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

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eCQMs for 2020 Performance Period

CMS2v9
CMS22v8
CMS50v8
CMS56v8
CMS66v8
CMS68v9
CMS69v8
CMS74v9
CMS75v8
CMS90v9
CMS117v8
CMS122v8
CMS124v8
CMS125v8
CMS127v8
CMS128v8
CMS129v9
CMS130v8
CMS131v8
CMS133v8
CMS134v8
CMS135v8
CMS136v9
CMS137v8
CMS138v8
CMS139v8
CMS142v8
CMS143v8
CMS144v8
CMS145v8
CMS146v8
CMS147v9
CMS149v8
CMS153v8
CMS154v8
CMS155v8
CMS156v8
CMS157v8
CMS159v8
CMS161v8
CMS165v8
CMS177v8
CMS249v2
CMS347v3
CMS349v2
CMS645v3
CMS771v1
Specifications
Attachment Size
CMS122v8.html 64.96 KB
CMS122v8.zip 87.29 KB
CMS122v8-TRN.xlsx 23.24 KB

Data Element Repository

General eCQM Information

CMS Measure ID CMS122v8
NQF Number Not Applicable
Measure Description

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
Initial Population Patients 18-75 years of age with diabetes with a visit during the measurement period
Denominator Statement

Equals Initial Population
Denominator Exclusions

Exclude patients whose hospice care overlaps the measurement period.

Exclude patients 66 and older who are living long term in an institution for more than 90 days during the measurement period.

Exclude patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured.
Numerator Statement

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

Not Applicable
Denominator Exceptions

None
Measure Steward National Committee for Quality Assurance
Domain Effective Clinical Care
Measure Scoring Proportion measure
Measure Type Outcome measure
Improvement Notation

Lower score indicates better quality
Guidance

Patient is numerator compliant if most recent HbA1c level >9%, the most recent HbA1c result is missing, or if there are no HbA1c tests performed and results documented during the measurement period. If the HbA1c test result is in the medical record, the test can be used to determine numerator compliance.

Only patients with a diagnosis of Type 1 or Type 2 diabetes should be included in the denominator of this measure; patients with a diagnosis of secondary diabetes due to another condition should not be included.
Quality ID 1
Meaningful Measure Management of Chronic Conditions
Telehealth Eligible Yes
Next Version
CMS122v9
Previous Version
CMS122v7
Release Notes

Header

  • Updated eCQM version number.

    Measure Section: eCQM Version number

    Source of Change: Measure Lead

  • Updated NQF number to 'Not Applicable.'

    Measure Section: NQF Number

    Source of Change: Standards Update

  • Updated endorsed by field to 'None.'

    Measure Section: Endorsed By

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated rationale.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated clinical recommendation statement.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated denominator exclusions statement with addition of patients 66 years of age and older who are living in a long-term institutional setting, such as a nursing home, for more than 90 days in the measurement period to align with the HEDIS parent measure exclusion.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated denominator exclusions statement with addition of patients with advanced illness and frailty because it is unlikely that patients will need the services being measured.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Revised logic to include new exclusion for patients with advanced illness and frailty. The new logic excludes patients who are 80 or older, use of frailty devices, dementia medications and encounters with diagnosis of advance illness encompassing the measurement period or encounter.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Revised logic to include new exclusion for patients 66 years of age and older who are living in a long-term institutional setting, such as a nursing home, for more than 90 days in the measurement period to align with the HEDIS parent measure exclusion.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated the sort order for the most recent HBA1c to the end of the relevant period to ensure only the last test is being evaluated.​​

    Measure Section: Numerator

    Source of Change: ONC Project Tracking System (JIRA): CQM-3186

  • Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Added new CQL library with advanced illness and frailty exclusion definitions (AdvancedIllnessandFrailtyExclusionECQM-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Adult_Outpatient_Encounters Library (Adult_Outpatient_Encounters-1.2.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated version number of the Hospice Library (Hospice-2.0.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1772) including 2 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001): Added 32 SNOMED CT codes and deleted 69 SNOMED CT codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083): Added Acute Inpatient.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Advanced Illness (2.16.840.1.113883.3.464.1003.110.12.1082): Added Advanced Illness.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Nonacute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1084): Added Nonacute Inpatient.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set ED (2.16.840.1.113883.3.464.1003.101.12.1085): Added ED.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Observation (2.16.840.1.113883.3.464.1003.101.12.1086): Added Observation.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Outpatient (2.16.840.1.113883.3.464.1003.101.12.1087): Added Outpatient.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300): Added Frailty Device.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Frailty Encounter (2.16.840.1.113883.3.464.1003.101.12.1088): Added Frailty Encounter.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Frailty Symptom (2.16.840.1.113883.3.464.1003.113.12.1075): Added Frailty Symptom.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Frailty Diagnosis (2.16.840.1.113883.3.464.1003.113.12.1074): Added Frailty Diagnosis.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Dementia Medications (2.16.840.1.113883.3.464.1003.196.12.1510): Added Dementia Medications.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012): Added Nursing Facility Visit.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Care Services in Long-Term Residential Facility (2.16.840.1.113883.3.464.1003.101.12.1014): Added Care Services in Long-Term Residential Facility.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Removed code system versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measure Logic and Implementation Guidance document for a list of code system versions used in the eCQM specifications for 2020 reporting/performance.

    Measure Section: Terminology

    Source of Change: Standards Update

  • Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001): Deleted three extensional value sets (2.16.840.1.113883.3.464.1003.103.11.1001 (ICD-9-CM), 2.16.840.1.113883.3.464.1003.103.11.1002 (ICD-10-CM), and 2.16.840.1.113883.3.464.1003.103.11.1003 (SNOMED CT)). Added eight extensional value sets (2.16.840.1.113883.3.464.1003.103.11.1025 (ICD-9-CM), 2.16.840.1.113883.3.464.1003.103.11.1026 (ICD-10-CM), 2.16.840.1.113883.3.464.1003.103.11.1027 (SNOMED CT), 2.16.840.1.113883.3.464.1003.103.11.1030 (SNOMED CT), 2.16.840.1.113883.3.464.1003.103.11.1031 (ICD-10-CM), 2.16.840.1.113883.3.464.1003.103.11.1032 (ICD-10-CM), 2.16.840.1.113883.3.464.1003.103.11.1033 (ICD-9-CM), 2.16.840.1.113883.3.464.1003.103.11.1034 (ICD-9-CM)).

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 01, 2020