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Key Clinical Interventions and Documentation Summary for Diabetes Measures


The successful documentation and completion of clinical quality measurement requirements requires many interventions to take place within a practice. The following resource provides a summation of the key clinical interventions that can be used for diabetes quality improvement and includes the general data elements needed for measure calculation. This resource is intended for educational purposes only. Practices should work with their vendor to determine which CQMs their EHR system are certified to report on, and any specific workflow changes needed to ensure CQMs calculate properly in their specific EHR system.

The following information is presented in a series of tables:

For more information on the specific data elements required for clinical quality measures, visit the Meaningful Use portal in USHIK.

For further information on CQMs and Meaningful Use, please visit: EHR Incentive Programs - Centers for Medicare & Medicaid Services

Meaningful Use Diabetes Measures


This table lists most of the Meaningful Use measures applicable to patients with diabetes, with the associated National Quality Forum (NQF) number noted parenthetically.

Meaningful Use Diabetes Measures
Diabetes: Eye Exam (NQF# 0055; CMS131v7)
Diabetes: Urine Screening (NQF# 0062; CMS134v7)
Diabetes: HbA1c Poor Control (NQF# 0059; CMS122v7)
Diabetes: HbA1c Control (NQF# 0575)
Diabetes: Foot Exam (NQF# 0056; CMS123v7)
Diabetes: Blood Pressure Management (NQF# 0061)
Diabetes: LDL Management & Control (NQF# Not Applicable; CMS163v5)
Hemoglobin A1c Test for Pediatric Patients (NQF# Not Applicable; CMS148v5)

Key Clinical Interventions


This table lists key interventions to be completed during a patient’s visit. Documentation of these interventions in the electronic health record will help ensure all of the necessary information needed to calculate Meaningful Use diabetes measures is available. For interventions that correlate to a specific diabetes measure, the applicable NQF number is noted parenthetically. Practices may find assigning responsibility for each of these interventions to specific staff members helpful in integrating each activity into the practice workflow. Technical information regarding specific diagnoses and procedures associated with diabetes measures can be found in the Meaningful Use portal of USHIK.

Key Clinical Interventions
  • Confirm patient's date of birth (all)
  • Record date and type of visit (all)
  • Assess patient or check their record for active diagnosis of diabetes (all)
  • Assess patient or check their record for active diagnosis of polycystic ovaries, gestational diabetes, or steroid induced diabetes (all)
  • Assess patient or check their record for active diagnosis of diabetic retinopathy (NQF# 0055; CMS131v7)
  • Check patient record of documentation of eye exam in the last two years. Order an eye exam if appropriate (NQF# 0055; CMS131v7)
  • Check patient record for foot exam. Perform one if needed. (NQF# 0056; CMS123v7)
  • Check patient record for HbA1c value. Order test if needed. (NQF# 0059; CMS122v7) (NQF# Not Applicable; CMS148v5)
  • Check patient record for active diagnosis of nephropathy or evidence of a nephropathy related procedure (NQF# 0062; CMS134v7)
  • Check patient record for documentation of most recent LDL-C test date and result. Order LDL-C test if needed (NQF# Not Applicable; CMS163v5)

Numerator Elements


This table specifies the information that needs to be documented in the electronic health record to appropriately calculate the numerator. The specific measure to which the element applies in noted by the NQF number in parentheses. Technical information related to the measure numerators can be found in the Meaningful Use portal of USHIK.

Elements Needed for the Numerator

Denominator Elements


This table specifies the information that needs to be documented in the electronic health record to appropriately calculate the denominator. These elements apply to all Meaningful Use diabetes measures. Technical information related to the measure denominators can be found in the Meaningful Use portal of USHIK.

Elements Needed for the Denominator
  • Patient Age
  • Encounter Codes
  • Active diagnosis of diabetes or medications indicative of diabetes

Exclusion/Exception Elements


This table specifies the information that needs to be documented in the electronic health record to appropriately determine measure exclusions. These elements apply to all Meaningful Use diabetes measures. Technical information related to the measure exclusions/exceptions can be found in the Meaningful Use portal of USHIK.

Elements Needed for Exclusions/Exceptions
  • Patient Age
  • Encounter Codes
  • Active diagnosis of polycystic ovaries, gestational diabetes, or steroid induced diabetes
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