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

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## Overview [CMS122v12](https://medicalcodify.com/eh/?f=layoutnouser&func=&module=&tabmodule=&name=RXDBmain&searchterm=cms122&showresult=CMS122v12&showresulttype=Measure) (2024) [CMS122v11](https://medicalcodify.com/eh/?f=layoutnouser&func=&module=&tabmodule=&name=RXDBmain&searchterm=cms122&showresult=CMS122v11&showresulttype=Measure) (2023) [CMS122v10](https://medicalcodify.com/eh/?f=layoutnouser&func=&module=&tabmodule=&name=RXDBmain&searchterm=cms122&showresult=CMS122v10&showresulttype=Measure) (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
  • 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.
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](../../../order-and-result-management/observation-code-merging.md). ### 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 a. Palliative Care b. Hospice Care c. 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) [eCQI CMS122](https://ecqi.healthit.gov/ecqm/ep/2024/cms122v12)

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Published: September 5, 2024