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

Medical Codify

CMS122v5 (2017)

CMS122v6 (2018)

CMS122v7 (2019)

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 with diabetes with a visit during the measurement period.

Denominator:  Equals Initial Population

Numerator: Patients whose most recent HbA1c level (performed during the measurement period) is >9.0%.

Inverse Measure:  Yes

Clinical Instructions

Track all patients between the ages of 18-75 whose most recent HbA1c level, performed during the measurement period, is >9.0%. Use either the Test and Procedures section of the encounter, or add the Lab Results - Set 1 to the encounter template. 

Regardless of how the HbA1c observation is added to the chart, clients will need to ensure that the appropriate observation is configured with LOINC 17856-6.  Clients should search the Observation Codes editor for the Hemoglobin A1c observation to determine if multiple HbA1c observations need to be merged.
  • While documenting the Visit encounter, document the results of the HbA1c one of two ways:
    • Option 1: Test and Procedures Section
      • Open the Tests and Procedures section.
      • Using the autocomplete, begin typing Hemoglobin A1c.
      • Click the Add to Exam button.
      • After adding the new section, open the Hemoglobin A1c section and add the result.
      • Click the Next button, or close the section.
    • Option 2: Add Lab Results - Set 1 to Encounter
      • Click the Tools icon in the upper-right corner of the encounter.
      • Click the Lab Results - Set 1 header to add the section to the encounter template. Close the Tools window.
      • Click the Lab Results - Set 1 header to open the section and add the result.
      • Click the Next button, or close the section.
  • Continue documenting the encounter, as needed.
  • When completed, Close and Archive the encounter.


Initial Patient Population

Name Value Set
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
Diagnosis: Diabetes 2.16.840.1.113883.3.464.1003.103.12.1001


Equals Initial Population


Name Value Set
Laboratory Test, Performed: HbA1c Laboratory Test 2.16.840.1.113883.3.464.1003.198.12.1013

Denominator Exclusion

Name Value Set
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


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Last Build: Wed, 29 Jun 2022 23:36:02 EDT Legacy Documentation