| Confirm Diagnosis of Diabetes Mellitus (DM) |
Instruction: Determine if the patient has a documented history
of DM during the measurement period or year prior to the measurement period.
|
Adult onset diabetes mellitus, AODM, adult onset diabetes, AOD, diabetes
mellitus, diabetes, Type II diabetes, IDDM, insulin dependent diabetes mellitus,
NIDDM, non-insulin dependent diabetes mellitus, Type I diabetes |
Exclude patients with a diagnosis of polycystic ovaries on the problem
list who did not also have a diagnosis of diabetes on the problem list during the
measurement period or year prior to the measurement period.
Diagnosis of polycystic ovaries can occur at any time in the patient’s history,
but must have occurred by the last day of the measurement period.
Exclude patients with a diagnosis of gestational diabetes or steroid–induced
diabetes on the problem list during the measurement period.
Diagnosis of gestational diabetes or steroid-induced diabetes can occur during the
measurement period or the year prior to the measurement period but must have occurred
by the last day of the measurement period. |
| [DMCONFIRMED] |
Yes (1): Select this option if
the patient has a documented history of DM in the office/clinic record.
No/No reason documented (0): Select this option
if the patient has no documented history of DM in the office/clinic record.
Not Included for Medical Reasons (3): Select this
option if the patient has polycystic ovaries, gestational diabetes or steroid induced
diabetes.
If ”No” or “Not Included for Medical Reasons”,
STOP ABSTRACTION
Medical record not found (2): Select this option if
you are unable to find the patient’s medical record. |
| HbA1c Management Testing/Poor Control |
Instruction: Determine if the patient had one or more HbA1c tests performed during the measurement period. |
Glycohemoglobin A1c, HbA1c, Hemoglobin A1c, HgbA1c, A1c |
None |
| [DMHBA1CTEST] |
Yes (1): Select this option if the patient had one or more A1c tests. |
| [DMHBA1CDATE] |
* Record the most recent date the blood was drawn for the A1c in MM/DD/YYYY format |
| [DMHBA1CVALUE] |
* Record the most recent A1c value |
| [DMHBA1CTEST] |
No/No reason documented (0):
Select this option if the patient did not have one or more A1c tests.
Note: At a minimum, documentation in the medical record must include
a note indicating the date on which the HbA1c test was performed and the result.
Use the following priority ranking:
- Lab report draw date
- Lab report date
- Flow sheet documentation
- Practitioner notes
- Other documentation
|
| Blood Pressure Management |
Instruction: Determine if the patient’s most recent BP during the measurement period was recorded. |
None |
None |
| [DMBPMEASURE] |
Yes (1): Select this option if the patient’s most recent BP was recorded. |
| [DMBPDATE] |
* Record the date of the most recent BP in MM/DD/YYYY format |
| [DMBPSYSTOLIC] |
* Enter the systolic BP recorded in mm Hg |
| [DMBPDIASTOLIC] |
* Enter the diastolic BP recorded in mm Hg |
| [DMBPMEASURE]
|
No /No
reason documented (0): Select this option if the patient’s most recent
BP measurement was not recorded. Note: If no valid blood pressure during the measurement
period, select “no”.
Note: Identify the BP reading from that visit. If there is one
BP reading from that visit, it becomes the representative BP. If there are multiple
BPs from a single visit, physicians should use the lowest BP of the visit as the
representative BP; however, sitting BP is preferred.
The following steps should be followed below to determine representative
BP:
- Identify the most recent visit to the practitioner’s office or clinic that
occurred during the measurement period in which a BP reading was noted.
- To be eligible, the representative BP must have been obtained during a visit to
the practitioner’s office or other nonemergency outpatient facility, such
as a clinic or urgent care center. Outpatient visits for the sole purpose of having
a diagnostic test or surgical procedure performed (e.g., sigmoidoscopy, removal
of a mole) are not eligible.
- BP measurements obtained the same day as a major diagnostic or surgical procedure
(e.g., stress test, administration of IV contrast for a radiology procedure, endoscopy)
or at an emergency room are not eligible.
|
| Lipid Management Testing/Control
|
Instruction: Determine if the patient had one or more
LDL-C tests during the measurement period. |
The following synonyms signify a test was performed
if present: Cholesterol analysis, cholesterol panel, cholesterol profile,
fasting lipids, LDL:HDL, LDL:HDL ratio, lipid analysis, lipid panel, lipid profile,
lipids, lipoprotein analysis, low density lipoprotein (LDL), LDL–Cholesterol,
LDL–C |
None |
| [DMLDLCTEST]
|
Yes (1):
Select this option if the patient had one or more LDL–C tests.
|
| [DMLDLCDATE]
|
* Record the most recent date the blood was drawn for LDL–C in MM/DD/YYYY
format
|
| [DMLDLCVALUE]
|
* Record the most recent LDL–C value [if laboratory unable to calculate
LDL–C value due to high triglycerides, record 0 (zero). If the test result
is labeled "unreliable" and a result is provided, also record 0 (zero). Do not enter
a ratio as a value (it is not a valid value)].
Note: A calculated LDL may be used for LDL–C screening and control indicators.
|
| [DMLDLCTEST] |
No /No reason documented (0):
Select this option if the patient did not have one or more LDL–C tests.
Note: At a minimum, documentation in the medical record must include
a note indicating the date on which the LDL–C test was performed and the result.
Use the following priority ranking:
- Lab report draw date
- Lab report date
- Flow sheet documentation
- Practitioner notes
- Other documentation
|
| Urine Protein Screening
|
Instruction: Determine if the patient had any test
for urine microalbumin, or who had evidence of medical attention for nephropathy,
or had a positive macroalbumin test or received ACE Inhibitor/ARB therapy
during the measurement period.
Note: The default setting for this element is Claim Not Found.
|
See drug list of ACE Inhibitor medications in Table 1 and ARBs in
Table 2. |
“Trace” urine macroalbumin test results are
not considered numerator compliant |
| [DMNEPHROPATHY] |
Yes (1): Select this
option if the patient had any test for urine microalbumin, or had evidence of medical
attention for nephropathy or had a positive macroalbumin test or received ACE Inhibitor/ARB
therapy.
No/No reason documented (0): Select this option
if the patient did not have any test for urine microalbumin, or evidence of medical
attention for nephropathy, or received ACE Inhibitor/ARB therapy.
Claim not found (2): Select this option if you
are not abstracting records for claims–based measures.
Note: At a minimum, documentation in the medical record must include
a note indicating the date on which the urine microalbumin test was performed and
the result. Notation of the following may count in the medical record for urine
microalbumin test:
- 24–hour urine for microalbumin
- Timed urine for microalbumin
- Spot urine for microalbumin
- Microalbumin/creatinine ratio
Note: At a minimum, documentation in the medical record must include
a note indicating the date on which the test was performed and a positive result
for protein in the urine. The following may count in the medical record:
- Positive urinalysis (timed, spot, microalbumin/creatinine ratio)
- Positive urine dipstick
- Positive tablet reagent
|
|
|
| Urine Protein Screening cont. |
Note: Medical attention for nephropathy:
- Visit to a nephrologist – documentation in the medical record must include,
at a minimum, a note indicating medical attention during the measurement year for:
- Diabetic nephropathy
- A positive test result for urine microalbumin (i.e., urine protein or proteinuria)
- End–stage renal disease (ESRD)
- Chronic renal failure (CRF)
- Renal insufficiency
- Acute renal failure (ARF)
- Dialysis, hemodialysis or peritoneal dialysis
Note: Evidence of ACE Inhibitor/ARB therapy – Documentation
must include, at a minimum, a note indicating that the patient received a prescription
for ACE Inhibitors/ARBs on an ambulatory basis within the measurement period.
|
|
|
| Eye Examination
|
Instruction: Determine if the patient had eye screening
for diabetic retinal disease identified by:
- a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist)
during the measurement period OR
- a negative retinal eye exam (no evidence of retinopathy)
by an eye care professional (optometrist or ophthalmologist) during the year prior
to the measurement period.(Year prior = 7/1/08 – 6/30/09.)
Note: The default setting for this element is Claim Not Found.
|
None |
None |
| [DMEYEEXAM] |
Yes (1): Select this
option if the patient had a dilated eye exam by an optometrist or ophthalmologist,
or a negative retinal eye exam during the year prior to the measurement period.
No/No reason documented (0): Select this option
if the patient did not have a dilated eye exam by an optometrist or ophthalmologist,
or a negative retinal eye exam during the year prior to the measurement period.
Claim not found (2): Select this option if you
are not abstracting records for claims–based measures.
Note: At a minimum, documentation in the medical record must include:
- A note or letter from an ophthalmologist, optometrist or other health care professional
summarizing the date on which the procedure was performed and the results of a retinal
evaluation performed by an eye care professional OR
- A chart or photograph of retinal abnormalities. If fundus photography was used in the
exam, there must be documentation in the medical record indicating the date on which
the procedure was performed and evidence that an eye care professional reviewed
the results. Alternatively, results may be read by a qualified reading center that
operates under the direction of a medical director who is a retinal specialist.
A note, which may be prepared by a primary care provider, indicating
the date on which the procedure was performed, and that an ophthalmoscopic exam
was completed by an eye–care professional, with results of the exam.
|
|
|
Foot Exam
[DMFOOTEXAM] |
Instruction: Determine if the patient had at least one of the following foot exam
components performed during the measurement period.
Yes (1): Select this option if the patient had
at least one foot exam component performed during the measurement period.
No/No reason documented (0): Select this option
if a foot exam was not performed or there was no reason documented for not performing
a foot exam.
Not performed for medical reasons (3): Select this
option if a complete foot exam was not performed due to history of bilateral foot/leg
amputation. |
A foot exam can include a visual inspection, a sensory exam with monofilament, or
a pulse exam.
Visual inspection
May refer to foot lesions, ulcers, deformities, clubbing, cyanosis, edema, toe nail
clipping, diabetic foot care (DFC)
Sensory exam
Testing with monofilament
Pulse exam
May refer to circulation in feet, temperature, pulses, dorsalis pedis, DP, pedal
pulse, posterior tibial, PT, ankle/arm ratio |
Documentation of lower extremities without mention of feet (e.g., “extremities,
no edema”), range of motion (ROM) exams, patient self–report of foot
condition, foot amputation, sensory exam with tuning fork |
|