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CMS 122 - Diabetes: Hemoglobin A1c (HbA1c) Poor Control (9.0%)

Updated: 12/09/2021
Views: 3524

CMS 122 / Quality ID #001

Percentage of patients 18-75 years of age with diabetes who had a hemoglobin A1c >9.0% during the measurement period.

Denominator: All patients aged 18-75 years of age at the start of the measurement period with diabetes with a visit during the measurement period.
  • Patient’s age is calculated based on the patient’s Date of Birth, which was entered when you created the patient’s account.
  • Create a note detailing the patient’s office visit.
  • The diagnosis of "Diabetes" with a Start Date is entered in the patient’s Problem List.
Denominator Exclusions: If patient was in Hospice during 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:

  • Long Term Care is documented under Long Term Care Facility in History. These patients will be excluded from the denominator.

Exclude patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured:

  • Patient’s age is calculated based on the patient’s Date of Birth.
  • "Advanced Illness" and "Frailty" is documented under Problems with a Start Date.
Numerator: Patients whose most recent HbA1c level (performed during the measurement period) is >9.0%.
  • An order for a "Hemoglobin A1c" needs to be created under Labs/Studies and provided to the patient via paper or submitted via eLabs.
  • The clinician will have to sign the results when received. If results are not received via eLabs, the results will have to be manually added on the order created in Labs/Studies.
  • Hemoglobin results > 9.0%, these patients will be included in the numerator.
Office Visit Documentation:

Once all steps have been completed, the measure will be added to the Quality Measures Report.

Inverse Measure: A lower calculated performance rate for this measure indicates better clinical care or control.
Guidance: Only patients with Type 1 or Type 2 diabetes will be included. Patients with a diagnosis of secondary diabetes due to another condition will not be included.
Measure type: Outcome
High Priority Measure: Yes
Telehealth Eligible: Yes
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