CMS 122 - Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

Overview

CMS122v12 (2024)

CMS122v11 (2023)

CMS122v10 (2022)

Identifiers

CMS eCQM IDNQF eCQM IDNQFMIPS Quality ID
CMS122v120059001

*MIE only supports data collection and reporting using eCQM specifications

Definitions

DescriptionPercentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
Initial Patient PopulationPatients 18-75 years of age by the end of the measurement period, with diabetes with a visit during the measurement period
DenominatorEquals Initial Population
Denominator Exclusions
  • Exclude patients who are in hospice care for any part of the measurement period.
  • Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period.
  • Exclude patients 66 and older with an indication of frailty for any part of the measurement period who meet any of the following criteria:
    • Advanced illness with two outpatient encounters during the measurement period or the year prior
    • Advanced illness with one inpatient encounter during the measurement period or the year prior
    • Taking dementia medications during the measurement period or the year prior
  • Exclude patients receiving palliative care during the measurement period.
NumeratorPatients whose most recent HbA1c level (performed during the measurement period) is >9.0% or is missing, or was not performed during the measurement period.
Numerator Exclusions
Denominator Exceptions

Additional Information

Measure TypeIntermediate Outcome measure
Measure ScoringProportion measure
GranularityPatient
Improvement NotationLower score indicates better quality
DomainEffective Clinical Care

Clinical Instructions

Track the HbA1c of all diabetic patients between the ages of 18-75. The most recently performed HbA1c during the measurement period should be <=9.0%. Laboratory screening tests will be recorded as observations with results either manually entered or received from a laboratory interface. Any patients with an HbA1c >9% will be included in the numerator and count against quality. This is an inverse measure. The goal is to NOT have patients in the numerator

Regardless of how the HbA1c observation is added to the chart, clients will need to ensure that the appropriate observation is configured with one of the following LOINC codes: 4548-4, 4549-2, or 17856-6.  Clients should search the Observation Codes editor for the Hemoglobin A1c observation to determine if multiple HbA1c observations need to be merged.

Numerator Compliance

Workflow A

  1. To document a known test and result while documenting the Visit encounter, open the Tests and Procedures section
  2. Search for the appropriate screening test (2.16.840.1.113883.3.464.1003.198.12.1013)
  3. Click Add to Exam
  4. Open the newly added test section and record the test result
  5. Complete the test and close the section
  6. Continue documenting the encounter, as appropriate
  7. When completed, Close and Archive the encounter

Workflow B

  1. To order a future test while documenting the Visit encounter, open the Visit Orders section
  2. Search for the appropriate screening test (2.16.840.1.113883.3.464.1003.198.12.1013)
  3. Click Add
  4. Close the Visit Orders section
  5. Continue documenting the encounter, as appropriate
  6. When completed, Close and Archive the encounter
  7. The order added during the encounter MUST be resulted and completed with an appropriately coded observation in order to meet numerator compliance

Denominator Exclusion Compliance

Workflow A

  1. Use the Long-Term, Chronic, and End of Life Care instructions to document one or more of the following
    1. Palliative Care
    2. Hospice Care
    3. Frailty Device Use

Evidence

Initial Patient Population

NameValue Set
Diagnosis: Diabetes2.16.840.1.113883.3.464.1003.103.12.1001
Encounter, Performed: Annual Wellness Visit2.16.840.1.113883.3.526.3.1240
Encounter, Performed: Home Healthcare Services2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed: Office Visit2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed: Telephone Visits2.16.840.1.113883.3.464.1003.101.12.1080

Denominator Exclusions

NameValue Set
Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)LOINC Code 71007-9
Device, Applied: Frailty Device2.16.840.1.113883.3.464.1003.118.12.1300
Device, Order: Frailty Device2.16.840.1.113883.3.464.1003.118.12.1300
Diagnosis: Frailty Diagnosis2.16.840.1.113883.3.464.1003.113.12.1074
Encounter, Performed: Acute Inpatient2.16.840.1.113883.3.464.1003.101.12.1083
Encounter, Performed: Care Services in Long-Term Residential Facility2.16.840.1.113883.3.464.1003.101.12.1014
Encounter, Performed: Emergency Department Visit2.16.840.1.113883.3.464.1003.101.12.1010
Encounter, Performed: Encounter Inpatient2.16.840.1.113883.3.666.5.307
Encounter, Performed: Frailty Encounter2.16.840.1.113883.3.464.1003.101.12.1088
Encounter, Performed: Nonacute Inpatient2.16.840.1.113883.3.464.1003.101.12.1084
Encounter, Performed: Nursing Facility Visit2.16.840.1.113883.3.464.1003.101.12.1012
Encounter, Performed: Observation2.16.840.1.113883.3.464.1003.101.12.1086
Encounter, Performed: Outpatient2.16.840.1.113883.3.464.1003.101.12.1087
Encounter, Performed: Palliative Care Encounter2.16.840.1.113883.3.464.1003.101.12.1090
Intervention, Order: Hospice care ambulatory2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Hospice care ambulatory2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Palliative Care Intervention2.16.840.1.113883.3.464.1003.198.12.1135
Medication, Active: Dementia Medications2.16.840.1.113883.3.464.1003.196.12.1510
Symptom: Frailty Symptom2.16.840.1.113883.3.464.1003.113.12.1075

Numerator

NameValue Set
Laboratory Test, Performed: HbA1c Laboratory Test2.16.840.1.113883.3.464.1003.198.12.1013

Source(s)

eCQI CMS122


WebChart Documentation

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