• Measure 1: Diabetes: Hemoglobin A1c Poor Control


    Updated January 2018.

    Reporting Options: 

    • IRIS Registry manual entry: groups and individuals
    • EHR through your vendor (if offered): groups and individuals
    • Claims-based reporting: individuals only

    Measure Type: Outcome

    Instructions:  This measure is to be reported a minimum of once per performance period for patients aged 18-75 years of age, with diabetes who had who had hemoglobin A1c > 9.0% seen during the performance period.

    The most recent quality-data code submitted will be used for performance calculation. This measure may be reported by clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

    To Which Patients Does the Measure Apply?

    Denominator: All patients aged 18-75 years of age with diabetes with a visit during the measurement period.

    There are three criteria for inclusion of a patient into the denominator.

    1. Patient characteristics: Description located in “Instructions” (see above).
    2. Diagnosis codes (ICD-10-CM): Codes located in “Diagnosis Codes.”
    3. Procedure codes (CPT and HCPCS): Codes located in “CPT Codes” and “HCPCS Codes.”

    The quality measure has exclusions for the denominator.

    Diagnosis Codes

    CMS has stated that providers should code ICD-10 to the greatest specificity; unspecified codes may be denied. You should not include the strikethrough codes listed below on your claim or submit them with this quality measure.

    E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.36, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319 E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.36, E13.37X1, E13.37X2, E13.37X3, E13.37X9, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83

    CPT Codes

    97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271, G0402, G0438, G0439

    Note: Eye codes 92002, 92004, 92012, and 92014 are not included in this measure.

    How to Report the Measure

    Claims and IRIS Registry Manual Reporting

    The mumerator is based on CPTII codes, and these quality data codes are organized into one of three categories.

    A lower calculated performance rate for this measure indicates better clinical care or control. Patient is numerator compliant if most recent HbA1c level >9% or is missing a result or if an HbA1c test was not done during the measurement year.

    For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control. Patient is numerator compliant if most recent HbA1c level >9% or is missing a result or if an HbA1c test was not done during the measurement year. Ranges and thresholds do not meet criteria for this indicator.

    Category II Codes:

    • Performance met (patient included in numerator and denominator): 3044F Most recent hemoglobin A1c (HbA1c) level < 7.0%
      3045F Most recent hemoglobin A1c (HbA1c) level 7.0 to 9.0%
    • Denominator cxclusion (patient not included in numerator or denominator): 3046F Most recent hemoglobin A1c level > 9.0%
    • Performance not met (patient not included in numerator, but included in denominator): 3046F 8P Hemoglobin A1c level was not performed during the performance period (12 months)

    Exclusion of Participation in Measure

    G9687 Hospice services provided to patient any time during the measurement period

    Clinical Recommendation Statements: 

    Updated for 2018

    American Diabetes Association (2017):

    A reasonable A1C goal for many nonpregnant adults is <7%. (Level of evidence: A)

    Providers might reasonably suggest more stringent A1C goals (such as <6.5%) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease (CVD). (Level of evidence: C)

    Less stringent A1C goals (such as <8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin. (Level of evidence: B)

    Rationale: 

    As the seventh leading cause of death in the U.S., diabetes kills approximately 75,000 people a year (CDC FastStats2015). Diabetes is a group of diseases marked by high blood glucose levels, resulting from the body’s inability to produce or use insulin (CDC Statistics 2014, ADA Basics 2013). People with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney failure, amputation of toes, feet or legs, and premature death. (CDC Fact Sheet 2014).

    In 2012, diabetes cost the U.S. an estimated $245 billion: $176 billion in direct medical costs and $69 billion in reduced productivity. This is a 41 percent increase from the estimated $174 billion spent on diabetes in 2007 (ADA Economic 2013).

    Reducing A1c blood level results by 1 percentage point (eg, from 8.0 percent to 7.0 percent) helps reduce the risk of microvascular complications (eye, kidney and nerve diseases) by as much as 40 percent (CDC Estimates 2011).

    How CMS Scores Your Performance

    • If you successfully report a measure for less than 60 percent of your patients, you will earn points based on your practice size:
      • Small practices (≤ 15 clinicians) will receive 3 points,
      • Larger practices (> 15 clinicians) will receive 1 point.
    • If you successfully report a measure for at least 60 percent of your patients, but do not report at least 20 cases, you will receive 3 points.
    • If you report this measure for at least 60 percent of applicable patients and on at least 20 patients during a reporting period, you will earn points based on the decile that corresponds to your performance rate. Not all measures offer points for every decile.
      Decile/Points EHR (including EHR-IRIS integration)   Claims Registry (No EHR)
      3 83.10 – 67.96 33.33 - 23.54 57.89 – 42.37  
      4 67.95 – 54.09 23.53 – 18.25 42.36 – 31.59  
      5 54.08 – 43.22 18.24 – 14.30 31.58 – 25.78  
      6 43.21 – 34.12 14.29 – 11.55 25.77 – 20.94  
      7 34.11 – 27.28 11.54 – 8.90 20.93 – 16.82  
      8 27.27 – 21.75 8.89 – 6.26 16.81 – 12.78  
      9 21.74 – 15.74 6.25 – 3.34 12.77 – 7.70  
      10 <= 15.73 <=3.33 <=7.69