eCQM Title

Diabetes: Glycemic Status Assessment Greater Than 9%

CMS ID

122

eCQM Version Number

15.0.000

CBE Number

Not Applicable

GUID

f2986519-5a4e-4149-a8f2-af0a1dc7f6bc

Measurement Period

January 1, 2027 through December 31, 2027

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 who had a glycemic status assessment (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) > 9.0% during the measurement period

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 endorsements about the quality of any product, test or protocol identified as numerator compliant or otherwise identified as meeting the requirements of the measure or specification. 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 may be used for internal, noncommercial purposes (e.g., use by healthcare providers in connection with their practices) without obtaining approval from NCQA. All other uses, including a commercial use (including but not limited to vendors using or embedding the measures and specifications into any product or service to calculate measure results for customers for any purpose), must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2026 National Committee for Quality Assurance. All Rights Reserved.

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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

Intermediate Outcome

Stratification

None

Risk Adjustment

None

Rate Aggregation

None

Rationale

Diabetes is the eighth leading cause of death in the United States. In 2021, diabetes affected more than 38 million Americans (11.6 percent of the U.S. population) and killed more than 103,000 people (American Diabetes Association [ADA], 2024). Diabetes is a long-lasting disease marked by high blood glucose levels, resulting from the body's inability to produce or use insulin properly (Centers for Disease Control and Prevention [CDC], 2024). 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, 2022).

In 2022, diabetes cost the U.S. an estimated $413 billion: $307 billion in direct medical costs and $106 billion in reduced productivity. The direct medical cost of diabetes increased by 7 percent between 2017 and 2022 (Parker et al., 2024).

Controlling A1c blood levels helps reduce the risk of microvascular complications (eye, kidney and nerve diseases) (CDC, 2022).

Clinical Recommendation Statement

American Diabetes Association (2025):

Assess glycemic status by A1C (Level of evidence: A) and/or continuous glucose monitoring (CGM) metrics such as time in range, time above range and time below range (Level of evidence: B) Fructosamine or CGM can be used for glycemic monitoring when an alternative to A1C is required. (Level of evidence: B)
Assess glycemic status at least two times a year, and more frequently for individuals not meeting glycemic goals or with recent treatment changes, frequent or severe hypoglycemia or hyperglycemia, or changes in health status, or during periods of rapid growth and development in youth. (Level of evidence: E)
An A1C of <7 percent (<53 mmol/mol) is appropriate for many nonpregnant adults without severe hypoglycemia or frequent hypoglycemia affecting health or quality of life. (Level of evidence: A)
Based on health care professional judgement and the preference of the person with diabetes, achievement of lower A1C levels than the goal of 7 percent (53 mmol/mol) may be acceptable and even beneficial if it can be achieved safely without frequent or severe hypoglycemia or other adverse effects of treatment. (Level of evidence: B)
Less stringent glycemic goals may be appropriate for individuals with limited life expectancy or where the harms of treatment are greater than the benefits. (Level of evidence: B)

Improvement Notation

Lower score indicates better quality

Reference

Reference Type: Citation

Reference Text:

American Diabetes Association Professional Practice Committee. (2025). 6. Glycemic goals and hypoglycemia: Standards of care in diabetes—2025. Diabetes Care, 48(Suppl. 1), S128–S145. https://doi.org/10.2337/dc25-S006

Reference

Reference Type: Citation

Reference Text:

American Diabetes Association. (2024). Statistics About Diabetes. Retrieved November 25, 2025, from https://diabetes.org/about-diabetes/statistics/about-diabetes

Reference

Reference Type: Citation

Reference Text:

Centers for Disease Control and Prevention. (2022). Diabetes Report Card 2021. U.S. Department of Health and Human Services. https://archive.cdc.gov/www_cdc_gov/diabetes/library/reports/reportcard.html

Reference

Reference Type: Citation

Reference Text:

Centers for Disease Control and Prevention. (2024). Diabetes Basics. Retrieved November 25, 2025, from https://www.cdc.gov/diabetes/about/index.html

Reference

Reference Type: Citation

Reference Text:

Parker, E., Lin, J., Mahoney, T., Ume, N., Yang, G., Gabbay, R., ElSayed, N., & Bannuru, R. (2024). Economic Costs of Diabetes in the U.S. in 2022. Diabetes Care, 47(1), 26–43. https://doi.org/10.2337/dci23-0085

Definition

None

Guidance

If the glycemic status assessment (HbA1c or GMI) is in the medical record, the test can be used to determine numerator compliance.

Glycemic status assessment (HbA1c or GMI) must be reported as a percentage (%).

If multiple glycemic status assessments were recorded for a single date, use the lowest result.

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 diagnosis 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 glycemic status assessment (HbA1c or GMI) (performed during the measurement period) is >9.0% or is missing, or was not performed during the measurement period

Numerator Exclusions

None

Denominator Exceptions

None

Supplemental Data Elements

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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"] DiabetesDiagnosis
        where DiabetesDiagnosis.prevalencePeriod overlaps day of "Measurement Period"
    )

- Denominator
  - "Initial Population"

Denominator Exclusions

  Hospice."Has Hospice Services"
    or AIFrailLTCF."Is Age 66 Or Older Living Long Term In A Nursing Home"
    or AIFrailLTCF."Is Age 66 Or Older With Advanced Illness And Frailty"
    or PalliativeCare."Has Palliative Care In The Measurement Period"

Numerator

  "Has Most Recent Glycemic Status Assessment Without Result"
    or "Has Most Recent Elevated Glycemic Status Assessment"
    or "Has No Record Of Glycemic Status Assessment"

- Numerator Exclusions
  - None

- Denominator Exceptions
  - None

- Stratification
  - None

Definitions

AIFrailLTCF.Has Advanced Illness In Year Before Or During Measurement Period

  exists ( ["Diagnosis": "Advanced Illness"] AdvancedIllnessDiagnosis
      where AdvancedIllnessDiagnosis.prevalencePeriod overlaps day of Interval[start of "Measurement Period" - 1 year, end of "Measurement Period"]
  )

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 day of "Measurement Period"
    )
    or exists ( ["Encounter, Performed": "Frailty Encounter"] FrailtyEncounter
        where FrailtyEncounter.relevantPeriod overlaps day of "Measurement Period"
    )
    or exists ( ["Symptom": "Frailty Symptom"] FrailtySymptom
        where FrailtySymptom.prevalencePeriod overlaps day of "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 day of Interval[start of "Measurement Period" - 1 year, 
    end of "Measurement Period"])

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 day of 
          end of "Measurement Period"
          sort by end of Global."NormalizeInterval"(relevantDatetime, relevantPeriod) asc
      ).result ~ "Lives in nursing home (finding)"

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 Advanced Illness In Year Before Or During Measurement Period"
          or "Has Dementia Medications In Year Before Or During Measurement Period"
      )

Denominator
- - "Initial Population"

Denominator Exclusions

  Hospice."Has Hospice Services"
    or AIFrailLTCF."Is Age 66 Or Older Living Long Term In A Nursing Home"
    or AIFrailLTCF."Is Age 66 Or Older With Advanced Illness And Frailty"
    or PalliativeCare."Has Palliative Care In The Measurement Period"

Glycemic Status Assessment

  ( ["Laboratory Test, Performed": "HbA1c Laboratory Test"]
    union ["Laboratory Test, Performed": "Glucose management indicator"] ) GlycemicStatus
    where Global."LatestOf" ( GlycemicStatus.relevantDatetime, GlycemicStatus.relevantPeriod ) during day of "Measurement Period"

Has Most Recent Elevated Glycemic Status Assessment

  "Most Recent Glycemic Status Assessment".result > 9 '%'

Has Most Recent Glycemic Status Assessment Without Result

  "Most Recent Glycemic Status Assessment" is not null
    and "Most Recent Glycemic Status Assessment".result is null

Has No Record Of Glycemic Status Assessment

  not exists "Glycemic Status Assessment"

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"] DiabetesDiagnosis
        where DiabetesDiagnosis.prevalencePeriod overlaps day of "Measurement Period"
    )

Lowest Glycemic Status Assessment With Numerical Result On Most Recent Day

First("Glycemic Status Assessment" QualifyingGlycemicStatus
        where date from Global."LatestOf"(QualifyingGlycemicStatus.relevantDatetime, QualifyingGlycemicStatus.relevantPeriod) same day as "Most Recent Glycemic Status Date"
          and QualifyingGlycemicStatus.result is not null
        sort by(result as Quantity) )

Most Recent Glycemic Status Assessment

  Coalesce(
    "Lowest Glycemic Status Assessment With Numerical Result On Most Recent Day",
    "Most Recent Glycemic Status Assessment With Numerical Result In Measurement Period",
    "Most Recent Glycemic Status Assessment With Null Result In Measurement Period"
    )

Most Recent Glycemic Status Assessment With Null Result In Measurement Period

  Last( "Glycemic Status Assessment" QualifyingGlycemicStatus
      where Global."LatestOf"(QualifyingGlycemicStatus.relevantDatetime, QualifyingGlycemicStatus.relevantPeriod) during day of "Measurement Period"
        and QualifyingGlycemicStatus.result is null
        sort by Global."LatestOf" (relevantDatetime, relevantPeriod)
        )

Most Recent Glycemic Status Assessment With Numerical Result In Measurement Period

  Last( "Glycemic Status Assessment" QualifyingGlycemicStatus
      where Global."LatestOf" ( QualifyingGlycemicStatus.relevantDatetime, QualifyingGlycemicStatus.relevantPeriod ) during day of "Measurement Period"
         and QualifyingGlycemicStatus.result is not null
         sort by Global."LatestOf" ( relevantDatetime, relevantPeriod )
         )

Most Recent Glycemic Status Date

  Last(("Glycemic Status Assessment" QualifyingGlycemicStatus
  where QualifyingGlycemicStatus.result as Quantity > 0 '%'
      return date from Global."LatestOf"(QualifyingGlycemicStatus.relevantDatetime, QualifyingGlycemicStatus.relevantPeriod)) QualifyingGlycemicStatusDays
      sort asc
      )

Numerator

  "Has Most Recent Glycemic Status Assessment Without Result"
    or "Has Most Recent Elevated Glycemic Status Assessment"
    or "Has No Record Of Glycemic Status Assessment"

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": "Nutrition Services"]
    union ["Encounter, Performed": "Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes"]
    union ["Encounter, Performed": "Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes"]
    union ["Encounter, Performed": "Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes"]
    union ["Encounter, Performed": "Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes"]
    union ["Encounter, Performed": "Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes"]
    union ["Encounter, Performed": "Telephone Visits"] ) ValidEncounters
    where ValidEncounters.relevantPeriod during day of "Measurement Period"

SDE Ethnicity

  ["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

  ["Patient Characteristic Payer": "Payer Type"]

SDE Race

  ["Patient Characteristic Race": "Race"]

SDE Sex

  ["Patient Characteristic Sex": "Federal Administrative Sex"]

Functions

Global.HasEnd(period Interval<DateTime>)

  not ( 
    end of period is null
      or 
      end of period = maximum DateTime
  )

Global.Latest(period Interval<DateTime>)

  if ( HasEnd(period)) then 
  end of period 
    else start of period

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

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 "Glucose management indicator" ("LOINC Code (97506-0)")
code "Hospice care [Minimum Data Set]" ("LOINC Code (45755-6)")
code "Housing status" ("LOINC Code (71802-3)")
code "Lives in nursing home (finding)" ("SNOMEDCT Code (160734000)")
code "Medical equipment used" ("LOINC Code (98181-1)")
code "Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes" ("HCPCS Code (G0271)")
code "Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes" ("CPT Code (97804)")
code "Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes" ("CPT Code (97802)")
code "Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes" ("CPT Code (97803)")
code "Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes" ("HCPCS Code (G0270)")
code "Yes (qualifier value)" ("SNOMEDCT Code (373066001)")
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 "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "Federal Administrative Sex" (2.16.840.1.113762.1.4.1021.121)
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 "HbA1c Laboratory Test" (2.16.840.1.113883.3.464.1003.198.12.1013)
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 "Nutrition Services" (2.16.840.1.113883.3.464.1003.1006)
valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
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 Type" (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 "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: Advanced Illness" using "Advanced Illness (2.16.840.1.113883.3.464.1003.110.12.1082)"
"Diagnosis: Diabetes" using "Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001)"
"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: Annual Wellness Visit" using "Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240)"
"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: Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes" using "Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes (HCPCS Code G0271)"
"Encounter, Performed: Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes" using "Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes (CPT Code 97804)"
"Encounter, Performed: Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes" using "Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (CPT Code 97802)"
"Encounter, Performed: Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes" using "Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes (CPT Code 97803)"
"Encounter, Performed: Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes" using "Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes (HCPCS Code G0270)"
"Encounter, Performed: Nutrition Services" using "Nutrition Services (2.16.840.1.113883.3.464.1003.1006)"
"Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
"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)"
"Laboratory Test, Performed: Glucose management indicator" using "Glucose management indicator (LOINC Code 97506-0)"
"Laboratory Test, Performed: HbA1c Laboratory Test" using "HbA1c Laboratory Test (2.16.840.1.113883.3.464.1003.198.12.1013)"
"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 Type" using "Payer Type (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: Federal Administrative Sex" using "Federal Administrative Sex (2.16.840.1.113762.1.4.1021.121)"
"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 Type"]

SDE Race

  ["Patient Characteristic Race": "Race"]

SDE Sex

  ["Patient Characteristic Sex": "Federal Administrative Sex"]

Risk Adjustment Variables

None

Measure Set

None