2025 HCPR28 Heart Failure (HF): SGLT-2 Inhibitor Therapy for Left Ventricular Systolic Dysfunction (LVSD) 

Denominator: Any patient aged 18 years or older evaluated by the Eligible Professional in Inpatient or PostAcute Care setting (E/M Codes 99238, 99239, 99234-99236, 99304-99310, 99315, 99316 and
Place of Service indicators 02, 21 or 31 OR equivalent in standardized code sets)
AND
• Diagnosis for heart failure (ICD-10-CM): I11.0, I13.0, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23,
I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.814, I50.82, I50.83, I50.84,
I50.89, I50.9
AND
• Left ventricular ejection fraction (LVEF) less than or equal to 40% or documentation of
moderately or severely depressed left ventricular systolic function: M1150

DENOMINATOR NOTE: LVEF ≤ 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction. The LVSD may be determined by quantitative or qualitative assessment, which may be current or historical.
Examples of a quantitative or qualitative assessment may include an echocardiogram:
1) that provides a numerical value of LVSD or
2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD. To meet the denominator criteria, a patient must have an active diagnosis of with HFrEF with or without Type 2 Diabetes encounter which is used to qualify for the denominator and evaluate the numerator. The encounter used to evaluate the numerator counts as 1 of the 2 encounters required for denominator inclusion. If the patient meets the HFrEF with or without Type 2 Diabetes diagnosis criterion, the diagnosis needs to be active only at the encounter being evaluated for the numerator action.

*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS) can be used to identify patients

Denominator Exclusions:

• Transferred, eloped, AMA, or expired patients are excluded (V0704)
• Discharged to hospice
• Patients with history of heart transplant or with a Left Ventricular Assist Device (LVAD) (M1151)
• Diabetic Ketoacidosis (DKA)
• Type 1 diabetes

Numerator: Adult patients Who Were Prescribed or Currently Taking SGLT-2 Inhibitor Therapy During SNF Stay
or at Time of Hospital Discharge

• Performance Met (VH275): SGLT-2 Inhibitor was prescribed or being taken
• Medical Performance Exclusion (Denominator Exception) (VH276): Documented medical
  reason for not prescribing SGLT-2 Inhibitor (e.g., hypoglycemia, allergy intolerance, fungal
  infection, renal failure, current UTI, LVEF not available)
• Performance Not Met (VH277): SGLT-2 Inhibitor was neither prescribed nor active – Reason not given

Note: The numerator action applies per performance year. Once an SGLT-2 inhibitor has been identified as
either a current medication, or is ordered, subsequent visits within the performance year do not need to be
repeated to meet the measure. The evaluation of the numerator can be done anytime during the
hospitalization or SNF stay, however certain CPT codes may only be applicable to discharge encounters.