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

Overview

CMS122v8 (2020)
CMS122v9 (2021)
CMS122v10 (2022)

Identifiers

CMS eCQM ID	NQF eCQM ID	NQF	MIPS Quality ID
CMS122v10	–	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 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%. Any patients with an HbA1c >9% will be included in the numerator and count against quality. Use either the preferred Preventive Care section or the alternate Test and Procedures or Lab Results - Set 1 sections of the encounter. 

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 .

Preferred Workflow

1. Preventive Care
2. Order A1c
   1. Add to exam - enter result
   2. Interfaced result completes the order
   3. Manually result
      1. Ordering doc->Add result->complete results encounter

Alternate Workflow

1. While documenting the Visit encounter, document the results of the HbA1c one of two ways:
   1. Option 1: Test and Procedures Section
      1. Open the Tests and Procedures section.
      2. Using the autocomplete, begin typing Hemoglobin A1c.
      3. Click the Add to Exam button.
      4. After adding the new section, open the Hemoglobin A1c section and add the result.
      5. Click the Next button, or close the section.
   2. Option 2: Add Lab Results - Set 1 to Encounter
      1. Click the Tools icon in the upper-right corner of the encounter.
      2. Click the Lab Results - Set 1 header to add the section to the encounter template. Close the Tools window.
      3. Click the Lab Results - Set 1 header to open the section and add the result.
      4. Click the Next button, or close the section.
2. Continue documenting the encounter, as needed.
3. When completed, Close and Archive the encounter.

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