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

Overview

CMS122v12 (2024)

CMS122v11 (2023)

CMS122v10 (2022)

Identifiers

*MIE only supports data collection and reporting using eCQM specifications

Definitions

Additional Information

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

Denominator Exclusions

Numerator

Source(s)

eCQI CMS122