| Measure Information | 2022 Performance Period |
|---|---|
| CMS eCQM ID | CMS122v10 |
| NQF Number | Not Applicable |
| MIPS Quality ID | 001 |
| 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 |
| 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 |
Not Applicable |
| 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 - 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. |
| Denominator Exceptions |
None |
| Steward | National Committee for Quality Assurance |
| Measure Scoring | Proportion measure |
| Measure Type | Intermediate Outcome measure |
| Improvement Notation |
Lower score indicates better quality |
| Guidance |
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. 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 | |
| Previous Version |
Compare eCQM Versions
The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.
Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.
| Measure Information | 2021 Performance Period | 2022 Performance Period | 2023 Performance Period | 2024 Performance Period |
|---|---|---|---|---|
| Title | Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) | Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) | Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) | Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) |
| CMS eCQM ID | CMS122v9 | CMS122v10 | CMS122v11 | CMS122v12 |
| NQF Number | Not Applicable | Not Applicable | Not Applicable | Not Applicable |
| Description |
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period |
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period |
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period |
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 |
Patients 18-75 years of age with diabetes with a visit during the measurement period |
Patients 18-75 years of age by the end of the measurement period, with diabetes with a visit during the measurement period |
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 |
Equals Initial Population |
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. | 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 during 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. | 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 whose most recent HbA1c level (performed during the measurement period) is >9.0% |
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. |
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 |
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 |
Not Applicable |
Not Applicable |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
None |
None |
None |
None |
| Measure Steward | National Committee for Quality Assurance | National Committee for Quality Assurance | National Committee for Quality Assurance | National Committee for Quality Assurance |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Intermediate Outcome measure | Intermediate Outcome measure | Intermediate Clinical Outcome measure | Intermediate Clinical Outcome measure |
| Improvement Notation |
Lower score indicates better quality |
Lower score indicates better quality |
Lower score indicates better quality |
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. 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. |
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. 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. |
If the HbA1c test result is in the medical record, the test can be used to determine numerator compliance. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
If the HbA1c test result is in the medical record, the test can be used to determine numerator compliance. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| MIPS Quality ID | 001 | 001 | 001 | 001 |
| Telehealth Eligible | Yes | Yes | Yes | Yes |
| Next Version | CMS122v10 | CMS122v11 | CMS122v12 | No Version Available |
| Previous Version | No Version Available |
Data Element Repository
Header
-
Updated the eCQM version number.
Measure Section: eCQM Version Number
Source of Change: Annual Update
-
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
-
Updated the rationale to align with current evidence.
Measure Section: Rationale
Source of Change: Measure Lead
-
Updated the clinical recommendation statement to align with current clinical recommendations.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
-
Updated references.
Measure Section: Reference
Source of Change: Annual Update
-
Updated the guidance to clarify the measure intent and support implementation.
Measure Section: Guidance
Source of Change: Measure Lead
-
Replaced 'overlaps' or 'overlapping' in the denominator exclusions with plain language to clarify the measure intent.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
-
Revised the advanced illness and frailty denominator exclusion to clarify the intent of the exclusion criteria.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
-
Updated the Denominator Exclusions to add an exclusion for palliative care.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
-
Revised the numerator to align with the guidance and measure intent.
Measure Section: Numerator
Source of Change: Measure Lead
Logic
-
Updated the names of Clinical Quality Language (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
-
Added telephone visits as appropriate encounters based on the increased use of telehealth services.
Measure Section: Multiple Sections
Source of Change: Measure Lead
-
Revised the advanced illness and frailty denominator exclusion to align with the header and adhere to QDMv5.5 standards..
Measure Section: Multiple Sections
Source of Change: Measure Lead
-
Updated Denominator Exclusions definition and added 'PalliativeCare.Palliative Care in the Measurement Period' definition to add an exclusion for palliative care.
Measure Section: Multiple Sections
Source of Change: Measure Lead
-
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.
Measure Section: Multiple Sections
Source of Change: Standards Update
-
Update Adult Outpatient Encounters CQL library to 2.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
-
Updated Advanced Illness and Frailty Exclusions CQL Library to version 6.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
-
Updated Hospice CQL Library to version 3.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
-
Added PalliativeCareExclusion CQL library to version 1.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
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Value set Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001): Added 37 SNOMED CT codes based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations. Deleted 12 SNOMED CT codes (421920002, 4783006, 75682002, 76751001, 769219006, 190388001, 190390000, 395204000, 421750000, 422014003, 703138006, 781000119106) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations.
Measure Section: Terminology
Source of Change: Measure Lead
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Value set Advanced Illness (2.16.840.1.113883.3.464.1003.110.12.1082): Added 34 ICD-10-CM codes based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations or terminology updates. Added 179 SNOMED CT codes based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations, and based on terminology updates.
Measure Section: Terminology
Source of Change: Measure Lead
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Value set Outpatient (2.16.840.1.113883.3.464.1003.101.12.1087): Added 11 SNOMED CT codes (185463005, 185464004, 185465003, 281036007, 30346009, 37894004, 3391000175108, 439740005, 77406008, 444971000124105, 84251009) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
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Value set Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300): Added 124 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 22 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
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Value set Frailty Encounter (2.16.840.1.113883.3.464.1003.101.12.1088): Deleted 1 SNOMED CT code (413467001) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
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Value set Frailty Symptom (2.16.840.1.113883.3.464.1003.113.12.1075): Added 13 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 69 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
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Value set Frailty Diagnosis (2.16.840.1.113883.3.464.1003.113.12.1074): Added 14 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 13 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Added 166 ICD-10-CM codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
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Value set Dementia Medications (2.16.840.1.113883.3.464.1003.196.12.1510): Added 4 RxNorm codes (1599803, 1599805, 1805420, 1805425) based on change in measure requirements/measure specification. Deleted 3 RxNorm codes (1858970, 996572, 996624) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
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Value set Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083): Added 10 SNOMED CT codes (10378005, 18083007, 183452005, 19951005, 2252009, 73607007, 305339001, 50699000, 74857009, 78680009) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations.
Measure Section: Terminology
Source of Change: Measure Lead
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Replaced value set ED (2.16.840.1.113883.3.464.1003.101.12.1085) with value set Emergency Department Visit (2.16.840.1.113883.3.464.1003.101.12.1010) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
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Added value set Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
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Added value set Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
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Added value set Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
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Added direct reference code LOINC code (71007-9) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead