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CMS 122 - Diabetes: Hemoglobin A1c (HbA1c) Poor Control (9.0%)

Updated: 05/16/2024|Views: 4008

CMS 122 / Quality ID #001

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.

Denominator: Patients 18-75 years of age by the end of the measurement period, with diabetes with a visit during the measurement period.
  • Patient’s age is calculated based on the patient’s Date of Birth, which was entered when you created the patient’s account.
  • Create a note detailing the patient’s office visit.
  • The diagnosis of "Diabetes" is entered in the patient’s Problems with a Start Date.
Denominator Exclusions: Exclude patients who are in hospice care for any part of the measurement period.
  • Hospice is documented under Hospice in History. These patients will be excluded from the denominator.

Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period.

  • Long Term Care is documented under Long Term Care Facility in History. These patients will be excluded from the denominator.
  • Patient’s age is calculated based on the patient’s Date of Birth.

Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advance illness criteria:

  1. Advanced illness with two outpatient encounters during the measurement period or the year prior, OR
  2. Advanced illness with one inpatient encounter during the measurement period or the year prior, OR
  3. Taking dementia medications during the measurement period or the year prior
  • Patient’s age is calculated based on the patient’s Date of Birth.
  • "Advanced Illness" and "Frailty" is documented under Problems with a Start Date.
  • “Dementia Medications” are documented under Medications.

Exclude patients receiving palliative care for any part of the measurement period.

  • Palliative Care is documented under Problems with a Start Date.
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.
  • An order for a "Hemoglobin A1c" needs to be created under Labs/Studies and provided to the patient via paper or submitted via eLabs.
  • The clinician will have to sign the results when received. If results are not received via eLabs, the results will have to be manually added on the order created in Labs/Studies.
  • Hemoglobin results > 9.0%, these patients will be included in the numerator.
Office Visit Documentation:

Once all steps have been completed, the measure will be added to the Quality Measures Report.

Measure type: Outcome
High Priority Measure: Yes
Telehealth Eligible: Yes
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