eCQM Title | # Diabetes: Eye Exam
eCQM Identifier (Measure Authoring Tool) | 131 | eCQM Version Number | 12.0.000
NQF Number | Not Applicable | GUID | d90bdab4-b9d2-4329-9993-5c34e2c0dc66
Measurement Period | January 1, 20XX through December 31, 20XX
Measure Steward | National Committee for Quality Assurance
Measure Developer | National Committee for Quality Assurance
Endorsed By | None
Description |
    Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period
Copyright |
    This Physician Performance Measure (Measure) and related data specifications are owned and were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2022 National Committee for Quality Assurance. All Rights Reserved.

    Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third-party codes contained in the specifications.

    CPT(R) codes, descriptions and other data are copyright 2022. American Medical Association. All rights reserved. CPT is a trademark of the American Medical Association. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

    LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc.

    This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation.

    ICD-10 copyright 2022 World Health Organization. All Rights Reserved.
Disclaimer |
    The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

    Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Measure Scoring | Proportion
Measure Type | Process
Stratification |
    None
Risk Adjustment |
    None
Rate Aggregation |
    None
Rationale |
    Diabetes is the seventh leading cause of death in the United States (Centers for Disease Control and Prevention [CDC], 2022a). In 2019, diabetes affected more than 37 million Americans (11.3 percent of the U.S. population) and killed more than 87,000 people (American Diabetes Association [ADA], 2022a). Diabetes is a long-lasting disease marked by high blood glucose levels, resulting from the body's inability to produce or use insulin properly (CDC, 2022a). People with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney damage, amputation of feet or legs, and premature death (CDC, 2022b).

    In 2017, diabetes cost the U.S. an estimated $327 billion: $237 billion in direct medical costs and $90 billion in reduced productivity. This is a 34 percent increase from the estimated $245 billion spent on diabetes in 2012 (ADA, 2018).

    Diabetic retinopathy is progressive damage to the small blood vessels in the retina that may result in loss of vision. It is the leading cause of blindness in adults between 20-74 years of age. Approximately 4.1 million adults are affected by diabetic retinopathy (CDC, 2020).
Clinical Recommendation Statement |
    American Diabetes Association (2022b):

    - Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. (Level of evidence: B)

    - Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis. (Level of evidence: B)

    - If there is no evidence of retinopathy for one or more annual eye exam and glycemia is well controlled, then screening every 1–2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist. If retinopathy is progressing or sight threatening, then examinations will be required more frequently. (Level of evidence: B)
Improvement Notation |
    Higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'American Diabetes Association. (2018). Economic Costs of Diabetes in the U.S. in 2017. Diabetes Care, 41, 917-928. Retrieved from http://care.diabetesjournals.org/content/early/2018/03/20/dci18-0007'
Reference |
    Reference Type: CITATION
    Reference Text: 'American Diabetes Association. (2022a). Statistics About Diabetes. Retrieved from https://diabetes.org/about-us/statistics/about-diabetes'
Reference |
    Reference Type: CITATION
    Reference Text: 'American Diabetes Association. (2022b). 12. Retinopathy, neuropathy, and foot care: Standards of Medical Care in Diabetes–2022. Diabetes Care 2022; 45(Suppl. 1):S185–S194. https://doi.org/10.2337/dc22-S012'
Reference |
    Reference Type: CITATION
    Reference Text: 'Centers for Disease Control and Prevention. (2020). Common Eye Disorders and Diseases. Retrieved from https://www.cdc.gov/visionhealth/basics/ced/index.html'
Reference |
    Reference Type: CITATION
    Reference Text: 'Centers for Disease Control and Prevention. (2022a). What is Diabetes? Retrieved from https://www.cdc.gov/diabetes/basics/diabetes.html'
Reference |
    Reference Type: CITATION
    Reference Text: 'Centers for Disease Control and Prevention. (2022b). National Diabetes Statistics Report, 2021. US Dept of Health and Human Services. Retrieved from https://www.cdc.gov/diabetes/library/reports/reportcard.html'
Definition |
    None
Guidance |
    The eye exam must be performed by an ophthalmologist or optometrist, or there must be evidence that fundus photography results were read by a system that provides an artificial intelligence (AI) interpretation.

    This eCQM is a patient-based measure.

    This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
Transmission Format |
    TBD
Initial 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 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.

    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 advanced illness criteria:
    - Advanced illness with two outpatient encounters during the measurement period or the year prior
    - OR advanced illness with one inpatient encounter during the measurement period or the year prior
    - OR taking dementia medications during the measurement period or the year prior

    Exclude patients receiving palliative care for any part of the measurement period.
Numerator |
    Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following:
    - Diabetic with a diagnosis of retinopathy in any part of the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period
    - Diabetic with no diagnosis of retinopathy in any part of the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period or the year prior to the measurement period
Numerator Exclusions |
    Not Applicable
Denominator Exceptions |
    None
Supplemental Data Elements |
    For every patient evaluated by this measure also identify payer, race, ethnicity and sex

## Table of Contents

- Population Criteria
- Definitions
- Functions
- Terminology
- Data Criteria (QDM Data Elements)
- Supplemental Data Elements
- Risk Adjustment Variables

### Population Criteria

- - Initial Population

    - -     AgeInYearsAt(date from
              end of "Measurement Period"
            )in Interval[18, 75]
              and exists ( "Qualifying Encounters" )
              and exists ( ["Diagnosis": "Diabetes"] Diabetes
                  where Diabetes.prevalencePeriod overlaps "Measurement Period"
              )

- - Denominator

    - -     "Initial Population"

- - Denominator Exclusions

    - -     Hospice."Has Hospice Services"
              or AIFrailLTCF."Is Age 66 or Older with Advanced Illness and Frailty"
              or AIFrailLTCF."Is Age 66 or Older Living Long Term in a Nursing Home"
              or PalliativeCare."Has Palliative Care in the Measurement Period"

- - Numerator

    - -     ( "Diabetic Retinopathy Overlapping Measurement Period"
                and exists ( "Retinal Exam in Measurement Period" )
            )
              or ( not ( "Diabetic Retinopathy Overlapping Measurement Period" )
                  and exists ( "Retinal Exam in Measurement Period or Year Prior" )
              )

- - Numerator Exclusions

    - -     None

- - Denominator Exceptions

    - -     None

- - Stratification

    - -     None

### Definitions

- - AIFrailLTCF.Has Criteria Indicating Frailty

    - -     exists ( ["Device, Order": "Frailty Device"] FrailtyDeviceOrder
                where FrailtyDeviceOrder.authorDatetime during day of "Measurement Period"
            )
              or exists ( ["Assessment, Performed": "Medical equipment used"] EquipmentUsed
                  where EquipmentUsed.result in "Frailty Device"
                    and Global."NormalizeInterval" ( EquipmentUsed.relevantDatetime, EquipmentUsed.relevantPeriod ) ends during day of "Measurement Period"
              )
              or exists ( ["Diagnosis": "Frailty Diagnosis"] FrailtyDiagnosis
                  where FrailtyDiagnosis.prevalencePeriod overlaps "Measurement Period"
              )
              or exists ( ["Encounter, Performed": "Frailty Encounter"] FrailtyEncounter
                  where FrailtyEncounter.relevantPeriod overlaps "Measurement Period"
              )
              or exists ( ["Symptom": "Frailty Symptom"] FrailtySymptom
                  where FrailtySymptom.prevalencePeriod overlaps "Measurement Period"
              )

  - AIFrailLTCF.Has Dementia Medications in Year Before or During Measurement Period

    - -     exists (["Medication, Active": "Dementia Medications"] DementiaMedication
              where Global."NormalizeInterval" ( DementiaMedication.relevantDatetime, DementiaMedication.relevantPeriod ) overlaps Interval[start of "Measurement Period" - 1 year,
              end of "Measurement Period"])

  - AIFrailLTCF.Has Inpatient Encounter with Advanced Illness

    - -     exists( ["Encounter, Performed": "Acute Inpatient"] InpatientEncounter
              where exists ( InpatientEncounter.diagnoses Diagnosis
                  where Diagnosis.code in "Advanced Illness"
              )
                and InpatientEncounter.relevantPeriod starts during day of Interval[start of "Measurement Period" - 1 year,
                end of "Measurement Period"])

  - AIFrailLTCF.Has Two Outpatient Encounters with Advanced Illness on Different Dates of Service

    - -     exists (
            from
              "Outpatient Encounters with Advanced Illness" OutpatientEncounter1,
              "Outpatient Encounters with Advanced Illness" OutpatientEncounter2
              where OutpatientEncounter2.relevantPeriod ends 1 day or more after day of
              end of OutpatientEncounter1.relevantPeriod
              return OutpatientEncounter1
              )

  - AIFrailLTCF.Is Age 66 or Older Living Long Term in a Nursing Home

    - -     ( AgeInYearsAt(date from
                end of "Measurement Period"
              )>= 66
            )
              and ( ( Last(["Assessment, Performed": "Housing status"] HousingStatus
                    where Global."NormalizeInterval"(HousingStatus.relevantDatetime, HousingStatus.relevantPeriod)ends on or before
                    end of "Measurement Period"
                    sort by
                    end of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)asc
                )) LastHousingStatus
                  where LastHousingStatus.result ~ "Lives in a nursing home (finding)"
              ) is not null

  - AIFrailLTCF.Is Age 66 or Older with Advanced Illness and Frailty

    - -     ( AgeInYearsAt(date from
                end of "Measurement Period"
              )>= 66
                and "Has Criteria Indicating Frailty"
                and ( "Has Two Outpatient Encounters with Advanced Illness on Different Dates of Service"
                    or "Has Inpatient Encounter with Advanced Illness"
                    or "Has Dementia Medications in Year Before or During Measurement Period"
                )
            )

  - AIFrailLTCF.Outpatient Encounters with Advanced Illness

    - -     ( ["Encounter, Performed": "Outpatient"]
              union ["Encounter, Performed": "Observation"]
              union ["Encounter, Performed": "Emergency Department Evaluation and Management Visit"]
              union ["Encounter, Performed": "Nonacute Inpatient"] ) OutpatientEncounter
              where exists ( OutpatientEncounter.diagnoses Diagnosis
                  where Diagnosis.code in "Advanced Illness"
              )
                and OutpatientEncounter.relevantPeriod starts during day of Interval[start of "Measurement Period" - 1 year,
                end of "Measurement Period"]

  - Denominator

    - -     "Initial Population"

  - Denominator Exclusions

    - -     Hospice."Has Hospice Services"
              or AIFrailLTCF."Is Age 66 or Older with Advanced Illness and Frailty"
              or AIFrailLTCF."Is Age 66 or Older Living Long Term in a Nursing Home"
              or PalliativeCare."Has Palliative Care in the Measurement Period"

  - Diabetic Retinopathy Overlapping Measurement Period

    - -     exists ( ["Diagnosis": "Diabetic Retinopathy"] Retinopathy
                where Retinopathy.prevalencePeriod overlaps "Measurement Period"
            )

  - Hospice.Has Hospice Services

    - -     exists ( ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
                where ( InpatientEncounter.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
                    or InpatientEncounter.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
                )
                  and InpatientEncounter.relevantPeriod ends during day of "Measurement Period"
            )
              or exists ( ["Encounter, Performed": "Hospice Encounter"] HospiceEncounter
                  where HospiceEncounter.relevantPeriod overlaps day of "Measurement Period"
              )
              or exists ( ["Assessment, Performed": "Hospice care [Minimum Data Set]"] HospiceAssessment
                  where HospiceAssessment.result ~ "Yes (qualifier value)"
                    and Global."NormalizeInterval" ( HospiceAssessment.relevantDatetime, HospiceAssessment.relevantPeriod ) overlaps day of "Measurement Period"
              )
              or exists ( ["Intervention, Order": "Hospice Care Ambulatory"] HospiceOrder
                  where HospiceOrder.authorDatetime during day of "Measurement Period"
              )
              or exists ( ["Intervention, Performed": "Hospice Care Ambulatory"] HospicePerformed
                  where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps day of "Measurement Period"
              )
            or exists ( ["Diagnosis": "Hospice Diagnosis"] HospiceCareDiagnosis
                  where HospiceCareDiagnosis.prevalencePeriod overlaps day of "Measurement Period"
              )

  - Initial Population

    - -     AgeInYearsAt(date from
              end of "Measurement Period"
            )in Interval[18, 75]
              and exists ( "Qualifying Encounters" )
              and exists ( ["Diagnosis": "Diabetes"] Diabetes
                  where Diabetes.prevalencePeriod overlaps "Measurement Period"
              )

  - Numerator

    - -     ( "Diabetic Retinopathy Overlapping Measurement Period"
                and exists ( "Retinal Exam in Measurement Period" )
            )
              or ( not ( "Diabetic Retinopathy Overlapping Measurement Period" )
                  and exists ( "Retinal Exam in Measurement Period or Year Prior" )
              )

  - PalliativeCare.Has Palliative Care in the Measurement Period

    - -     exists ( ["Assessment, Performed": "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"] PalliativeAssessment
                where Global."NormalizeInterval" ( PalliativeAssessment.relevantDatetime, PalliativeAssessment.relevantPeriod ) overlaps day of "Measurement Period"
            )
              or exists ( ["Diagnosis": "Palliative Care Diagnosis"] PalliativeDiagnosis
                  where PalliativeDiagnosis.prevalencePeriod overlaps day of "Measurement Period"
              )
              or exists ( ["Encounter, Performed": "Palliative Care Encounter"] PalliativeEncounter
                  where PalliativeEncounter.relevantPeriod overlaps day of "Measurement Period"
              )
              or exists ( ["Intervention, Performed": "Palliative Care Intervention"] PalliativeIntervention
                  where Global."NormalizeInterval" ( PalliativeIntervention.relevantDatetime, PalliativeIntervention.relevantPeriod ) overlaps day of "Measurement Period"
              )

  - Qualifying Encounters

    - -     ( ["Encounter, Performed": "Office Visit"]
              union ["Encounter, Performed": "Annual Wellness Visit"]
              union ["Encounter, Performed": "Preventive Care Services Established Office Visit, 18 and Up"]
              union ["Encounter, Performed": "Preventive Care Services Initial Office Visit, 18 and Up"]
              union ["Encounter, Performed": "Home Healthcare Services"]
              union ["Encounter, Performed": "Ophthalmological Services"]
              union ["Encounter, Performed": "Telephone Visits"] ) ValidEncounters
              where ValidEncounters.relevantPeriod during day of "Measurement Period"

  - Retinal Exam in Measurement Period

    - -     ["Physical Exam, Performed": "Retinal or Dilated Eye Exam"] RetinalExam
              where Global."NormalizeInterval" ( RetinalExam.relevantDatetime, RetinalExam.relevantPeriod ) during day of "Measurement Period"

  - Retinal Exam in Measurement Period or Year Prior

    - -     ["Physical Exam, Performed": "Retinal or Dilated Eye Exam"] RetinalExam
              where Global."NormalizeInterval" ( RetinalExam.relevantDatetime, RetinalExam.relevantPeriod ) during day of Interval[start of "Measurement Period" - 1 year,
              end of "Measurement Period"]

  - SDE Ethnicity

    - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

  - SDE Payer

    - -     ["Patient Characteristic Payer": "Payer"]

  - SDE Race

    - -     ["Patient Characteristic Race": "Race"]

  - SDE Sex

    - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Functions

- - Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

    - -     if pointInTime is not null then Interval[pointInTime, pointInTime]
              else if period is not null then period
              else null as Interval<DateTime>

### Terminology

- code "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)")
- code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)")
- code "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" ("LOINC Code (71007-9)")
- code "Hospice care [Minimum Data Set]" ("LOINC Code (45755-6)")
- code "Housing status" ("LOINC Code (71802-3)")
- code "Lives in a nursing home (finding)" ("SNOMEDCT Code (160734000)")
- code "Medical equipment used" ("LOINC Code (98181-1)")
- code "Yes (qualifier value)" ("SNOMEDCT Code (373066001)")
- valueset "Acute Inpatient" (2.16.840.1.113883.3.464.1003.101.12.1083)
- valueset "Advanced Illness" (2.16.840.1.113883.3.464.1003.110.12.1082)
- valueset "Annual Wellness Visit" (2.16.840.1.113883.3.526.3.1240)
- valueset "Dementia Medications" (2.16.840.1.113883.3.464.1003.196.12.1510)
- valueset "Diabetes" (2.16.840.1.113883.3.464.1003.103.12.1001)
- valueset "Diabetic Retinopathy" (2.16.840.1.113883.3.526.3.327)
- valueset "Emergency Department Evaluation and Management Visit" (2.16.840.1.113883.3.464.1003.101.12.1010)
- valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "Frailty Device" (2.16.840.1.113883.3.464.1003.118.12.1300)
- valueset "Frailty Diagnosis" (2.16.840.1.113883.3.464.1003.113.12.1074)
- valueset "Frailty Encounter" (2.16.840.1.113883.3.464.1003.101.12.1088)
- valueset "Frailty Symptom" (2.16.840.1.113883.3.464.1003.113.12.1075)
- valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016)
- valueset "Hospice Care Ambulatory" (2.16.840.1.113883.3.526.3.1584)
- valueset "Hospice Diagnosis" (2.16.840.1.113883.3.464.1003.1165)
- valueset "Hospice Encounter" (2.16.840.1.113883.3.464.1003.1003)
- valueset "Nonacute Inpatient" (2.16.840.1.113883.3.464.1003.101.12.1084)
- valueset "Observation" (2.16.840.1.113883.3.464.1003.101.12.1086)
- valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
- valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
- valueset "Ophthalmological Services" (2.16.840.1.113883.3.526.3.1285)
- valueset "Outpatient" (2.16.840.1.113883.3.464.1003.101.12.1087)
- valueset "Palliative Care Diagnosis" (2.16.840.1.113883.3.464.1003.1167)
- valueset "Palliative Care Encounter" (2.16.840.1.113883.3.464.1003.101.12.1090)
- valueset "Palliative Care Intervention" (2.16.840.1.113883.3.464.1003.198.12.1135)
- valueset "Payer" (2.16.840.1.114222.4.11.3591)
- valueset "Preventive Care Services Established Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1025)
- valueset "Preventive Care Services Initial Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1023)
- valueset "Race" (2.16.840.1.114222.4.11.836)
- valueset "Retinal or Dilated Eye Exam" (2.16.840.1.113883.3.464.1003.115.12.1088)
- valueset "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)

### Data Criteria (QDM Data Elements)

- "Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" using "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal) (LOINC Code 71007-9)"
- "Assessment, Performed: Hospice care [Minimum Data Set]" using "Hospice care [Minimum Data Set] (LOINC Code 45755-6)"
- "Assessment, Performed: Housing status" using "Housing status (LOINC Code 71802-3)"
- "Assessment, Performed: Medical equipment used" using "Medical equipment used (LOINC Code 98181-1)"
- "Device, Order: Frailty Device" using "Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300)"
- "Diagnosis: Diabetes" using "Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001)"
- "Diagnosis: Diabetic Retinopathy" using "Diabetic Retinopathy (2.16.840.1.113883.3.526.3.327)"
- "Diagnosis: Frailty Diagnosis" using "Frailty Diagnosis (2.16.840.1.113883.3.464.1003.113.12.1074)"
- "Diagnosis: Hospice Diagnosis" using "Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165)"
- "Diagnosis: Palliative Care Diagnosis" using "Palliative Care Diagnosis (2.16.840.1.113883.3.464.1003.1167)"
- "Encounter, Performed: Acute Inpatient" using "Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083)"
- "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240)"
- "Encounter, Performed: Emergency Department Evaluation and Management Visit" using "Emergency Department Evaluation and Management Visit (2.16.840.1.113883.3.464.1003.101.12.1010)"
- "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
- "Encounter, Performed: Frailty Encounter" using "Frailty Encounter (2.16.840.1.113883.3.464.1003.101.12.1088)"
- "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016)"
- "Encounter, Performed: Hospice Encounter" using "Hospice Encounter (2.16.840.1.113883.3.464.1003.1003)"
- "Encounter, Performed: Nonacute Inpatient" using "Nonacute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1084)"
- "Encounter, Performed: Observation" using "Observation (2.16.840.1.113883.3.464.1003.101.12.1086)"
- "Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
- "Encounter, Performed: Ophthalmological Services" using "Ophthalmological Services (2.16.840.1.113883.3.526.3.1285)"
- "Encounter, Performed: Outpatient" using "Outpatient (2.16.840.1.113883.3.464.1003.101.12.1087)"
- "Encounter, Performed: Palliative Care Encounter" using "Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090)"
- "Encounter, Performed: Preventive Care Services Established Office Visit, 18 and Up" using "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" using "Preventive Care Services Initial Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1023)"
- "Encounter, Performed: Telephone Visits" using "Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080)"
- "Intervention, Order: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
- "Intervention, Performed: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
- "Intervention, Performed: Palliative Care Intervention" using "Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135)"
- "Medication, Active: Dementia Medications" using "Dementia Medications (2.16.840.1.113883.3.464.1003.196.12.1510)"
- "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
- "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
- "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
- "Physical Exam, Performed: Retinal or Dilated Eye Exam" using "Retinal or Dilated Eye Exam (2.16.840.1.113883.3.464.1003.115.12.1088)"
- "Symptom: Frailty Symptom" using "Frailty Symptom (2.16.840.1.113883.3.464.1003.113.12.1075)"

### Supplemental Data Elements

- SDE Ethnicity

  - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

- SDE Payer

  - -     ["Patient Characteristic Payer": "Payer"]

- SDE Race

  - -     ["Patient Characteristic Race": "Race"]

- SDE Sex

  - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Risk Adjustment Variables

- None

Measure Set |
    None