eCQM Title

Diabetes: Glycemic Status Assessment Greater Than 9%

eCQM Identifier (Measure Authoring Tool)

122

eCQM Version Number

13.0.000

CBE Number

Not Applicable

GUID

f2986519-5a4e-4149-a8f2-af0a1dc7f6bc

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 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 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) 2012-2024 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 2024. American Medical Association. All rights reserved. CPT is a trademark of the American Medical Association. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Applicable FARS/DFARS restrictions apply to government use.

Some measure specifications contain coding from LOINC(R) (http://loinc.org). The LOINC table, LOINC codes, LOINC panels and form file, LOINC linguistic variants file, LOINC/RSNA Radiology Playbook, and LOINC/IEEE Medical Device Code Mapping Table are copyright 2004-2024 Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee, and are available at no cost under the license at http://loinc.org/terms-of-use.

Some measures use RxNorm, a standardized nomenclature and coding for clinical drugs and drug delivery devices, which is made publicly available courtesy of the U.S. National Library of Medicine (NLM), National Institutes of Health, Department of Health and Human Services. NLM is not responsible for the measures and does not endorse or recommend this or any other product.

“HL7” is the registered trademark of Health Level Seven International.

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 Clinical Outcome

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% 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% increase from the estimated $245 billion spent on diabetes in 2012 (ADA, 2018).

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

Clinical Recommendation Statement

American Diabetes Association (2023):

- Assess glycemic status (A1C or other glycemic measurement such as time in range or glucose management indicator) at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). (Level of evidence: E)

- An A1C goal for many nonpregnant adults of <7% (53 mmol/mol) without significant hypoglycemia is appropriate. (Level of evidence: A)

- On the basis of health care professional judgement and patient preference, achievement of lower A1C levels than the goal of 7% may be acceptable and even beneficial if it can be achieved safely without significant hypoglycemia or other adverse effects of treatment. (Level of evidence: B)

- Less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients with limited life expectancy or where the harms of treatment are greater than the benefits. Health care professionals should consider deintensification of therapy if appropriate to reduce the risk of hypoglycemia in patients with inappropriate stringent A1C targets. (Level of evidence: B)

- Standardized, single-page glucose reports from continuous glucose monitoring (CGM) devices with visual cues, such as the ambulatory glucose profile, should be considered as a standard summary for all CGM devices. Level of evidence: E

Improvement Notation

Lower 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: '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). Diabetes Report Card 2021. US Dept of Health and Human Services. Retrieved from https://archive.cdc.gov/www_cdc_gov/diabetes/library/reports/reportcard.html'

Reference

Reference Type: CITATION

Reference Text: 'ElSayed, N.A., Aleppo, G., Ardoda, V.R., Bannuru, R.B., Brown, F.M., Bruemmer, D.,…Staton, R.C., American Diabetes Association (ADA). (2022). 6. Glycemic Targets: Standards of Care in Diabetes—2023. Diabetes Care 2023,46(Supplement_1):S97–S110. https://doi.org/10.2337/dc23-S006'

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

Not Applicable

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"] Diabetes
      where Diabetes.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 starts during 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
    )) LastHousingStatus
      where LastHousingStatus.result ~ "Lives in 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 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

"Lowest Glycemic Status Assessment Reading on Most Recent Day".result > 9 '%'

Has Most Recent Glycemic Status Assessment Without Result

"Lowest Glycemic Status Assessment Reading on Most Recent Day" is not null
  and "Lowest Glycemic Status Assessment Reading on Most Recent Day".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"] Diabetes
      where Diabetes.prevalencePeriod overlaps day of "Measurement Period"
  )

Lowest Glycemic Status Assessment Reading on Most Recent Day

First("Glycemic Status Assessment" QualifyingGlycemicStatus
    where Global."LatestOf"(QualifyingGlycemicStatus.relevantDatetime, QualifyingGlycemicStatus.relevantPeriod) same day as "Most Recent Glycemic Status Date"
    sort by(result as Quantity)
)

Most Recent Glycemic Status Date

Last(("Glycemic Status Assessment" QualifyingGlycemicStatus
    return date from start of Global."NormalizeInterval"(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": "ONC 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 "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 "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
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: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
"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": "ONC Administrative Sex"]

Risk Adjustment Variables

None

Measure Set

None