CMS 122 - Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
Covered by this topic
Overview
CMS122v12 (2024)
CMS122v11 (2023)
CMS122v10 (2022)
Identifiers
CMS eCQM ID | NQF eCQM ID | NQF | MIPS Quality ID |
CMS122v12 | – | 0059 | 001 |
*MIE only supports data collection and reporting using eCQM specifications
Definitions
Description | Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period |
Initial Patient Population | Patients 18-75 years of age by the end of the measurement period, with diabetes with a visit during the measurement period |
Denominator | Equals Initial Population |
Denominator Exclusions |
|
Numerator | Patients 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 Type | Intermediate Outcome measure |
Measure Scoring | Proportion measure |
Granularity | Patient |
Improvement Notation | Lower score indicates better quality |
Domain | Effective 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
- To document a known test and result while documenting the Visit encounter, open the Tests and Procedures section
- Search for the appropriate screening test (2.16.840.1.113883.3.464.1003.198.12.1013)
- Click Add to Exam
- Open the newly added test section and record the test result
- Complete the test and close the section
- Continue documenting the encounter, as appropriate
- When completed, Close and Archive the encounter
Workflow B
- To order a future test while documenting the Visit encounter, open the Visit Orders section
- Search for the appropriate screening test (2.16.840.1.113883.3.464.1003.198.12.1013)
- Click Add
- Close the Visit Orders section
- Continue documenting the encounter, as appropriate
- When completed, Close and Archive the encounter
- 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
- Use the Long-Term, Chronic, and End of Life Care instructions to document one or more of the following
- Palliative Care
- Hospice Care
- Frailty Device Use
Evidence
Initial Patient Population
Name | Value Set |
Diagnosis: Diabetes | 2.16.840.1.113883.3.464.1003.103.12.1001 |
Encounter, Performed: Annual Wellness Visit | 2.16.840.1.113883.3.526.3.1240 |
Encounter, Performed: Home Healthcare Services | 2.16.840.1.113883.3.464.1003.101.12.1016 |
Encounter, Performed: Office Visit | 2.16.840.1.113883.3.464.1003.101.12.1001 |
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up | 2.16.840.1.113883.3.464.1003.101.12.1025 |
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up | 2.16.840.1.113883.3.464.1003.101.12.1023 |
Encounter, Performed: Telephone Visits | 2.16.840.1.113883.3.464.1003.101.12.1080 |
Denominator Exclusions
Name | Value Set |
Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal) | LOINC Code 71007-9 |
Device, Applied: Frailty Device | 2.16.840.1.113883.3.464.1003.118.12.1300 |
Device, Order: Frailty Device | 2.16.840.1.113883.3.464.1003.118.12.1300 |
Diagnosis: Frailty Diagnosis | 2.16.840.1.113883.3.464.1003.113.12.1074 |
Encounter, Performed: Acute Inpatient | 2.16.840.1.113883.3.464.1003.101.12.1083 |
Encounter, Performed: Care Services in Long-Term Residential Facility | 2.16.840.1.113883.3.464.1003.101.12.1014 |
Encounter, Performed: Emergency Department Visit | 2.16.840.1.113883.3.464.1003.101.12.1010 |
Encounter, Performed: Encounter Inpatient | 2.16.840.1.113883.3.666.5.307 |
Encounter, Performed: Frailty Encounter | 2.16.840.1.113883.3.464.1003.101.12.1088 |
Encounter, Performed: Nonacute Inpatient | 2.16.840.1.113883.3.464.1003.101.12.1084 |
Encounter, Performed: Nursing Facility Visit | 2.16.840.1.113883.3.464.1003.101.12.1012 |
Encounter, Performed: Observation | 2.16.840.1.113883.3.464.1003.101.12.1086 |
Encounter, Performed: Outpatient | 2.16.840.1.113883.3.464.1003.101.12.1087 |
Encounter, Performed: Palliative Care Encounter | 2.16.840.1.113883.3.464.1003.101.12.1090 |
Intervention, Order: Hospice care ambulatory | 2.16.840.1.113762.1.4.1108.15 |
Intervention, Performed: Hospice care ambulatory | 2.16.840.1.113762.1.4.1108.15 |
Intervention, Performed: Palliative Care Intervention | 2.16.840.1.113883.3.464.1003.198.12.1135 |
Medication, Active: Dementia Medications | 2.16.840.1.113883.3.464.1003.196.12.1510 |
Symptom: Frailty Symptom | 2.16.840.1.113883.3.464.1003.113.12.1075 |
Numerator
Name | Value Set |
Laboratory Test, Performed: HbA1c Laboratory Test | 2.16.840.1.113883.3.464.1003.198.12.1013 |
Source(s)
WebChart Documentation
Last Updated:
Last Build:
Thu, 05 Dec 2024 18:17:23 UTC
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