Type:
Structured ‐ multiselect)
Urgent referral
Referral to general medical service
Referral to general practitioner
Referral to hypertension clinic
Referral to service
Referral to doctor
Referral to general physician
(4) Structured data in Preventive Medicine >
Counseling > BP Management > Physical Activity >
(Type: Structured ‐ multiselect)
Recommendation to exercise
Exercise education
Given encouragement to exercise
Exercise promotion: strength training
Exercise promotion: stretching
Nutrition therapy
Prescribed activity/exercise education
Exercises education, guidance, and counseling
(continued on next page)
ACO Definitions eClinicalWorks Data Points
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ACO Setup ACO 21
Numerator
(continued)
(5) Structured data in Preventive Medicine >
Counseling > BP Management > Weight Reduction
Recommendation > (Type: Structured ‐ multiselect)
Follow‐up obesity assessment
Weight‐reducing diet education
Target weight discussed
Refer to weight management program
Weight control education
(6) Structured data in Preventive Medicine >
Counseling > BP Management > Dietary
Recommendation > (Type: Structured ‐ multiselect)
Patient referral to dietitian
Diet education
Dietary regime
Dietary prophylaxis
Low carbohydrate diet – prophylaxis
Low calorie diet – prophylaxis
Unsaturated fat diet – prophylaxis
Low fat diet education
Low carbohydrate diet education
Vegetarian diet education
Vegan diet education
Sugar‐free diet education
Dietary treatment for disorder
Obesity diet education
Dietary education for disorder
Referral to dietetics service
Prescribed dietary intake
Dietary needs education
Prescribed diet education
Dietary compliance education
Nutrition care education
Special diet education
Nutritionist education, guidance, and
counseling
(continued on next page)
ACO Definitions eClinicalWorks Data Points
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ACO Setup ACO 21
Numerator
(continued)
Nutrition / feeding management
Feeding regime
Dietary management education, guidance, and
counseling
Lifestyle education regarding diet
Nutrition education
(7) Structured data in Preventive Medicine >
Counseling > BP Management > Moderation of
ETOH Consumption Recommendation > (Type:
Structured ‐ multiselect)
Alcoholism counseling
Patient referral for alcoholism rehabilitation
Referral to community alcohol team
Alcohol abuse prevention education
Counseling about alcohol consumption
Referral to community drug and alcohol team
Referral to specialist alcohol treatment service
BP Follow‐Up Plan:
Dietary Recommendations:
HCPCS Codes: S9452, S9470
ICD Codes: Z71.3, V65.3
Physical Activity Recommendation:
HCPCS Code: S9451
ICD Code: V65.41
Weight Management Classes:
HCPCS Code: S9449
Second Hypertensive Reading Interventions:
Map one of the following LOINC codes from EMR >
Labs/DI/Procedures > Labs: 24321‐2, 24323‐8,
24356‐6, 24362‐6, 2888‐6, 57021‐8, 57782‐5,
58410‐2, 80047, 80048, 80050, 80053, 80069
Medications: Anti‐Hypertensives
Map one of the following LOINC codes from EMR >
Labs/DI/Procedures > ECG: 11524‐6, 34534‐8
(continued on next page)
ACO Definitions eClinicalWorks Data Points
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 23
ACO Setup ACO 21
Numerator
(continued)
Note: No follow‐up is needed for a normal BP reading.
The following readings require follow‐ups:
Pre‐Hypertensive Reading ‐ Structured data (1) +
(one or more) Structured Data (4), (5), (6), (7) OR
Structured data (3) only
1st Hypertensive Reading ‐ Structured data (2) +
(one or more) Structured Data (4), (5), (6), (7) OR
Structured data (3) only
2nd Hypertensive Reading ‐ (one or more)
Structured data (4), (5), (6), (7) + (one or more)
(Anti‐Hypertensive Medications, Lab tests, or ECG)
OR Structured Data (3) only
Note: The numerator is satisfied by recording vitals and,
if applicable, one of the following: structured data, a
medication, a CPT II code, or an ICD code.
Exclusions Documentation of medical or
patient reason(s) for not
receiving screening for high
blood pressure (e.g., patient
has an active diagnosis of
hypertension, patient is in an
urgent or emergent situation
where time is of the essence
and to delay treatment would
jeopardize the patient’s health
status. This may include, but is
not limited to severely elevated
BP when immediate medical
treatment is indicated; patient
refuses BP measurement, etc.)
No eClinicalWorks setup required.
Note: Exclusions only apply if
the patient did not receive a
screening for high blood
pressure during the
measurement period.
ICD Codes: Hypertension Dx
HCPCS Codes: G8784 ‐ Blood pressure not documented,
patient not eligible/not appropriate
G8951 ‐ Pre‐hypertensive or hypertensive blood
pressure reading documented, indicated follow‐up not
documented, patient not eligible/not appropriate
ACO Definitions eClinicalWorks Data Points
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 24
ACO Setup ACO 22
ACO 22
ACO Definitions eClinicalWorks Data Points
Denominator Patients 18 to 75 years
of age with a diagnosis
of diabetes mellitus with
two or more face‐to‐
face visits for diabetes in
the last two years and at
least one visit for any
reason in the last 12
months
No eClinicalWorks setup required.
ICD Codes: Diabetes Dx
Numerator Patients with most
recent hemoglobin A1c
<8.0 percent
Setup Requirements:
The Hemoglobin A1c lab attribute must be mapped to one of
the following LOINC codes: 4548‐4, 4549‐2, 17856‐6
Note: Hemoglobin A1c lab should be ordered during the
reporting period. Lab results must be entered in the yellow
grid on the Lab Results window and the Received box must be
checked.
IMPORTANT! Do not enter special characters in the results
field. Only numbers and the percentage sign (%) are
recognized by the system when calculating measure
compliance.
Exclusions Diagnosis of polycystic
ovaries, gestational
diabetes or steroid‐
induced diabetes
No eClinicalWorks setup required.
ICD Codes: Polycystic Ovaries Dx, Gestational Diabetes Dx, or
Steroid Induced Diabetes Dx
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 25
ACO Setup ACO 23
ACO 23
ACO Definitions eClinicalWorks Data Points
Denominator Patients 18 to 75 years
of age with a diagnosis
of diabetes mellitus with
two or more face‐to‐
face visits for diabetes in
the last two years and at
least one visit for any
reason in the last 12
months
No eClinicalWorks setup required.
ICD Codes: Diabetes Dx
Numerator Patients with most
recent low density
lipoprotein <100 mg/dL
Setup Requirements:
Map the following LOINC codes to the LDL‐C lab attribute:
2089‐1, 12773‐8, 13457‐7, 18261‐8, 18262‐6, 22748‐8,
39469‐2, 49132‐4, 55440‐2
Map the following LOINC codes to the Total Cholesterol lab
attribute: 14647‐2, 2093‐3
Map the following LOINC codes to the Triglycerides lab
attribute: 12951‐0, 14927‐8, 2571‐8, 47210‐0
Map the following LOINC codes to the HDL lab attribute:
14646‐4, 18263‐4, 2085‐9
IMPORTANT! All four components of LDL, Total Cholesterol,
HDL, and Triglycerides must be linked to a corresponding LOINC
code and their values entered into the Lab Result window to
satisfy this measure.
Note: The LDL‐C lab should be ordered during the reporting
period. Lab results must be entered in the yellow grid on the
Lab Results window and the Received box must be checked.
IMPORTANT! Do not enter special characters in the results
field. Only numbers and mg/dL are recognized by the system
when calculating measure compliance.
Exclusions Diagnosis of polycystic
ovaries, gestational
diabetes or steroid
induced diabetes
No eClinicalWorks setup required.
ICD Codes: Polycystic Ovaries Dx, Gestational Diabetes Dx, or
Steroid Induced Diabetes Dx
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 26
ACO Setup ACO 24
ACO 24
ACO Definitions eClinicalWorks Data Points
Denominator Patients 18 to 75 years
of age with a diagnosis
of diabetes mellitus with
two or more face‐to‐
face visits for diabetes in
the last two years and at
least one visit for any
reason in the last 12
months
No eClinicalWorks setup required.
ICD Codes: Diabetes Dx
Numerator Patients with most
recent blood pressure
<140/90 mmHg
Setup Requirements:
Configure the blood pressure vital from: EMR > Vitals >
Configure Vitals (Mandatory) > BP
Note: The BP value should be ordered during the reporting
period.
IMPORTANT! When entering a BP value on the Vitals window,
special characters should not be entered right next to numeric
values (e.g., BP 120/80 AH).
The only allowable special character is unit of measure mmHg.
Exclusions Diagnosis of polycystic
ovaries, gestational
diabetes or steroid
induced diabetes
No eClinicalWorks setup required.
ICD Codes: Polycystic Ovaries Dx, Gestational Diabetes Dx, or
Steroid Induced Diabetes Dx
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 27
ACO Setup ACO 25
ACO 25
ACO Definitions eClinicalWorks Data Points
Denominator Patients 18 to 75 years
of age with a diagnosis
of diabetes mellitus with
two or more face‐to‐
face visits for diabetes in
the last two years and at
least one visit for any
reason in the last 12
months
No eClinicalWorks setup required.
ICD Codes: Diabetes Dx
Numerator Patients who were
identified as non‐users
of tobacco
Setup Requirements:
Structured data in Social History > Tobacco Use > Smoking
> are you a: > (Data Type: Structured ‐ single select):
Current Smoker
Former Smoker
Non‐Smoker
Current Everyday Smoker
Current Someday Smoker
Smoker current status unknown
Unknown if ever smoked
Structured data in Social History > Tobacco Use > Tobacco
Use Other than smoking > are you an other tobacco user: >
(Data Type: Boolean)
Note: The numerator is satisfied by recording information for
both structured data options.
Exclusions Diagnosis of polycystic
ovaries, gestational
diabetes or steroid
induced diabetes
No eClinicalWorks setup required.
ICD Codes: Polycystic Ovaries Dx, Gestational Diabetes Dx, or
Steroid Induced Diabetes Dx
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 28
ACO Setup ACO 26
ACO 26
ACO Definitions eClinicalWorks Data Points
Denominator Patients 18 to 75 years of age with a diagnosis of diabetes
mellitus with two or more face‐to‐face visits for diabetes in
the last two years and at least one visit for any reason in
the last 12 months and a diagnosis of ischemic vascular
disease
No eClinicalWorks setup
required.
ICD Codes: Diabetes Dx and
Ischemic Vascular Disease Dx
Numerator Patients with the diagnosis of diabetes and ischemic
vascular disease with documentation of taking daily aspirin
or antiplatelet medication or have a documented
contraindication in the measurement year
No eClinicalWorks setup
required.
ICD Codes: Diabetes Dx and
Ischemic Vascular Disease Dx
Note: The following are accepted contraindications for this
measure:
Anticoagulant use, Lovenox (enoxaparin) or Coumadin
(warfarin)
Any history of gastrointestinal (GI)* or intracranial
bleed (ICB)
Allergy to aspirin (ASA)
Gastroesophogeal reflux disease (GERD) is not
automatically considered a contraindication but may
be included if specifically documented as a
contraindication by the physician.
The following may be exclusions if specifically documented
by the physician:
Use of non‐steroidal anti‐inflammatory agents
Documented risk for drug interaction
Uncontrolled hypertension defined as 180 systolic, 110
diastolic
Other provider documented reason for not being on
ASA therapy
Note: The numerator is
satisfied by recording an ICD
code and a medication.
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 29
ACO Setup ACO 26
Exclusions Patients may be excluded for one of the following reasons:
Diagnosis of polycystic ovaries, gestational diabetes or
steroid induced diabetes
No eClinicalWorks setup
required.
ICD Codes: Polycystic Ovaries
Dx, Gestational Diabetes Dx,
or Steroid Induced Diabetes
Dx
CPT* II Code: 4086F‐1P ‐
Documentation of medical
reason(s) for not prescribing
Aspirin or Clopidogrel
Note: This exclusion only applies if the patient was
not prescribed daily aspirin or antiplatelet
medication.
Documentation of medical reason(s) for not
prescribing daily aspirin or antiplatelet medication
*. CPT copyright 2012 American Medical Association. All rights reserved.
ACO Definitions eClinicalWorks Data Points
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 30
ACO Setup ACO 27
ACO 27
ACO Definitions eClinicalWorks Data Points
Denominator Patients aged 18
through 75 years with
the diagnosis of
diabetes
No eClinicalWorks setup required.
ICD Codes: Diabetes Dx
Numerator Patients with most
recent hemoglobin A1c
level >9.0%
Setup Requirements:
Map one of the following LOINC codes to the Hemoglobin A1c
lab attribute: 4548‐4, 4549‐2, 17856‐6
Note: The Hemoglobin A1c lab should be ordered during the
reporting period. Lab results must be entered in the yellow
grid on the Lab Results window and the Received box must be
checked.
IMPORTANT! Do not enter special characters in the results
field. Only numbers and the percentage sign (%) are
recognized by the system when calculating measure
compliance.
Exclusions Diagnosis of polycystic
ovaries, gestational
diabetes or steroid
induced diabetes
No eClinicalWorks setup required.
ICD Codes: Polycystic Ovaries Dx, Gestational Diabetes Dx, and
Steroid Induced Diabetes Dx
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 31
ACO Setup ACO 28
ACO 28
ACO Definitions eClinicalWorks Data Points
Denominator Patients aged 18
through 85 years with
the diagnosis of
hypertension
No eClinicalWorks setup required.
ICD Codes: 362.11, 401, 401.1, 401.9, 402.00, 402.01, 402.10,
402.11, 402.90, 402.91, 403.00, 403.01, 403.10, 403.11, 403.90,
403.91, 404.00, 404.01, 404.02, 404.03, 404.10, 404.11,
404.12, 404.13, 404.90, 404.91, 404.92, 404.93, 405.01,
405.09, 405.11, 405.19, 405.91, 405.99
Numerator Patients whose most
recent blood pressure
<140/90 mmHg
Setup Requirements:
Configure the blood pressure vital from: EMR > Vitals >
Configure Vitals (Mandatory) > BP
Note: The BP value should be ordered during the reporting
period.
IMPORTANT! When entering a BP value on the Vitals window,
special characters should not be entered right next to numeric
values (e.g., BP 120/80 AH).
The only allowable special character is unit of measure mmHg.
Exclusions Documentation of
medical reason(s) for
not recording a blood
pressure measurement
(diagnosis for End‐Stage
Renal Disease [ESRD]
and pregnancy are the
only acceptable
exclusions)
No eClinicalWorks setup required.
Note: Exclusions only
apply if the patient did
not receive a blood
pressure measurement.
ICD Codes: ESRD Dx and Pregnancy Dx
CPT Codes: ESRD related procedures
HCPCS Codes: G0257 (UNSCHD/EMERG DIALYSIS TX), S9339
(ESRD PT HOS OP NOT CERT)
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 32
ACO Setup ACO 29
ACO 29
ACO Definitions eClinicalWorks Data Points
Denominator Patients aged 18 years
and older with the
diagnosis of ischemic
vascular disease, or who
were discharged alive
for acute myocardial
infarction (AMI),
coronary artery bypass
graft (CABG) or
percutaneous coronary
interventions (PCI)
No eClinicalWorks setup required.
ICD Codes: 410.01, 410.11, 410.21, 410.31, 410.41, 410.51,
410.61, 410.71, 410.81, 410.91, 411, 411.1, 411.81, 411.89,
412, 413, 413.1, 413.9, 414, 414.01, 414.02, 414.03, 414.04,
414.05, 414.06, 414.07, 414.2, 414.3, 414.8, 414.9, 429.2, 433,
433.01, 433.1, 433.11, 433.2, 433.21, 433.3, 433.31, 433.8,
433.81, 433.9, 433.91, 434, 434.01, 434.1, 434.11, 434.9,
434.91, 440, 440.1, 440.2, 440.21, 440.22, 440.23, 440.24,
440.29, 440.4, 444, 444.01, 444.09, 444.1, 444.21, 444.22,
444.81, 444.89, 444.9, 445.01, 445.02, 445.81, 0.66, 36.06,
36.07, 36.09, 36.1, 36.11, 36.12, 36.13, 36.14, 36.15, 36.16,
36.17, 36.19, 36.2
CPT* Codes: 33510, 33511, 33512, 33513, 33514, 33516,
33517, 33518, 33519, 33140, 33521, 33522, 33523, 33533,
33534, 33535, 33536, 92920, 92924, 92928, 92933, 92937,
92941, 92943
HCPCS Codes: S2205, S2206, S2207, S2208, S2209
Note: The denominator is satisfied by recording an ICD code, a
CPT code, or a HCPCS code.
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 33
ACO Setup ACO 29
Numerator Patients who received at
least one lipid profile (or
ALL component tests)
with most recent LDL‐C
<100 mg/dL
Setup Requirements:
Map the following LOINC codes to the LDL‐C lab attribute:
2089‐1, 12773‐8, 13457‐7, 18261‐8, 18262‐6, 22748‐8,
39469‐2, 49132‐4, 55440‐2
Map the following LOINC codes to the Total Cholesterol lab
attribute: 14647‐2, 2093‐3
Map the following LOINC codes to the Triglycerides lab
attribute: 12951‐0, 14927‐8, 2571‐8, 47210‐0
Map the following LOINC codes to the HDL lab attribute:
14646‐4, 18263‐4, 2085‐9
IMPORTANT! All four components of LDL, Total Cholesterol,
HDL, and Triglycerides must be linked to a corresponding LOINC
code and their values entered into the Lab Result window to
satisfy this measure.
Note: Lipid Panel includes an LDL‐C lab should be ordered
during the reporting period. Lab results must be entered in the
yellow grid on the Lab Results window and the Received box
must be checked.
IMPORTANT! Do not enter special characters in the results
field. Only numbers and mg/dL are recognized by the system
when calculating measure compliance.
*. CPT copyright 2012 American Medical Association. All rights reserved.
ACO Definitions eClinicalWorks Data Points
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 34
ACO Setup ACO 30
ACO 30
ACO Definitions eClinicalWorks Data Points
Denominator Patients aged 18 years
and older with the
diagnosis of ischemic
vascular disease, or who
were discharged alive
for acute myocardial
infarction (AMI),
coronary artery bypass
graft (CABG) or
percutaneous coronary
interventions (PCI)
No eClinicalWorks setup required.
ICD Codes: 410.01, 410.11, 410.21, 410.31, 410.41, 410.51,
410.61, 410.71, 410.81, 410.91, 411, 411.1, 411.81, 411.89,
412, 413, 413.1, 413.9, 414, 414.01, 414.02, 414.03, 414.04,
414.05, 414.06, 414.07, 414.2, 414.3, 414.8, 414.9, 429.2, 433,
433.01, 433.1, 433.11, 433.2, 433.21, 433.3, 433.31, 433.8,
433.81, 433.9, 433.91, 434, 434.01, 434.1, 434.11, 434.9,
434.91, 440, 440.1, 440.2, 440.21, 440.22, 440.23, 440.24,
440.29, 440.4, 444, 444.01, 444.09, 444.1, 444.21, 444.22,
444.81, 444.89, 444.9, 445.01, 445.02, 445.81, 0.66, 36.06,
36.07, 36.09, 36.1, 36.11, 36.12, 36.13, 36.14, 36.15, 36.16,
36.17, 36.19, 36.2
CPT* Codes: 33510, 33511, 33512, 33513, 33514, 33516,
33517, 33518, 33519, 33140, 33521, 33522, 33523, 33533,
33534, 33535, 33536, 92920, 92924, 92928, 92933, 92937,
92941, 92943
HCPCS Codes: S2205, S2206, S2207, S2208, S2209
*. CPT copyright 2012 American Medical Association. All rights reserved.
Note: The denominator is satisfied by recording an ICD code, a
CPT code, or a HCPCS code.
Numerator Patients who are using
aspirin or another
antithrombotic therapy
No eClinicalWorks setup required.
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 35
ACO Setup ACO 31
ACO 31
ACO Definitions eClinicalWorks Data Points
Denominator All patients aged 18
years and older with a
diagnosis of heart
failure with a current or
prior LVEF <40%
Setup Requirements:
Structured data in HPI > Echocardiogram > Left ventricular
assessment > Result (%) (Data Type: Number)
OR
Structured data in HPI > Echocardiogram > Ejection fraction
> Result (%) (Data Type: Number)
ICD Codes: 402.01, 402.11, 402.91, 404.01, 404.03, 404.11,
404.13, 404.91, 404.93, 428, 428.1, 428.2, 428.21, 428.22,
428.23, 428.3, 428.31, 428.32, 428.33, 428.4, 428.41, 428.42,
428.43, 428.9
CPT* Codes: 78414, 78451, 78452, 78453, 78454, 78468,
78472, 78473, 78481, 78483, 78494, 78496, 93303, 93304,
93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316,
93317, 93350, 93351, 93352, 93452, 93453, 93458, 93459,
93460, 93461
HCPCS Codes: G8923 ‐ Left ventricular ejection fraction (LVEF)
<40% or documentation of moderately or severely depressed
left ventricular systolic function
G8934 ‐ Left ventricular ejection fraction (LVEF) <40% or
documentation of moderately or severely depressed left
ventricular systolic function
Note: Both Heart Failure Diagnosis and LVEF % must be
documented for the denominator
Note: The denominator is satisfied by recording structured data
information, an ICD code, a CPT code, or a HCPCS code.
Numerator Patients who were
prescribed beta‐blocker
therapy either within a
12 month period when
seen in the outpatient
setting OR at EACH
hospital discharge
No eClinicalWorks setup required.
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 36
ACO Setup ACO 31
Exclusions Documentation of
medical, patient, or
system reason(s) for not
prescribing beta‐blocker
therapy (e.g., low blood
pressure, fluid overload,
asthma, patients
recently treated with an
intravenous positive
inotropic agent, allergy,
intolerance, other
medical reasons; patient
declined; other reasons
attributable to the
healthcare system, etc.)
No eClinicalWorks setup required.
Note: Exclusions only
apply if the patient was
not prescribed beta‐
blocker therapy.
ICD Codes: 337.09, 427.81, 427.89, 458.0, 458.1, 458.21,
458.29, 458.8, 458.9, 493.00, 493.01, 493.02, 493.10, 493.11,
493.12, 493.20, 493.21, 493.22, 493.81, 493.82, 493.90,
493.91, 493.92, 440.0, 426.0, 426.12, 426.13, V45.01
CPT II Codes: 4008F‐1P ‐ Beta‐Blocker therapy not prescribed
or being currently taken, medical reason
4008F‐2P ‐ Beta‐Blocker therapy not prescribed or being
currently taken, patient reason
4008F‐3P ‐ Beta‐Blocker therapy not prescribed or being
currently taken, system reason
*. CPT copyright 2012 American Medical Association. All rights reserved.
ACO Definitions eClinicalWorks Data Points
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 37
ACO Setup ACO 32
ACO 32
ACO Definitions eClinicalWorks Data Points
Denominator All patients aged
18 years and older
with a diagnosis of
coronary artery
disease seen within
a 12 month period
No eClinicalWorks setup required.
ICD Codes: 410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20,
410.21, 410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42,
410.50, 410.51, 410.52, 410.60, 410.61, 410.62, 410.70, 410.71,
410.72, 410.80, 410.81, 410.82, 410.90, 410.91, 410.92, 411, 411.1,
411.81, 411.89, 412, 413, 413.1, 413.9, 414, 414.01, 414.02, 414.03,
414.04, 414.05, 414.06, 414.07, 414.2, 414.3, 414.8, 414.9, V45.81,
V45.82
CPT* Codes: 33140, 33510, 33511, 33512, 33513, 33514, 33516,
33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535,
33536, 92980, 92981, 92982, 92984, 92995, 92996
Note: The denominator is satisfied by recording an ICD code or a
CPT code.
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 38
ACO Setup ACO 32
Numerator Patients who have
an LDL‐C result
<100 mg/dL OR
patients who have
an LDL‐C result
>=100 mg/dL AND
have a
documented plan
of care to achieve
LDL‐C <100 mg/dL,
including at a
minimum the
prescription of a
statin
Setup Requirements:
Map one of the following LOINC codes to the LDL‐C lab
attribute: 2089‐1, 2090‐9, 2091‐7, 2092‐5, 2569‐2, 3046‐0,
3047‐8, 12773‐8, 13457‐7, 13458‐5, 14155‐6, 16615‐7, 16616‐
5, 18261‐8, 18262‐6, 22748‐8, 24331‐1, 25371‐6, 35198‐1,
35199‐9, 39469‐2, 39229‐0, 49132‐4, 55440‐2
Map the following LOINC codes to the Total Cholesterol lab
attribute: 14647‐2, 2093‐3
Map the following LOINC codes to the Triglycerides lab
attribute: 12951‐0, 14927‐8, 2571‐8, 47210‐0
Map the following LOINC codes to the HDL lab attribute:
14646‐4, 18263‐4, 2085‐9
Structured data in Preventive Medicine > Intervention/High
Risk > Coronary Artery Disease: Lipid Control > Plan of care to
bring LDL‐C under control > (Data Type: Structured ‐
multiselect):
Discussed lifestyle modification(s) (diet and exercise)
Scheduled re‐assessment of LDL‐C
Medications: Statins
IMPORTANT! The documented plan of care MUST include, at a
minimum, the prescription of a Statin medication. It may also
include the documentation of lifestyle modifications or a scheduled
reassessment of LDL‐C.
Note: The LDL‐C lab should be ordered during the reporting period.
Lab results must be entered in the yellow grid on the Lab Results
window and the Received box must be checked.
IMPORTANT! Do not enter special characters in the results field.
Only numbers and mg/dL are recognized by the system when
calculating measure compliance.
Note: The numerator is satisfied by recording a lab and, if
applicable, a statin medication and/or structured data.
IMPORTANT! All four components of LDL, Total Cholesterol, HDL,
and Triglycerides must be linked to a corresponding LOINC code and
their values entered into the Lab Result window to satisfy this
measure.
ACO Definitions eClinicalWorks Data Points
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 39
ACO Setup ACO 32
Exclusions Documentation of
medical, patient, or
system reason(s)
for not prescribing
statin therapy (e.g.,
allergy, intolerance
to statin
medication(s),
other medical
reasons; patient
declined; financial
reasons, etc.)
No eClinicalWorks setup required.
Note: Exclusions
only apply if the
patient was not
prescribed statin
therapy.
CPT II Codes: 4013F‐1P ‐ Documentation of medical reason(s) for
statin therapy not prescribed or currently being taken
4013F‐2P ‐ Documentation of patient reason(s) for statin therapy
not prescribed or currently being taken
4013F‐3P ‐ Documentation of system reason(s) for statin therapy
not prescribed or currently being taken
*. CPT copyright 2012 American Medical Association. All rights reserved.
ACO Definitions eClinicalWorks Data Points
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 40
ACO Setup ACO 33
ACO 33
ACO Definitions eClinicalWorks Data Points
Denominator All patients aged 18
years and older with a
diagnosis of coronary
artery disease seen
within a 12 month
period who also have a
current or prior LVEF
<40%
OR
All patients aged 18
years and older with a
diagnosis of coronary
artery disease seen
within a 12 month
period who also have a
diagnosis of diabetes
Setup Requirements:
Structured data in HPI > Echocardiogram > Left ventricular
assessment > Result (%) > (Data Type: Number)
ICD Codes: 410.00, 410.01, 410.02, 410.10, 410.11, 410.12,
410.20, 410.21, 410.22, 410.30, 410.31, 410.32, 410.40,
410.41, 410.42, 410.50, 410.51, 410.52, 410.60, 410.61, 410.62,
410.70, 410.71, 410.72, 410.80, 410.81, 410.82, 410.90,
410.91, 410.92, 411, 411.1, 411.81, 411.89, 412, 413, 413.1,
413.9, 414, 414.01, 414.02, 414.03, 414.04, 414.05, 414.06,
414.07, 414.2, 414.3, 414.8, 414.9, V45.81, V45.82, 250.00,
250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20,
250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40,
250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60,
250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80,
250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93,
CPT* Codes: 33140, 33510, 33511, 33512, 33513, 33514,
33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533,
33534, 33535, 33536, 92980, 92981, 92982, 92984, 92995,
92996, 78414, 78451, 78452, 78453, 78454, 78468, 78472,
78473, 78481, 78483, 78494, 78496, 93303, 93304, 93306,
93307, 93308, 93312, 93313, 93314, 93315, 93317, 93350,
93351, 93352, 93452, 93453, 93458, 93459, 93460, 93461
HCPCS Codes: G8934 ‐ Left Ventricular Ejection Fraction (LVEF)
<40% or documentation of moderately or severely depressed
left ventricular systolic function
G8923 ‐ Left Ventricular Ejection Fraction (LVEF) <40% or
documentation of moderately or severely depressed left
ventricular systolic function
Note: The denominator can be satisfied using any of the
following methods:
record structured data and an ICD or CPT code
record an ICD or CPT code and a HCPCs Code
record an ICD or CPT code
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 41
ACO Setup ACO 33
Numerator Patients who were
prescribed ACE inhibitor
or ARB therapy
No eClinicalWorks setup required.
Exclusions Documentation of
medical, patient, or
system reason(s) for not
prescribing ACE or ARB
therapy (e.g., allergy,
intolerance, patient
declined, lack of drug
availability, etc.)
No eClinicalWorks setup required.
Note: Exclusions only
apply if the patient was
not prescribed ACE or
ARB therapy.
ICD Codes: 395.0, 395.2, 396.0, 396.2, 396.8, 403.01, 403.11,
403.91, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93, 440.1,
584.5, 584.6, 584.7, 584.8, 584.9, 585.1, 585.2, 585.3, 585.4,
585.5, 585.6, 586, 440.0, 747.22, 788.5, V56.0, V56.8, 39.95,
54.98, 249.00, 249.01, 249.10, 249.11, 249.20, 249.21, 249.30,
249.31, 249.40, 249.41, 249.50, 249.51, 249.60, 249.61, 249.70,
249.71, 249.80, 249.81, 249.90, 249.91, 251.8, 256.4, 648.80,
648.81, 648.82, 648.83, 648.84, 962.0, Pregnancy Dx codes
CPT II Codes: 4010F‐1P ‐ ACE/ARB therapy not prescribed or
being currently taken, medical reason
4010F‐2P ‐ ACE/ARB therapy not prescribed or being currently
taken, patient reason
4010F‐3P ‐ ACE/ARB therapy not prescribed or being currently
taken, system reason
*. CPT copyright 2012 American Medical Association. All rights reserved.
ACO Definitions eClinicalWorks Data Points
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 42
© Copyright eClinicalWorks, November 2013 ‐ Accountable Care Organization Quick‐Reference Setup Guide 43
APPENDIX A: NOTICES
TrademarkseClinicalWorks®
eClinicalWorks is a registered trademark of eClinicalWorks, LLC. All other trademarks or service marks
contained herein are the property of their respective owners.
LOINC®
LOINC is a registered trademark
CopyrightCPT Copyright Notice
CPT only © 2012 American Medical Association. All rights reserved.
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 AMA assumes no liability for
data contained or not contained herein.
CPT® is a registered trademark of the American Medical Association