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Diabetes: Medical Attention for Nephropathy

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Measure Information 2021 Performance Period
CMS eCQM ID CMS134v9
NQF Number Not Applicable
MIPS Quality ID 119
Description

The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period
Initial Population

Patients 18-75 years of age with diabetes with a visit during the measurement period
Numerator

Patients with a screening for nephropathy or evidence of nephropathy during the measurement period
Numerator Exclusions

Not Applicable
Denominator

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 consecutive 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.
Denominator Exceptions

None
Steward National Committee for Quality Assurance
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

Higher score indicates better quality
Guidance

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.

This eCQM is a patient-based measure.

 

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.
Telehealth Eligible Yes
Next Version
CMS134v10
Previous Version No Version Available

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Measure Information 2021 Performance Period 2022 Performance Period
Title Diabetes: Medical Attention for Nephropathy Diabetes: Medical Attention for Nephropathy
CMS eCQM ID CMS134v9 CMS134v10
NQF Number Not Applicable Not Applicable
Description

The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period

The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period
Initial Population

Patients 18-75 years of age with diabetes with a visit during the measurement period

Patients 18-75 years of age with diabetes with a visit during the measurement period
Denominator

Equals Initial Population

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 consecutive 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. 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 - 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 during the measurement period.
Numerator

Patients with a screening for nephropathy or evidence of nephropathy during the measurement period

Patients with a screening for nephropathy or evidence of nephropathy during the measurement period
Numerator Exclusions

Not Applicable

Not Applicable
Denominator Exceptions

None

None
Measure Steward National Committee for Quality Assurance National Committee for Quality Assurance
Measure Scoring Proportion measure Proportion measure
Measure Type Process measure Process measure
Improvement Notation

Higher score indicates better quality

Higher score indicates better quality
Guidance

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.

This eCQM is a patient-based measure.

 

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

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.

This eCQM is a patient-based measure.

 

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.
MIPS Quality ID 119 119
Telehealth Eligible Yes Yes
Next Version CMS134v10 No Version Available
Previous Version No Version Available
CMS134v9
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Specifications
Attachment Size
CMS134v9.html 78.35 KB
CMS134v9.zip 96.41 KB
CMS134v9-TRN.xlsx 22.8 KB

Data Element Repository

Value Sets
Value Sets to be used with CMS134v9

Release Notes

CMS134v9-TRN.xlsx

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated the rationale to remove outdated references and content and to update references.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated the clinical recommendations statement to remove outdated references and update with the most recent clinical recommendations.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Standards Update

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Updated denominator exclusions to add the word 'consecutive' to clarify that the Long-Term Illness (LTI) exclusion should be for 90 consecutive days.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Logic

  • Updated denominator exclusion logic for frailty and clarified that the long-term illness exclusion should be for 90 'consecutive' days to reduce ambiguity.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Clinical Quality Language (CQL) Library version update: Updated version number of the Adult_Outpatient_Encounters Library (Adult_Outpatient_Encounters-1.3.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • CQL Library version update: Updated version number of the Hospice Library (Hospice-2.2.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated CQL Library version number of the advanced illness and frailty exclusion library (AdvancedIllnessandFrailtyExclusionECQM-5.5.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

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

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    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 Proteinuria (2.16.840.1.113883.3.526.3.1003): Deleted 1 ICD-9-CM code (791.0) Removed ICD-9 codes from all measures that do not have lookback periods or removed ICD-9 codes from all measures with lookback period for which the ICD-9 codes were no longer relevant.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.526.3.1139): Renamed to ACE Inhibitor or ARB or ARNI. Revised value set name and purpose statement (Clinical Focus) to be consistent with value set intent.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set ACE Inhibitor or ARB or ARNI (2.16.840.1.113883.3.526.3.1139): Deleted 1 RxNorm code (249851) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Vascular Access for Dialysis (2.16.840.1.113883.3.464.1003.109.12.1011): Deleted 2 CPT codes (36147, 36148) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Glomerulonephritis and Nephrotic Syndrome (2.16.840.1.113883.3.464.1003.109.12.1018): Deleted 11 SNOMED CT codes (197577008, 197699008, 197700009, 197701008, 197702001, 197703006, 197704000, 197705004, 197706003, 236420000, 236437007) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001): Deleted 3 SNOMED CT codes (314772004, 421164006, 314894004) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300): Removed extensional value set Frailty Device (2.16.840.1.113883.3.464.1003.118.11.1114) with HCPCS codes from the grouping and added Frailty Device SNOMED (2.16.840.1.113883.3.464.1003.118.11.1220) with SNOMED CT codes to the grouping to align with recommended terminology.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Frailty Symptom (2.16.840.1.113883.3.464.1003.113.12.1075): Deleted 4 SNOMED CT codes (267031002, 272060000, 272062008, 314109004) based on terminology update.

    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 3 CPT codes (99315, 99316, 99318) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations, to capture additional nursing facility visit encounter types.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083): Deleted 1 SNOMED CT code (2876009) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value Set Dialysis Services (2.16.840.1.113883.3.464.1003.109.12.1013): Deleted 4 CPT codes (90920, 90921, 90924, 90925) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: Apr 24, 2023