American Osteopathic Association
Clinical Assessment Program for Physicians
Diabetes Mellitus Data Dictionary
This data dictionary provides directions on chart abstraction for the Diabetes Mellitus CAP for
Physician Module. The measures for the Diabetes Mellitus module include a combination of PQRS
measures and additional CAP measures that are pertinent to the osteopathic care for Diabetes
Mellitus patients. In total, there are eight PQRS measures and three additional CAP measures.
In addition to the data dictionary, use the Diabetes Mellitus CAP Patient Visit Form to answer the
measure questions and abstract the patient data. The form is downloadable from the Stage A Chart
Review page within the module. The data dictionary groups the PQRS measures first and then the
additional CAP measures. The measure questions follow the sequence as listed in the paper
abstraction tool.
PATIENT SAMPLE CRITERIA
Patient sample criteria for the Diabetes Mellitus Measures Group are patients aged 18 through 75
years with a specific diagnosis of diabetes accompanied by a specific patient encounter:
One of the following diagnosis codes indicating diabetes: 250.00, 250.01, 250.02,
250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30,
250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52,
250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80,
250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 357.2, 362.01, 362.02,
362.03, 362.04, 362.05, 362.06, 362.07, 366.41, 648.00, 648.01, 648.02, 648.03,
648.04
Accompanied by One of the following patient encounter codes: 97802, 97803,
97804, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304,
99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328,
99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348,
99349, 99350, G0270, G0271
PATIENT SELECTION AND DATA COLLECTION:
There are several ways of identifying patients for this study, therefore, you may pick any of the
following methods:

Use the diagnosis codes and encounter codes to identify the last 20 patients treated at your
practice and determine if each of the patients are eligible to be abstracted using the
following criteria: 18 - 75 years, with a diagnosis of diabetes. When you have 20 charts that
are eligible then enter the data as described in the data dictionary. The most convenient way
to do this may be to abstract the information onto the paper abstraction tool available in
PDF and, when finished, enter the data directly into the web site.

Or, starting at some point in time, use the diagnosis codes and encounter codes and collect
data from the next 20 sequential patients you see with age 18 - 75 years with a diagnosis of
diabetes. The paper abstraction tool can be used and then data can be directly entered as
indicated above.
These methods can be used for the baseline abstraction of 20 charts and then repeated for the remeasurement abstraction of 20 charts. A total of 40 charts are necessary to complete the project
and receive 20 hours of 1B CME activity. A period of at least 1 month must elapse between the
baseline and re-measurement abstraction. During this time you may complete any of the
interventions available from the website and develop an action plan.
CAP for PQRS
Please note that if you choose to report the CAP for PQRS, you must select 30 patients for your
baseline abstraction for a total of 50 charts. The additional requirements for the CAP for PQRS
include:
1. You will need to abstract 30 unique Medicare Part B Fee For Service (FFS) patients who
meet patient sample criteria for the measures group.
2. You will need to satisfy and report each measure within the measure group at least one time.
CMS guidelines indicate that each measure you report must have a performance rate greater
than 0%.
DEMOGRPHIC INFORMATION
1. Patient ID
▫ Use the Patient ID that is automatically assigned, or enter an identifier that is meaningful
to your practice. Keep a record of this identifier in case you need to make edits.
2. Patient Visit Date
▫ The visit date you are reporting on must occur within the 2012 Reporting Period
(1/1/2012 – 12/31/2012).
3. Patient Age
▫ The patient must be between the ages of 18 through 75 to qualify for the 2012 Diabetes
Mellitus Measure Group.
4. Patient Gender
▫ Male
▫ Female
5. Is the patient Hispanic or Latino origin or descent?
▫ Yes
▫ No
6. What is the patient’s race?
▫ American Indian or Alaska Native
▫ Asian
▫ Black or African American
▫ Native Hawaiian or Pacific Islander
▫ White
▫ Skip the question
7. What is the patient’s primary insurance?
▫ Medicare
▫ Medicaid
▫ Commercial
▫ Self Pay
▫ Other/Unknown
8.
If commercial insurance, what insurance does the patient have?
_________________
9.
Is the patient a Medicare Part B Fee-For-Service (FFS) beneficiary?
(includes Railroad Retirement Board and Medicare Secondary Payer; does not include Medicare Advantage beneficiaries). If
“No,” and you are following the CAP Plus PQRS path, the patient is not eligible for the 2012 Diabetes Mellitus
Measure Group.
10. Please choose the applicable diagnosis code for Diabetes Mellitus. The diagnosis code for
the patient must be one of those listed in the question. If you have a diagnosis code that is
not listed, this patient is not eligible to be reported for the 2012 Diabetes Mellitus Measure
Group.
▫ 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21,
250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43,
250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71,
250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93,
357.2, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 366.41, 648.00,
648.01, 648.02, 648.03, 648.04
11. Was the diagnosis code selected above billed to Medicare for a visit that occurred within the
2011 Reporting Period (1/1/2012 – 12/31/2012)?
▫ Yes
▫ No
CAP PQRS MEASURES
The following measures are CMS 2011 Physician Quality Reporting System (PQRS) measures that
are included in the CAP Diabetes Mellitus Module.
#1.
#2.
#3.
#117.
#119.
Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus
Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus
Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus
Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient
Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy
in Diabetic Patients
#163. Diabetes Mellitus: Foot Exam
#110. Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old
#226. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
INSTRUCTIONS FOR REPORTING PQRS MEASURES:
 It is not necessary to submit the measures group-specific intent G-code for registry-based
submissions.
 For PQRS: 30 Patient Sample Method: 30 unique Medicare Part B FFS (fee for service)
patients meeting patient sample criteria for the measures group.
 Patient sample criteria for the Diabetes Mellitus Measures Group are patients aged 18 through
75 years with a specific diagnosis of diabetes accompanied by a specific patient encounter.


To report satisfactorily the Diabetes Mellitus Measures Group requires all measures for each
patient within the eligible professional’s patient sample to be reported a minimum of once
during the reporting period.
When using the 30 Patient Sample Method, report all measures for the 30 unique Medicare
Part B FFS patients seen.
MEASURE #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus
12. Was a Hemoglobin A1c test performed within the reporting year (2012)?
If “No,” skip question 12 and move on to question 13.
▫ Yes
▫ No
13. Most recent Hemoglobin A1c level within the reporting year (2012).
Description
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent
hemoglobin A1c greater than 9.0%
Numerator:
Patients with most recent hemoglobin A1c level > 9.0%
Numerator Instructions: For performance, a lower rate indicates better performance/control
Numerator Note: The performance period for this measure is 12 months
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Most Recent Hemoglobin A1c Level > 9.0%
Most recent hemoglobin A1c level > 9.0%
OR
Hemoglobin A1c not Performed
Hemoglobin A1c level was not performed during the performance period (12 months)
OR
Most Recent Hemoglobin A1c Level ≤ 9.0%
Most recent hemoglobin A1c (HbA1c) level < 7.0%
OR
Most recent hemoglobin A1c (HbA1c) level 7.0 to 9.0%
MEASURE #2: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes
Mellitus
14. Was an LDL-C level performed within the reporting year (2012)?
▫ Yes
▫ No
If “No,” skip question 15 and move on to question 16.
15. Most recent LDL-C level within the reporting year (2012)
Description:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent
LDL-C level in control (less than 100 mg/dl)
Numerator:
Patients with most recent LDL-C < 100 mg/dL
Numerator Note: The performance period for this measure is 12 months
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Most Recent LDL-C Level < 100 mg/dL
Most recent LDL-C < 100 mg/dL
OR
Most Recent LDL-C Level ≥ 100 mg/dL
Most recent LDL-C 100-129 mg/dL
OR
Most recent LDL-C ≥ 130 mg/dL
OR
LDL-C Level not Performed
LDL-C was not performed during the performance period (12 months)
MEASURE #3: Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus
16. Was a blood pressure measurement performed within the reporting year (2012)?
If “No,” skip questions 17 and 18 and move on to question 19.
▫ Yes
▫ No
17. Most recent systolic blood pressure within the reporting year (2012)
If “No,” skip questions 16 and 17 and move on to question 18. If there are multiple blood pressures on the
same most recent date of service, use the lowest systolic and the lowest diastolic blood pressure on that date as
the representative blood pressure.
18. Most recent diastolic blood pressure within the reporting year (2012)
If there are multiple blood pressures on the same most recent date of service, use the lowest systolic and the
lowest diastolic blood pressure on that date as the representative blood pressure.
Description:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent blood
pressure in control (less than 140/90 mmHg)
Numerator:
Patients whose most recent blood pressure < 140/90 mmHg
Numerator Instructions: Describe both systolic and diastolic blood pressure values.
If there are multiple blood pressures on the same date of service, use the lowest systolic and lowest
diastolic blood pressure on that date as the representative blood pressure
Numerator Note: The performance period for this measure is 12 months
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Most Recent Blood Pressure Measurement Performed
Most recent systolic blood pressure < 130 mmHg
OR
Most recent systolic blood pressure 130 - 139 mmHg
OR
Most recent systolic blood pressure ≥ 140 mmHg
AND
Most recent diastolic blood pressure < 80 mmHg
OR
Most recent diastolic blood pressure 80 - 89 mmHg
OR
Most recent diastolic blood pressure ≥ 90 mmHg
OR
Blood Pressure Measurement not Performed
No documentation of blood pressure measurement
MEASURE #117: Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient
19. Was an appropriate dilated eye exam for diabetic retinal disease performed at least once
within the reporting year (2012)?
If “Yes,” skip question 20 and move on to question 21.
An appropriate exam is a dilated retinal eye exam performed with interpretation by an ophthalmologist or
optometrist documented and reviewed; Seven standard field stereoscopic photos taken with interpretation by
an ophthalmologist or optometrist documented and reviewed; or Eye imaging validated to match diagnosis
from seven standard field stereoscopic photos results documented and reviewed.
▫ Yes
▫ No
20. Did the patient have a negative retinal exam (no evidence of retinopathy) in the year prior
to the reporting year? (If retinal exam not done in previous year, answer no.)
▫ Yes
▫ No
Description:
Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who had a
dilated eye exam
Numerator:
Patients who had a dilated eye exam for diabetic retinal disease at least once within 12 months
Numerator Instructions: This measure includes patients with diabetes who had one of the
following: A retinal or dilated eye exam by an eye care professional (optometrist or
ophthalmologist) during the reporting period, or a negative retinal exam (no evidence of
retinopathy) by an eye care professional in the year prior to the reporting period. For dilated eye
exams performed 12 months prior to the reporting period, an automated result must be available.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Dilated Eye Exam Performed by an Eye Care Professional
Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and
reviewed
OR
Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist
documented and reviewed
OR
Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results
documented and reviewed
OR
Low risk for retinopathy (no evidence of retinopathy in the prior year)
OR
Dilated Eye Exam not Performed, Reason not Specified
Dilated eye exam was not performed, reason not otherwise specified.
MEASURE #119: Diabetes Mellitus: Urine Screening for Microalbumin or Medical
Attention for Nephropathy in Diabetic Patients
21. Was a urine protein screening performed that was documented and reviewed, or is there
documentation of treatment for nephropathy during at least one office visit within the
reporting year (2012)?
▫ Yes
▫ Not
If “Yes,” skip question 22 and move on to question 23.
22. Is the patient receiving angiotensin converting enzyme (ACE) inhibitor or angiotensin
receptor blocker (ARB) therapy?
▫ Yes
▫ No
Description:
Percentage of patients aged 18 through 75 years with diabetes mellitus who received urine protein
screening or medical attention for nephropathy during at least one office visit within 12 months
Numerator:
Patients who have a nephropathy screening during at least one office visit within 12 months
Numerator Instructions: This measure is looking for a nephropathy screening test or
evidence of nephropathy
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Nephropathy Screening Performed
Positive microalbuminuria test result documented and reviewed
OR
Negative microalbuminuria test result documented and reviewed
OR
Positive macroalbuminuria test result documented and reviewed
OR
Documentation of treatment for nephropathy (e.g., patient receiving dialysis, patient being treated
for ESRD, CRF, ARF, or renal insufficiency, any visit to a nephrologist)
OR
Patient receiving angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker
(ARB) therapy
OR
Nephropathy Screening not Performed, Reason not Specified
Nephropathy screening was not performed, reason not otherwise specified
MEASURE #163: Diabetes Mellitus: Foot Exam
23. Was a foot exam (visual inspection, sensory exam with monofilament, or pulse exam)
performed at least once within the reporting year (2012)?
▫ Yes
▫ No, medical reason documented
▫ No, other reason or reason not specified
Description:
The percentage of patients aged 18 through 75 years with diabetes who had a foot examination
Numerator:
Patients who received a foot exam (visual inspection, sensory exam with monofilament, or pulse
exam)
Numerator Note: Patients who received a foot exam at least once within the prior 12 months
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Foot Exam Performed
Foot examination performed (includes examination through visual inspection, sensory exam with
monofilament, and pulse exam – report when any of the three components are completed)
OR
Foot Exam not Performed for Medical Reason
OR
Foot Exam not Performed, Reason not Specified
Foot exam was not performed, reason not otherwise specified
MEASURE #110: Preventive Care and Screening: Influenza Immunization for Patients ≥ 50
Years Old
27. Is there documentation stating the patient received an influenza immunization during the
appropriate flu season?
▫ Yes, influenza immunization was ordered or administered during the appropriate flu
season
▫ No, reason(s) documented by clinician for not ordering or administering an influenza
immunization during the appropriate flu season
▫ No, reason not documented for not ordering or administering an influenza
immunization during the appropriate flu season
Description:
Percentage of patients aged 50 years and older who received an influenza immunization during the
flu season (September through February)
Numerator:
Patients who received an influenza immunization during the flu season (September through
February)
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Influenza Immunization Administered
Influenza immunization was ordered or administered
OR
Influenza Immunization not Administered for Documented Reasons
Influenza immunization was not ordered or administered for reasons documented by clinician
OR
Influenza Immunization not Administered, Reason not Specified
Influenza immunization was not ordered or administered, reason not specified
MEASURE #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation
Intervention
28. Was the patient screened for tobacco use within the last 24 months and received tobacco
cessation counseling intervention when identified as a tobacco user (current tobacco
smoker or current smokeless tobacco user)?
▫ Yes, patient was screened, is a current tobacco user and received cessation counseling
intervention (counseling or pharmacotherapy)
▫ Yes, patient was screened and is not a current tobacco user
▫ No, there are medical reason(s) documented for not screening for tobacco use, or the
patient is a current tobacco user but did not receive cessation counseling intervention
(counseling or pharmacotherapy)
▫ No, there are medical reason(s) or no reason(s) documented for not screening for
tobacco use, or the patient is a current tobacco user but did not receive cessation
counseling intervention (counseling or pharmacotherapy)
Description:
Percentage of patients aged 18 years and older who were screened for tobacco use one or more
times within 24 months AND who received cessation counseling intervention if identified as a
tobacco user
Numerator:
Patients who were screened for tobacco use at least once within 24 months AND who received
tobacco cessation counseling intervention if identified as a tobacco user
Definitions:
Tobacco Use – Includes any type of tobacco
Cessation Counseling Intervention – Includes counseling or pharmacotherapy
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Patient Screened for Tobacco Use
Patient screened for tobacco use AND received tobacco cessation counseling, if identified as a
tobacco user
OR
Patient Screened for Tobacco Use and Identified as a Non-User of Tobacco
Current tobacco non-user
OR
Tobacco Screening not Performed for Medical Reasons
OR
Tobacco Screening not Performed Reason Not Specified
ADDITIONAL CAP MEASURES
These measures are not PQRS measures but are additional measures that are pertinent to the
Osteopathic care for Diabetes Mellitus patients.
Complete Lipid Profile Done
24. Is there evidence in the medical record that a LDL, HDL, Total Cholesterol and
Triglycerides were completed during the year prior to the last patient visit (inclusive of the
last visit)? If any element was ordered, but not calculated due to high Triglycerides enter
yes.
▫ Yes
▫ No
Instructions:
Click yes if there is evidence in the medical record that a LDL, HDL, Total Cholesterol and
Triglycerides were completed during the year prior to the last patient visit (inclusive of the
last visit). If any element was ordered but not calculated due to high Triglycerides click yes.
Osteopathic Structural Examination Done
25. Is there evidence in the medical record that a complete structural examination was done? A
complete structural examination must include all of the following components:
1. Evaluation of AP and lateral curvature of the spine or other bony landmark asymmetries.
2. Evaluation of soft tissue abnormalities including tenderness.
3. Evaluation of range of motion or restrictions thereof.
▫ Yes
▫ No
Instructions:
Click yes if there is evidence in the medical record that a complete structural examination
was done.
Osteopathic Manipulative Treatment
26. Is there evidence in the medical record that osteopathic manipulative treatment was done?
▫ Yes
▫ No
Instructions:
Click yes if there is evidence in the in medical record that osteopathic manipulative treatment
was done.