American Medical Association (AMA) Prediabetes Quality Measures · • History of gestational diabetes mellitus . Denominator Exclusions/ Exceptions . Denominator Exclusions: Exclude

Copyright 2018 American Medical Association. All Rights Reserved.

American Medical Association (AMA)

Prediabetes Quality Measures Developed by AMA’s Prediabetes Quality Measures Technical Expert Panel

PUBLIC COMMENT—OBSOLETE AFTER MAY 31, 2018

CONFIDENTIAL DRAFT FOR COMMENT ONLY-DO NOT DISTRIBUTE

Copyright 2018 American Medical Association. All Rights Reserved. 1

Table of Contents Disclaimer Notice .................................................................................................................................................... 2 AMA Prediabetes Technical Expert Panel Members .............................................................................................. 3 Purpose of the Measurement Set ........................................................................................................................... 4 Measure #1: Screening for Abnormal Blood Glucose in Overweight/Obese Patients ........................................... 5 Measure #2: Screening for Abnormal Blood Glucose in High Risk Patients ......................................................... 6 Measure #3: Intervention for Prediabetes .............................................................................................................. 8 Measure #4: Retesting of Abnormal Blood Glucose in Patients with Prediabetes .............................................. 10 Evidence Classification/Rating Schemes .............................................................................................................. 11



Disclaimer Notice The Measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and American Medical Association (AMA). The AMA shall not be responsible for any use of the Measures. The AMA encourages use of the Measures by other health care professionals, where appropriate. THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND. © 2018 American Medical Association. All Rights Reserved.∗ Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications. CPT® contained in the Measures specifications is copyright 2004-2017 American Medical Association. LOINC® copyright 2004-2017 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT®) copyright 2004-2017 The International Health Terminology Standards Development Organisation (IHTSDO). ICD-10 is copyright 2017 World Health Organization. All Rights Reserved.

∗ The date of the copyright notice shall be the date of first publication of the Measure by the AMA or the date of subsequent updating and publication of the Measure.



AMA Prediabetes Technical Expert Panel Members

Ronald Ackermann, MD, MPH (Co-Chair) William Golden, MD, MACP (Co-Chair)

Stephen Benoit, MD, MPH Leslie Kolb, RN, BSN, MBA Ameldia R. Brown, MDiv, BSN, RN Tannaz Moin, MD, MBA, MSHS Brian S. Cohen, PhD Jennifer Torres Most, PhD, MscPH, MSSW Laura Clapper, MD, MPPA, CPE, FAAPL Maria Prince, MD, MPH Mary Carol Greenlee, MD, FACP, FACE James L. Rosenzweig, MD Elizabeth Joy, MD, MPH Anita Stewart, MD, MPH, JD Mary E. Krebs, MD

AMA Staff PCPI Foundation Staff Kate Kirley, MD, MS Beth Bostrom, MPH Karen Kmetik, PhD Kerri Fei, MSN, RN Koryn Rubin Diedra Gray, MPH Beth Tapper, MA Courtney Hurt, MSW, LCSW Greg Wozniak, PhD Sam Tierney, MPH

Patrick Yep, MS, MPH

CDC Subject Matter Expert Ann Albright, PhD, RD



Purpose of the Measurement Set The AMA convened a cross-specialty, multidisciplinary technical expert panel (TEP) to identify and define new measures for prediabetes. The focus of these measures is to support the prevention of type 2 diabetes in our nation. Specific areas of focus include increasing screening and testing for prediabetes, referring/providing those at risk an intervention, and follow-up testing. The recommendations of this Technical Expert Panel have resulted in the first measurement set in the U.S. for use at the individual physician/group practice level intended to help prevent type 2 diabetes. Currently, eighty-four million Americans have prediabetes and 9 out 10 of these individuals are unaware that they have this condition. CDC-recognized lifestyle change programs are included in the health benefit plans of many private health insurers and the Medicare Diabetes Prevention Program will extend the program to Medicare beneficiaries in April 2018.



Measure #1: Screening for Abnormal Blood Glucose in Overweight/Obese Patients

Measure Description Percentage of patients aged 40 to 70 years who are overweight or obese who are seen for at least two visits or at least one preventive visit during the 12-month measurement period who were screened or have documented previous results for abnormal blood glucose at least once in the last 3 years

Numerator Statement

Patients who were screened* for abnormal blood glucose at least once in the last 3 years *Screening for abnormal blood glucose may include using a fasting plasma glucose, 2-h plasma glucose during a 75g oral glucose tolerance test, or A1C.

Denominator Statement

All patients aged 43 to 70 years who are overweight or obese* seen for at least two office visits or one preventive visit during the 12-month measurement period *Overweight or obese adults are defined as those with a BMI ≥25 kg/m2

Denominator Exclusions/ Exceptions

Denominator Exclusions: Exclude patients who are pregnant. Exclude patients who have any existing diagnosis of diabetes (Type 1, Type 2, latent autoimmune diabetes of adults [LADA], monogenic diabetes [MODY]). Exclude patients in palliative care/hospice

Guideline Recommendations

The following evidence statements are quoted verbatim from the referenced clinical guidelines and other sources, where applicable: The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years of age who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity1. (USPSTF, 2015) (B recommendation)

Rationale Overall, screening patients for prediabetes does not occur as often as it should. In a nationally representative sample of patients from the National Health and Nutrition Examination Survey (NHANES) from 2005-2012, only 45% of those who met screening criteria were actually screened.2 Additionally, survey data show that while primary care physicians are aware of the guidelines that support screening for prediabetes, there is a disconnect between this knowledge and actual practice3,4

Measure Designation

Measure Purpose Quality Improvement Accountability

Measure Type Process

Level of Measurement

Individual Practitioner Group Practice

Improvement Notation

Higher score indicates better quality

National Quality Strategy Priority/CMS Measure Domain

☐Communication and Care Coordination ☒Community/Population Health ☒Effective Clinical Care ☐Efficiency and Cost Reduction ☐Patient Safety ☐Person and Caregiver-Centered Experience



Measure #2: Screening for Abnormal Blood Glucose in High Risk Patients

Measure Description Percentage of patients aged 18 years and older who have risk factors* for diabetes who were seen for at least two office visits or one preventive visit in the 12-month measurement period who were screened or have documented previous results for abnormal blood glucose at least once in the last 3 years

Numerator Statement

Patients who were screened* for abnormal blood glucose at least once in the last 3 years *Screening for abnormal blood glucose may include using a fasting plasma glucose, 2-h plasma glucose during a 75g oral glucose tolerance test, or A1C.


All patients aged 21 years and older who have risk factors* for diabetes seen for at least 2 office visits or one preventive visit during the 12-month measurement period *Risk factors for diabetes include: Adults who are overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) who have one or more of the following:

• First-degree relative with diabetes • High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian

American, Pacific Islander) • History of CVD • Blood pressure ≥140/90 mmHg or on therapy for hypertension • HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or triglyceride level >250

mg/dL (2.82 mmol/L) or on therapy for hypercholesterolemia • Women with polycystic ovary syndrome • Physical inactivity • Other clinical conditions associated with insulin resistance (e.g., severe obesity,

acanthosis nirgricans) • History of gestational diabetes mellitus


Denominator Exclusions: Exclude patients who are pregnant. Exclude patients who have any existing diagnosis 2 diabetes (Type 1, Type 2, latent autoimmune diabetes of adults [LADA], monogenic diabetes [MODY]). Exclude patients in palliative care/hospice


The following evidence statements are quoted verbatim from the referenced clinical guidelines and other sources, where applicable: Testing for prediabetes and risk for future diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI >=25kg.m2 or >=23kg/m2 in Asian Americans) and who have one or more additional risk factors for diabetes5 (ADA, 2018) (B) . To test for prediabetes, fasting plasma glucose, 2-h plasma glucose after 75-g oral glucose tolerance test, and A1C are equally appropriate5 (ADA, 2018) (B). Testing for prediabetes should be considered in children and adolescents who are overweight or obese and who have two or more risk factors for diabetes5 (ADA, 2018) (E). If tests are normal, repeat testing carried out at a minimum of 3-year intervals is reasonable5 (ADA, 2018) (C).



Rationale Overall, screening patients for prediabetes does not occur as often as it should. In a nationally representative sample of patients from the National Health and Nutrition Examination Survey (NHANES) from 2005-2012, only 45% of those who met screening criteria were actually screened.2 Additionally, survey data show that while primary care physicians are aware of the guidelines that support screening for prediabetes, there is a disconnect between this knowledge and actual practice.4.Error! Bookmark not defined.

Measure Designation











Measure #3: Intervention for Prediabetes Measure Description

Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention*

Numerator Statement

Patients who were provided an intervention* *Intervention must include one of the following: referral to a CDC-recognized diabetes prevention program; referral to medical nutrition therapy with a registered dietician; prescription of metformin.


All patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period **Abnormal lab result in the range of prediabetes includes a fasting plasma glucose level between 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L) OR a 2-hour glucose during a 75g oral glucose tolerance test between 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L) OR and A1C between 5.7-6.4% (39-47 mmol/mol).


Denominator Exclusions: Exclude patients who are pregnant. Exclude patients who have any existing diagnosis of diabetes (Type 1, Type 2, latent autoimmune diabetes of adults [LADA], monogenic diabetes [MODY]). Denominator Exceptions: Documentation of medical reason(s) for not providing an intervention for prediabetes (eg, limited life expectancy, lack of program availability, other medical reason) Documentation of patient reason(s) for not providing an intervention (eg, patient refusal)


The following evidence statements are quoted verbatim from the referenced clinical guidelines and other sources, where applicable: The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years of age who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity1. (USPSTF, 2015) (B recommendation) Patients with prediabetes should be referred to an intensive behavioral lifestyle intervention program modeled on the Diabetes Prevention Program to achieve and maintain 7% loss of initial body weight and increase moderate-intensity physical activity (such as brisk walking) to at least 150 min/week5. (ADA, 2018) (A). Metformin therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially for those with BMI ≥35 kg/m2, those aged <60 years, women with prior gestational diabetes mellitus5. (ADA, 2018) (A).

Rationale Patients who are diagnosed with prediabetes benefit from referral to intervention programs. Data from the 2012 National Ambulatory Medical Care Survey show that only 23% of visits that were associated with prediabetes showed that any type of referral or intervention was made6. In a small study, survey data show that while providers report following patients with prediabetes closely, only 11% reported referring to a behavioral weight loss program4. Data support that there is room for improvement in providing patients with prediabetes an intervention.



Measure Designation











Measure #4: Retesting of Abnormal Blood Glucose in Patients with Prediabetes

Measure Description Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period

Numerator Statement

Patients who had a blood glucose test performed *Retesting for abnormal blood glucose may include using a fasting plasma glucose, 2-h plasma glucose during a 75g oral glucose tolerance test, or A1C.


All patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of prediabetes in the year prior to the one-year measurement period **Abnormal lab result in the range of prediabetes includes a fasting plasma glucose level between 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L) OR a 2-hour glucose during a 75g oral glucose tolerance test between 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L) OR and A1C between 5.7-6.4% (39-47 mmol/mol).


Denominator Exceptions. Documentation of patient reasons for exception (eg, patient moved, changed insurance coverage)


The following evidence statements are quoted verbatim from the referenced clinical guidelines and other sources, where applicable: At least annual monitoring for the development of diabetes in those with prediabetes is suggested5 (ADA, 2018) (E)

Rationale At least annual glucose testing in patients who were previously found to have lab results in the range of prediabetes is an important aspect of care so that patients can be monitored for improvement or potential transition to Type 2 diabetes5. While there are no current studies that show patients with prediabetes do not have follow-up testing completed, the TEP felt that this is a key area in which to have a measure.

Measure Designation








☐Communication and Care Coordination ☐Community/Population Health ☒Effective Clinical Care ☐Efficiency and Cost Reduction ☐Patient Safety ☐Person and Caregiver-Centered Experience



Evidence Classification/Rating Schemes United States Preventive Services Task Force (USPSTF) Recommendation Grade Definitions7

Grade Definition A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. B The USPSTF recommends the service. There is high certainty that the net benefit is moderate

or there is moderate certainty that the net benefit is moderate to substantial. C The USPSTF recommends selectively offering or providing this service to individual patients

based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Level of Certainty* Regarding Net Benefit7 *The USPSTF defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.

Level of Certainty Description High The available evidence usually includes consistent results from well-designed, well-

conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.

Medium The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as:

• The number, size, or quality of individual studies. • Inconsistency of findings across individual studies. • Limited generalizability of findings to routine primary care practice. • Lack of coherence in the chain of evidence.

As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.

Low The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:

• The limited number or size of studies. • Important flaws in study design or methods. • Inconsistency of findings across individual studies. • Gaps in the chain of evidence. • Findings not generalizable to routine primary care practice. • Lack of information on important health outcomes.

More information may allow estimation of effects on health outcomes.



American Diabetes Association (ADA) Evidence Grading System5



References

1 Siu L on behalf of the U. S. Preventive Services Taskforce. Screening for abnormal blood glucose and type 2 diabetes mellitus: U. S. Preventive Services Task Force recommendation. Ann Intern Med. 2015;163:861-868. 2 Kiefer M, et al. National patterns in diabetes screening: Data from the National Health and Nutrition Examination Survey (NHANES) 2005-2012. J Gen Intern Med. 2014;30(5): 612-618 3 Mehta S, Mocarski M, Wisniewski T, Gillepsie K, Narayan Venkat KM, Lang K. Primary care physician’s utilization of type 2 diabetes screening guidelines and referrals to behavioral interventions: a survey-linked retrospective study. BMJ Open Diab Res Care. 2017;5:e000406. Doi:10.1136/bmjdrc-2017-000406. 4 Tseng E, Greer R C, O’Rourke, P, Yeh, H-C, McGuire, M M, Clark, J M, & Maruthur, N M. Survey of primary care providers’ knowledge of screening for, diagnosing and managing prediabetes. Journal of General Internal Medicine, 32(11), 1172–1178. 5 American Diabetes Association. Standards in medical care in diabetes—2018. Diabetes Care. 2018:41 (Suppl.1);S1-S159. 6 Mainous A G, Tanner R J, & Baker R. Prediabetes Diagnosis and Treatment in Primary Care. The Journal of the American Board of Family Medicine. 2016. 29(2), 283–285. 7 Grade Definitions. U.S. Preventive Services Task Force. November 2017. https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions

https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions

American Medical Association Prediabetes Quality Measures

Measure Component QDM Datatype Value Set Name Standard Terminology OID or Reference Code Attributes/Relationships Comments/Rationale

n/a Measurement Period n/a n/a TBD by Measure Implementer

Patient Characteristic Age LOINC 2.16.840.1.113883.3.560.100.4 age at start of ["Measurement Period"] >= 43 yearsage at start of ["Measurement Period"] <=70 years To ensure the measure is only looking for a blood test after an individual turns 40, the youngest age in this population is 43.

GROUPING 2.16.840.1.113883.3.464.1003.101.12.1001

CPT 2.16.840.1.113883.3.464.1003.101.11.1005

SNOMED-CT 2.16.840.1.113883.3.464.1003.101.11.1264

GROUPING 2.16.840.1.113883.3.464.1003.101.12.1008

CPT 2.16.840.1.113883.3.464.1003.101.11.1040

SNOMED-CT 2.16.840.1.113883.3.464.1003.101.11.1266

GROUPING 2.16.840.1.113883.3.464.1003.101.12.1012

CPT 2.16.840.1.113883.3.464.1003.101.11.1060

SNOMED-CT 2.16.840.1.113883.3.464.1003.101.11.1261

GROUPING 2.16.840.1.113883.3.526.3.1240HCPCS 2.16.840.1.113883.3.526.2.1363

GROUPING 2.16.840.1.113883.3.464.1003.101.12.1025

CPT 2.16.840.1.113883.3.464.1003.101.11.1125

GROUPING 2.16.840.1.113883.3.464.1003.101.12.1023

CPT 2.16.840.1.113883.3.464.1003.101.11.1115

GROUPING 2.16.840.1.113883.3.464.1003.101.12.1030CPT 2.16.840.1.113883.3.464.1003.101.11.1150

Physical Exam, Performed Body mass index (BMI) [Ratio] LOINC 39156-5

during ["Office Based Visits"] BMIexam.result: >=25 kg/m2

ORduring ["Preventive Visit"]

BMIexam.result: >=25 kg/m2

Denominator

GROUPING 2.16.840.1.113883.3.526.2.242ICD-10-CM 2.16.840.1.113883.3.526.2.242

SNOMED-CT 2.16.840.1.113883.3.526.2.532GROUPING 2.16.840.1.113883.3.464.1003.103.12.1001ICD-9-CM 2.16.840.1.113883.3.464.1003.103.11.1001ICD-10-CM 2.16.840.1.113883.3.464.1003.103.11.1002

SNOMED-CT 2.16.840.1.113883.3.464.1003.103.11.1003

Diagnosis Diabetes mellitus due to underlying condition without complications ICD-10-CM E08.9

overlaps after ["Office Based Visits"]OR

overlaps after ["Preventive Visit"]

Based upon TEP feedback, code will be included to account for other unspecified diabetes diagnoses such as: cystic fibrosis diabetes, pancreatogenic diabetes (pancreatitis, pancreatectomy).

Encounter, Performed Encounter Inpatient SNOMED-CT 2.16.840.1.113883.3.666.5.307 ends during ["Measurement Period"]

Attribute: Discharge Disposition Discharge to home for hospice care (procedure) SNOMED-CT 428361000124107 n/a This attribute is applicable to the value set "Encounter Inpatient" using QDM datatype Encounter, Performed.

Attribute: Discharge Disposition Discharge to healthcare facility for hospice care (procedure) SNOMED-CT 428371000124100.00 n/a This attribute is applicable to the value set "Encounter Inpatient" using QDM datatype Encounter, Performed.

Intervention, Order Hospice care ambulatory SNOMED-CT 2.16.840.1.113762.1.4.1108.15 during ["Measurement Period"]

Intervention, Performed Hospice care ambulatory SNOMED-CT 2.16.840.1.113762.1.4.1108.15 overlaps ["Measurement Period"]GROUPING 2.16.840.1.113883.3.600.1.1579

SNOMED-CT 2.16.840.1.113883.3.600.1.1578SNOMED-CT 1.3.6.1.4.1.33895.1.3.0.45GROUPING 2.16.840.1.113883.3.600.1.1579

SNOMED-CT 2.16.840.1.113883.3.600.1.1578SNOMED-CT 1.3.6.1.4.1.33895.1.3.0.45

GROUPING 2.16.840.1.113883.3.464.1003.198.12.1013

LOINC 2.16.840.1.113883.3.464.1003.198.11.1024

GROUPING TBD

LOINC TBD

GROUPING TBD

LOINC TBD

Denominator Exceptions

Measure Title: Screening for Abnormal Blood Glucose in Overweight/Obese Patients

Encounter, Performed Office Visit

Encounter, Performed Outpatient Consultation

To satisfy the measure requirements, there must be at least two encounters of any of these types documented during the measurement period to establish a patient-provider relationship. Once the count of two or more visits has been met, one of those encounters may be used to meet additional measure criteria.

Reference to an encounter in the constraints column for another data element will be specific to a single instance of an encounter, unless otherwise noted, so that the measure requirements will be assessed using the same instance of the encounter.

["Preventive Visit"] Count >=1 during ["Measurement Period"]

Denominator Exclusions

Numerator

To satisfy the measure requirements, there must be at least one encounter of any of these types documented during the measurement period to establish a patient-provider relationship. Once the count of one or more visits has been met, one of those encounters may be used to meet additional measure criteria.


Diagnosis Pregnancy

["Fasting Plasma Glucose Test"] Performed 3 years or less before end of "Measurement Period"

AND result is "not null"

Equals Initial Population

["2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"] Performed 3 years or less before end of "Measurement Period"

AND result is "not null"Laboratory Test, Performed



Diagnosis Diabetesoverlaps after ["Office Based Visits"]

ORoverlaps after ["Preventive Visit"]

Diabetes value set includes diagnosis codes for Type 1 and Type 2 Diabetes, latent autoimmune diabetes of adults (LADA), and monogeneic diabetes (MODY).

Laboratory Test, Performed Fasting Plasma Glucose Test

Laboratory Test, Performed["HbA1c Laboratory Test Grouping Value Set"] Performed 3 years or

less before end of "Measurement Period"AND result is "not null"

Intervention, Performed Palliative Care overlaps ["Measurement Period"]

Intervention, Order Palliative Care starts during ["Measurement Period"]

HbA1c Laboratory Test Grouping Value Set

Initial Population

Encounter, Performed Preventive Care Services - Established Office Visit, 18 and Up

Encounter, Performed Nursing Facility Visit

Annual Wellness VisitEncounter, Performed

2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test

["Office Based Visits"] Count >= 2 during ["Measurement Period"]

None

Encounter, Performed Preventive Care Services-Initial Office Visit, 18 and Up

Preventive Care Services - OtherEncounter, Performed

*This document uses Quality Data Model (QDM) version 5.3 © 2018 American Medical Association. All Rights Reserved.

American Medical AssociationPrediabetes Quality Measures

Measure Component QDM Datatype Value Set Name Standard Terminology OID or Reference Code Constraints Comments/Rationale


Patient Characteristic Age LOINC 2.16.840.1.113883.3.560.100.4 age at start of ["Measurement Period"] >= 18 years

GROUPING 2.16.840.1.113883.3.464.1003.101.12.1001CPT 2.16.840.1.113883.3.464.1003.101.11.1005

SNOMED-CT 2.16.840.1.113883.3.464.1003.101.11.1264GROUPING 2.16.840.1.113883.3.464.1003.101.12.1008

CPT 2.16.840.1.113883.3.464.1003.101.11.1040SNOMED-CT 2.16.840.1.113883.3.464.1003.101.11.1266GROUPING 2.16.840.1.113883.3.464.1003.101.12.1012

CPT 2.16.840.1.113883.3.464.1003.101.11.1060SNOMED-CT 2.16.840.1.113883.3.464.1003.101.11.1261GROUPING 2.16.840.1.113883.3.526.3.1240

HCPCS 2.16.840.1.113883.3.526.2.1363GROUPING 2.16.840.1.113883.3.464.1003.101.12.1025

CPT 2.16.840.1.113883.3.464.1003.101.11.1125GROUPING 2.16.840.1.113883.3.464.1003.101.12.1023

CPT 2.16.840.1.113883.3.464.1003.101.11.1115GROUPING 2.16.840.1.113883.3.464.1003.101.12.1030

CPT 2.16.840.1.113883.3.464.1003.101.11.1150

Physical Exam, Performed Body mass index (BMI) [Ratio] LOINC 39156-5

Patient Characteristic Race Asian CDCREC 2028-9

Family History Family history: Diabetes mellitus in first degree relative (situation) SNOMED-CT 416855002 starts before end of ["Measurement Period"]

Family History Family history of diabetes mellitus ICD-10-CM Z83.3 starts before end of ["Measurement Period"]

Patient Characteristic Race Black or African American CDCREC 2054-5 during ["Measurement Period"]

Patient Characteristic Race African American CDCREC 2058-6 during ["Measurement Period"] This concept is not included as a supplemental data element which are regularly captured in electronic measures. There is potential that this code is not utilized.

Patient Characteristic Ethnicity Hispanic or Latino CDCREC 2135-2 during ["Measurement Period"]Patient Characteristic Race American Indian or Alaska Native CDCREC 1002-5 during ["Measurement Period"]Patient Characteristic Race Asian CDCREC 2028-9 during ["Measurement Period"]Patient Characteristic Race Native Hawaiian or Other Pacific Islander CDCREC 2076-8 during ["Measurement Period"]

GROUPING TBD

LOINC 2.16.840.1.113883.3.117.1.7.1.215

GROUPING 2.16.840.1.113883.3.464.1003.104.12.1012

LOINC 2.16.840.1.113883.3.464.1003.104.11.1032

GROUPING TBD

RX NORM TBDGROUPING TBD

ICD-10-CM TBD

SNOMED-CT TBD

overlaps ["Office Based Visits"]HDLTest.result <35 'mg/dL'

ORoverlaps ["Preventive Visit"]HDLTest.result < 35 'mg/dL'

Medication, Active Hypercholesterolemia Pharmacotherapyoverlaps after ["Office Based Visits"]

ORoverlaps after["Preventive Visit"]

Diagnosis Polycystic Ovary Syndrome

Laboratory Test, Performed

Laboratory Test, Performed LDL-C Test

overlaps ["Office Based Visits"]LDLTest.result > 250 'mg/dL'

ORoverlaps ["Preventive Visit"]

LDLTest.result > 250 'mg/dL'

HDL-C Laboratory Test

Measure Title: Screening for Abnormal Blood Glucose in High Risk Patients

Encounter, Performed Annual Wellness Visit


To satisfy the measure requirements, there must be at least one encounter of any of these types documented during the measurement period to establish a patient-provider relationship. Once the count has been met, one of those encounters may be used to meet additional measure criteria.


Initial Population


Encounter, Performed Preventive Care Services - Other


Encounter, Performed Outpatient Consultation

Encounter, Performed Nursing Facility Visit







BMIexam.result: >=25 kg/m2OR


where ["Patient Characteristic Race": "Asian"] OR

during ["Preventive Visit"]BMIexam.result: >=23 kg/m2

where ["Patient Characteristic Race": "Asian"]

Denominator

What classes of medication should be included in value set? Should statin therapies be included? If so, what intensity of statin therapies should be included?







GROUPING TBDICD-10-CM TBD

SNOMED-CT TBD

Assessment, Performed Minutes of moderate aerobic physical activity per week LOINC TBD

during ["Office Based Visits"]Test.result < 150 minutes/week'


Test.result < 150 minutes/week'

Currently, no concepts exist to capture the intent of this data element. Recommend considering requesting new concept.

Assessment, Performed Minutes of vigorous aerobic physical activity per week LOINC TBD

during ["Office Based Visits"]Test.result < 75 minutes/week'


Test.result < 75 minutes/week'

Currently, no concepts exist to capture the intent of this data element. Recommend considering requesting new concept.

GROUPING 2.16.840.1.113883.3.464.1003.103.12.1010ICD-10-CM 2.16.840.1.113883.3.464.1003.103.11.1014

SNOMED-CT 2.16.840.1.113883.3.464.1003.103.11.1012GROUPING 2.16.840.1.113883.3.526.3.403ICD-9-CM 2.16.840.1.113883.3.526.2.118

ICD-10-CM 2.16.840.1.113883.3.526.2.119SNOMED-CT 2.16.840.1.113883.3.526.2.58GROUPING 2.16.840.1.113762.1.4.1047.44ICD-9-CM 2.16.840.1.113762.1.4.1047.33




ICD-10-CM 2.16.840.1.113762.1.4.1047.37SNOMED-CT 2.16.840.1.113762.1.4.1047.69GROUPING 2.16.840.1.113883.3.666.5.694ICD-9-PCS 2.16.840.1.113883.3.666.5.1669

ICD-10-PCS 2.16.840.1.113883.3.666.5.1668SNOMED-CT 2.16.840.1.113883.3.666.5.1669GROUPING 2.16.840.1.113883.3.666.5.694ICD-9-PCS 2.16.840.1.113883.3.666.5.1669

ICD-10-PCS 2.16.840.1.113883.3.666.5.1668SNOMED-CT 2.16.840.1.113883.3.666.5.1669GROUPING 2.16.840.1.113883.3.117.1.7.1.204ICD-9-PCS 2.16.840.1.113883.3.117.1.7.1.237

ICD-10-PCS 2.16.840.1.113883.3.117.1.7.1.238SNOMED-CT 2.16.840.1.113883.3.117.1.7.1.239

GROUPING 2.16.840.1.113883.3.526.3.1032

LOINC 2.16.840.1.113883.3.526.2.1044

GROUPING 2.16.840.1.113883.3.526.3.1033

LOINC 2.16.840.1.113883.3.526.2.1045

GROUPING TBD

RX NORM TBD

Procedure, Performed PCI starts before end of ["Measurement Period"]

Procedure, Performed CABG Surgeries starts before end of ["Measurement Period"]

Diagnosis Myocardial Infarction

Medication, Active Hypertension Therapyoverlaps after ["Office Based Visits"]

ORoverlaps after ["Preventive Visit"]

Value set to include high blood pressure medications from the following classes: Diuretics, Beta Blockers, ACE inhibitors, Angiotensin II receptor blockers, Calcium channel blockers, Alpha blockers, Alpha-2 Receptor Agonists, Combined alpha and beta-blockers, Central agonists, Peripheral adrenergic inhibitors, Blood vessel dilators (vasodilators)

Source: http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/Types-of-Blood-Pressure-Medications_UCM_303247_Article.jsp#.WtDY2IjwZPY

Physical Exam, Performed Diastolic Blood Pressure

during ["Office Based Visits"]DiastolicBP.result >= 90 'mm[Hg]'


DiastolicBP.result >= 90 'mm[Hg]'

Procedure, Performed Carotid Intervention starts before end of ["Measurement Period"]

Physical Exam, Performed Systolic Blood Pressure

during ["Office Based Visits"] SystolicBP.result >= 140 'mm[Hg]'


SystolicBP.result >= 140 'mm[Hg]'



Gestational Diabetes Diagnosis starts before end of ["Measurement Period"]

Diagnosis Acanthosis Nigricans

starts before end of ["Measurement Period"]

For the purposes of this measure, a history of CVD is defined as the folllowing diagnoses and procedures: -Myocardial Infarction-Cerebrovascular disease, Stroke, TIA-Atherosclerosis and Peripheral Arterial Disease-Ischemic heart disease or coronary occlusion, rupture, or thrombosis-Stable and Unstable Angina-PCI-CABG Surgeries -Carotid Intervention

Denominator

Diagnosis Cerebrovascular disease, Stroke, TIA starts before end of ["Measurement Period"]

Diagnosis Atherosclerosis and Peripheral Arterial Disease starts before end of ["Measurement Period"]

Diagnosis Ischemic heart disease or coronary occlusion, rupture, or thrombosis starts before end of ["Measurement Period"]

Diagnosis Stable and Unstable Angina starts before end of ["Measurement Period"]





GROUPING 2.16.840.1.113883.3.526.2.242ICD-10-CM 2.16.840.1.113883.3.526.2.242

SNOMED-CT 2.16.840.1.113883.3.526.2.532GROUPING 2.16.840.1.113883.3.464.1003.103.12.1001ICD-9-CM 2.16.840.1.113883.3.464.1003.103.11.1001

ICD-10-CM 2.16.840.1.113883.3.464.1003.103.11.1002SNOMED-CT 2.16.840.1.113883.3.464.1003.103.11.1003




Based upon TEP feedback, code will be included to account for other unspecified diabetes diagnoses such as: cystic fibrosis diabetes, pancreatogenic diabetes (pancreatitis, s/p pancreatectomy).





Intervention, Performed Hospice care ambulatory SNOMED-CT 2.16.840.1.113762.1.4.1108.15 overlaps ["Measurement Period"]

GROUPING 2.16.840.1.113883.3.600.1.1579SNOMED-CT 2.16.840.1.113883.3.600.1.1578SNOMED-CT 1.3.6.1.4.1.33895.1.3.0.45GROUPING 2.16.840.1.113883.3.600.1.1579


GROUPING 2.16.840.1.113883.3.464.1003.198.12.1013

LOINC 2.16.840.1.113883.3.464.1003.198.11.1024

GROUPING TBD

LOINC TBD

GROUPING TBD

LOINC TBD


["2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"] Performed 3 years or less before end of ["Measurement Period"]

AND result is "not null"

Numerator

Diagnosis

None





Fasting Plasma Glucose Test



["HbA1c Laboratory Test Grouping Value Set"] Performed 3 years or less before end of ["Measurement Period"]

AND result is "not null"["Fasting Plasma Glucose Test"] Performed 3 years or less before

end of ["Measurement Period"] AND result is "not null"







starts during ["Measurement Period"]Intervention, Order Palliative Care

Diabetes

Diagnosis Pregnancy






GROUPING 2.16.840.1.113883.3.464.1003.101.12.1001CPT 2.16.840.1.113883.3.464.1003.101.11.1005




HCPCS 2.16.840.1.113883.3.526.2.1363GROUPING 2.16.840.1.113883.3.464.1003.101.12.1025

CPT 2.16.840.1.113883.3.464.1003.101.11.1125GROUPING 2.16.840.1.113883.3.464.1003.101.12.1023

CPT 2.16.840.1.113883.3.464.1003.101.11.1115GROUPING 2.16.840.1.113883.3.464.1003.101.12.1030

CPT 2.16.840.1.113883.3.464.1003.101.11.1150

GROUPING 2.16.840.1.113883.3.464.1003.198.12.1013

LOINC 2.16.840.1.113883.3.464.1003.198.11.1024

GROUPING TBD

LOINC TBD

GROUPING TBD

LOINC TBD

Denominator

GROUPING 2.16.840.1.113883.3.526.2.242ICD-10-CM 2.16.840.1.113883.3.526.2.242

SNOMED-CT 2.16.840.1.113883.3.526.2.532GROUPING 2.16.840.1.113883.3.464.1003.103.12.1001ICD-9-CM 2.16.840.1.113883.3.464.1003.103.11.1001

ICD-10-CM 2.16.840.1.113883.3.464.1003.103.11.1002SNOMED-CT 2.16.840.1.113883.3.464.1003.103.11.1003


overlaps after ["Office Based Visits"]or


Based upon TEP feedback, code will be included to account for other unspecified diabetes diagnoses such as: cystic fibrosis diabetes, pancreatogenic diabetes (pancreatitis, pancreatectomy).





Intervention, Performed Hospice care ambulatory SNOMED-CT 2.16.840.1.113762.1.4.1108.15 overlaps ["Measurement Period"]GROUPING 2.16.840.1.113883.3.600.1.1579

SNOMED-CT 2.16.840.1.113883.3.600.1.1578SNOMED-CT 1.3.6.1.4.1.33895.1.3.0.45GROUPING 2.16.840.1.113883.3.600.1.1579



Palliative Care


Diagnosis

Office Visit


Initial Population

Intervention, Order

Pregnancyoverlaps after ["Office Based Visits"]

oroverlaps after ["Preventive Visit"]



Measure Title: Intervention for Prediabetes




Encounter, Performed Annual Wellness Visit To satisfy the measure requirements, there must be at least one encounter of any of these types documented during the measurement period to establish a patient-provider relationship. Once the count has been met, one of those encounters may be used to meet additional measure criteria.



["Office Based Visits Count"] >= 2 during ["Measurement Period"]Encounter, Performed Outpatient Consultation

Encounter, Performed


overlaps after ["Preventive Visit"]Diagnosis Diabetes

starts during ["Measurement Period"]


Reference to an encounter in the constraints column for another data element will be specific to a single instance of an encounter, unless otherwise noted, so that the measure requirements will be assessed using the same instance of the encounter. Encounter, Performed Nursing Facility Visit

["HbA1c Laboratory Test Grouping Value Set"] Performed 12 months or less before end of ["Measurement Period"]

AND result >= 5.7% AND result =< 6.4%

["Fasting Plasma Glucose Test"] Performed 12 months or less before end of ["Measurement Period"]

AND result >= 100 mg/dL (5.6 mmol/L) AND result =< 125 mg/dL (6.9 mmol/L)

["2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"] Performed 12 months or less before end of ["Measurement Period"]

AND result >= 140 mg/dL AND result =< 199 mg/dL


Laboratory Test, Performed HbA1c Laboratory Test Grouping Value Set





Measure Title: Intervention for Prediabetes

Intervention, Performed Referral to CDC-Recognized Diabetes Prevention Program SNOMED-CT TBD

starts after end of: ["Laboratory Test, Performed": "HbA1c Laboratory Test Grouping

Value Set"] OR

["Laboratory Test, Performed: "Fasting Plasma Glucose Test"]OR

["Laboratory Test, Performed": "2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"]

Currently no concepts exist to capture the intent of this data element. Would recommend requesting new concept.

Intervention, Performed Patient referral to dietitian (procedure) SNOMED-CT 103699006


Value Set"] OR



GROUPING TBD

RX NORM TBD

Intervention, Not Performed Referral to CDC-Recognized Diabetes Prevention Program SNOMED-CT TBD

during ["Office Based Visits"]or

during ["Preventive Visit"]

Intervention, Not Performed Patient referral to dietitian (procedure) SNOMED-CT 103699006during ["Office Based Visits"]

orduring ["Preventive Visit"]

GROUPING TBD

RXNORM TBD

GROUPING 2.16.840.1.113883.3.526.3.1007

SNOMED-CT 2.16.840.1.113883.3.526.2.313

GROUPING 2.16.840.1.113883.3.526.3.1008

SNOMED-CT 2.16.840.1.113883.3.526.2.311

GROUPING 2.16.840.1.113883.3.526.3.1259

SNOMED-CT 2.16.840.1.113883.3.526.2.1353Limited Life Expectancy

Attribute: Negation Rationale Medical Reason

Metformin

Patient Reason

during ["Office Based Visits"]or

during ["Preventive Visit"]This attribute is applicable to the value sets "Referral to CDC-Recognized Diabetes Prevention Program" and "Patient referral to dietitian (procedure)" using QDM datatype Intervention, Not Performed. This attribute is also applicable to the value set "Metformin" using QDM datatype, Medication, Not Ordered.

Medication, Not Ordered

n/a

Numerator

Medication, Order Metformin


Value Set"]OR




overlaps after ["Preventive Visit"]Diagnosis

Attribute: Negation Rationale


This attribute is applicable to the value sets "Referral to CDC-Recognized Diabetes Prevention Program" and "Patient referral to dietitian (procedure)" using QDM datatype Intervention, Not Performed. This attribute is also applicable to the value set "Metformin" using QDM datatype, Medication, Not Ordered.

n/a






GROUPING 2.16.840.1.113883.3.464.1003.101.12.1001CPT 2.16.840.1.113883.3.464.1003.101.11.1005




HCPCS 2.16.840.1.113883.3.526.2.1363GROUPING 2.16.840.1.113883.3.464.1003.101.12.1025

CPT 2.16.840.1.113883.3.464.1003.101.11.1125GROUPING 2.16.840.1.113883.3.464.1003.101.12.1023

CPT 2.16.840.1.113883.3.464.1003.101.11.1115GROUPING 2.16.840.1.113883.3.464.1003.101.12.1030

CPT 2.16.840.1.113883.3.464.1003.101.11.1150

GROUPING 2.16.840.1.113883.3.464.1003.198.12.1013

LOINC 2.16.840.1.113883.3.464.1003.198.11.1024

GROUPING TBD

LOINC TBD

GROUPING TBD

LOINC TBD

Denominator


GROUPING 2.16.840.1.113883.3.464.1003.198.12.1013

LOINC 2.16.840.1.113883.3.464.1003.198.11.1024

GROUPING TBD

LOINC TBD

GROUPING TBD

LOINC TBD

GROUPING 2.16.840.1.113883.3.464.1003.198.12.1013

LOINC 2.16.840.1.113883.3.464.1003.198.11.1024

GROUPING TBD

LOINC TBD

GROUPING TBD

LOINC TBD

GROUPING 2.16.840.1.113883.3.526.3.1008

SNOMED-CT 2.16.840.1.113883.3.526.2.311

["HbA1c Laboratory Test Grouping Value Set"] Performed 12 months or less before start of ["Measurement Period"]

AND result >= 5.7% ["Fasting Plasma Glucose Test"] Performed 12 months or less

before start of "Measurement Period" AND result >= 100 mg/dL (5.6 mmol/L) AND result =< 125 mg/dL (6.9 mmol/L)

["2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"] Performed 12 months or less before start of ["Measurement

Period"] AND result >= 140 mg/dL AND result =< 199 mg/dL

Laboratory Test, Performed HbA1c Laboratory Test Grouping Value Set


Initial Population






Fasting Plasma Glucose Test


Laboratory Test, Performed 2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test


["Fasting Plasma Glucose Test"] during ["Measurement Period"] AND result is "not null"Laboratory Test, Performed

None


Numerator

["HbA1c Laboratory Test Grouping Value Set"] during ["Measurement Period"]AND result is "not null"



during ["Measurement Period"]

Laboratory Test, Not Performed 2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test during ["Measurement Period"]

Attribute: Negation Rationale Patient Reason n/a

Laboratory Test, Not Performed

This attribute is applicable to the value sets "HbA1c Laboratory Test Grouping Value Set," "Fasting Plasma Glucose Test," and "2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test" using QDM datatype Laboratory Test, Not Performed.

HbA1c Laboratory Test Grouping Value Set during ["Measurement Period"]

Laboratory Test, Not Performed Fasting Plasma Glucose Test

Nursing Facility Visit

["2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"] during ["Measurement Period"]

AND result is "not null"Laboratory Test, Performed 2-H Plasma Glucose During a 75g Oral Glucose

Tolerance Test

Measure Title: Retesting of Abnormal Blood Glucose in Patients with Prediabetes

Encounter, Performed Annual Wellness Visit


To satisfy the measure requirements, there must be at least one encounter of any of these types documented during the measurement period to establish a patient-provider relationship. Once the count has been met, one of those encounters may be used to meet additional measure criteria.





Outpatient Consultation


Documents

American Medical Association (AMA) Prediabetes Quality Measures · • History of gestational diabetes mellitus . Denominator Exclusions/ Exceptions . Denominator Exclusions: Exclude