WCHQ Ambulatory Measure Specification
WCHQ 1 – Diabetes Care: A1c Blood Sugar Testing
Measurement Period: 01/01/2015 – 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
MEASURE DESCRIPTION
This measure assesses the percentage of patients who had two or more A1c tests, one A1c test, or
no A1c tests within the last 12 months [Measurement Period].
Disclaimer: Measures reported by WCHQ healthcare organizations represent a specific aspect of care in relation to an
evidence-based standard, but are not clinical guidelines and do not establish standards of care. All providers should have
an individual care plan established with their patient.
GENERAL INFORMATION/RATIONALE
In an effort to align with National Quality Form (NQF) endorsed diabetes measures, and referencing
the 2013 American Diabetes Association (ADA) guidelines, the following goals for people with
diabetes are measured by the WCHQ:
 Two A1c tests annually, at a minimum
References:
American Diabetes Association Clinical Practice Recommendations 2013:
http://care.diabetesjournals.org/content/36/Supplement_1/S4.full
DEFINITIONS
12 Months: Measurement Period
24 Months: Measurement Period + Prior Year
Office Visit: Office visit in an outpatient, non-urgent care setting
PCP: For WCHQ measure purposes, a primary care provider is defined as any General Practice,
Internal Medicine, Family Medicine, Pediatrics provider with the following degree types (MD, DO,
PA, and NP), and any other practitioners identified by the healthcare system as primary care
practitioners. The rationale for the additional practitioner(s) must be documented and must be
applied consistently across all preventive care and chronic care measures by the organization.
 Measure Specific Specialist: As part of the denominator population for this measure visits
to an Endocrinologist qualify as office visits for the denominator population.
Age Range 18-75: Patients born between 01/01/1940 and 01/01/1997.
DENOMINATOR DESCRIPTION
Patients with diabetes 18-75 years of age and alive as of the last day of the MP. A minimum of two
diabetes coded office visits and must be seen by a PCP / Endocrinologist for two office visits in 24
months and one office visit in 12 months. Gestational Diabetes (code 648.8) is excluded.
Patients whose age at the beginning of the one year measurement period is at least 18 and whose
age at the end of the measurement period is less than 76 and are alive as of the last day of the
Measurement Period. Expired patients for whom a specific date of expiration cannot be found are
excluded from the denominator population
The rationale for the denominator population is built from the following criteria:
[Question 1] – Is this a patient with the disease or condition?
[Question 2] – Is this a patient whose care is managed within the physician group?
[Question 3] – Is this a patient currently managed in our system?
Diabetes Care: A1c Blood Sugar Testing – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
1
WCHQ Ambulatory Measure Specification
WCHQ 1 – Diabetes Care: A1c Blood Sugar Testing
Measurement Period: 01/01/2015 – 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
ENCOUNTER DATA
Patients eligible for inclusion in the denominator include:
[Question 1] – Is this a patient with the disease, or condition?
Those who had a minimum of two diabetes coded (including any diagnoses coded
for the visit) – (Table D-1) office visits (Table D-2), with any provider (MD, DO, PA,
NP) in the Physician Group with different dates of service in an ambulatory setting
during the last 24 Months [Measurement Period + Prior Year], and
[Question 2] – Is this a patient whose care is managed within the physician group?
Patients who had at least two office visits (Table D-2), regardless of diagnosis code,
on different dates of service, to a PCP and/or Endocrinologist in the past 24 months.
If the Endocrinologist is not considered a PCP, at least one of the two office visits
must be to a PCP.
[Question 3] – Is this a patient current in our system?
Those who had at least one office visit (Table D-2), regardless of diagnosis code,
with a PCP and/or an Endocrinologist during the last 12 Months [Measurement
Period].
NUMERATOR DESCRIPTIONS
A1c BLOOD SUGAR TESTING – Two or more A1c tests within the Measurement Period. One A1c
test and no A1c tests are also measured in the final result.
This measure assesses the percentage of patients who had two or more A1c tests, one A1c test, or
no A1c tests (Table D-3) within the last 12 Months [Measurement Period] as demonstrated through
any of the following:
1. Administrative Data, which can include:
a) Table D-3, using the Lab Test Collection Date, and if unavailable, the Result/Test Date
b) Internal or external A1C tests extracted electronically and requiring Test Date and
Result
2. Medical Record Review (refer to Medical Record Review for Numerator
Inclusion/Denominator Exclusion section)
Testing Definitions:
 Two or more A1c tests: The subset of denominator patients who had two or more A1c tests,
on different dates of service, conducted within the last 12 Months [Measurement Period] and
identified through either administrative data or medical record review (see Sampling).
 Only one A1c test: The subset of denominator patients who had only one A1c test
conducted within the last 12 months [Measurement Period].
 Not Tested: The subset of denominator patients who did not have an A1c test result during
the last 12 Months [Measurement Period].
Diabetes Care: A1c Blood Sugar Testing – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
2
WCHQ Ambulatory Measure Specification
WCHQ 1 – Diabetes Care: A1c Blood Sugar Testing
Measurement Period: 01/01/2015 – 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
INTERNALLY DEVELOPED CODES – DATA TRANSLATION/MAPPING REQUIREMENTS
If a medical group utilizes internally generated codes to identify specific services or events required
for a given WCHQ performance measure, the group may translate or map the information to the
WCHQ performance measurement specifications. The medical group must assure that the
internally generated code matches the clinical specificity of the standard (ICD-9, CPT) codes
included in the WCHQ performance measurement specifications.
In order to use internally developed codes for WCHQ performance measure reporting, the medical
group needs to document the translation/mapping to the codes in the specifications. This
documentation should include the internally generated code, a description of the internally
developed code, any additional clinical information for the internally developed code, and the
equivalent standard code with description from the WCHQ performance measurement
specifications. Once the translation/ mapping documentation is established, the medical group’s
WCHQ performance measurement team must review the mapping on a yearly basis and document
that internally developed codes have not changed and are being used in the manner described in
the translation/ mapping document.
The medical group must have documented processes in place for adding codes to the medical
group’s administrative data system and procedures to implement the internally developed codes.
MEDICAL RECORD REVIEW FOR NUMERATOR INCLUSION/DENOMINATOR EXCLUSION
If appropriate, and/or when necessary, every organization may complement their electronic capture
of patient medical history with electronic or manual record review. The following criteria apply only
to data captured/reviewed during medical record review.
For WCHQ Chronic Condition Measures, proof of Numerator compliance requires:
 Date test was performed.
 Value of test (e.g., Blood Pressure, lab result)
Denominator Exclusion
For all WCHQ Measures, proof of Denominator exclusion requires:
 Existence of exclusion criteria.
This data may be retrieved, in whole or in part, from any of the following:
 Notation in Progress Note
 Notation in Medical History or Surgical History
 Flag/Field in Electronic Medical Record
 Documentation in patient chart
FIELDS REQUIRED FOR MEASURE VALIDATION
Validation of this measure will require patient level data files for Administrative Data and/or for
Manual Review. The following indicates fields needed for validation, which may be helpful to
consider when querying the measure:
Diabetes Care: A1c Blood Sugar Testing – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
3
WCHQ Ambulatory Measure Specification
WCHQ 1 – Diabetes Care: A1c Blood Sugar Testing
Measurement Period: 01/01/2015 – 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
Denominator Data File fields:
1.
2.
3.
4.
5.
Patient Identifier (can be medical record number or other ID)
Office Visit Dates
Provider Specialty
Patient Date of Birth
Diabetes Diagnosis Codes
Numerator Data File fields:
1. Blood Sugar (A1C) Screening within the last 12 months
 Patient Identifier (De-Identified)
 Lab Date(s) of Service (identify whether collection date versus test date)
 Lab ID Code(s) or Equivalent Test Name
Diabetes Care: A1c Blood Sugar Testing – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
4
WCHQ Ambulatory Measure Specification
WCHQ 1 – Diabetes Care: A1c Blood Sugar Testing
Measurement Period: 01/01/2015 – 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
Appendix A
Primary Payer
In keeping with the changing atmosphere of quality measurement and reporting, WCHQ would like
for participating organizations to include the primary payer source with their data submissions for
the ambulatory care measures.
The primary payer source should be identified in the denominator upon answering the question, “Is
this patient current in our system?” Once it has been determined that a patient is current because
of a visit to their physician within the specified time period (12 months for chronic care measures
and 24 months for preventive care measures), the payer should be “pulled” into the query. The
primary payer should be the payer at the most recent office visit within the measurement period.
There will be four categories of primary payer that will need to be submitted to WCHQ via the data
submission tool: Medicare FFS, Medicaid (all types), Commercial (including Medicare HMO) and
Uninsured/Self-Pay. The raw numbers for the denominator and numerator should be included for
all three types of data submission, total population, hybrid, and sample.
Rationale
Opportunities exist for WCHQ to collect and report data on specific populations, like the Medicare
population, through grant applications to begin to understand the disparities in quality of care. The
purpose of this is to begin to understand the challenges of putting in additional data elements and
complexities of data display for public reporting. At this time, the primary payer information will not
be publicly reported.
Definitions:
Commercial: All plans not Medicaid or Medicare FFS (Includes VA, DoD, etc.)
FFS Medicare: FFS plans, not Medicare HMO (Medicare Railroad is FFS Medicare)
Medicaid: All Medicaid plans including those managed by commercial plans
Uninsured: Self-pay individuals
Diabetes Care: A1c Blood Sugar Testing – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
5
WCHQ Ambulatory Measure Specification
WCHQ 1 – Diabetes Care: A1c Blood Sugar Testing
Measurement Period: 01/01/2015 – 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
APPENDIX B
TABLE D-1: Diagnosis Codes to Identify Patients with Diabetes
ICD-9-CM
Description
Diagnosis Codes
250.xx
Diabetes mellitus
250.00
Diabetes mellitus without mention of complication, type ii or unspecified type,
not stated as uncontrolled
250.01
Diabetes mellitus without mention of complication, type i [juvenile type], not
stated as uncontrolled
250.02
Diabetes mellitus without mention of complication, type ii or unspecified type,
uncontrolled
250.03
Diabetes mellitus without mention of complication, type i [juvenile type],
uncontrolled
250.10
Diabetes with ketoacidosis, type ii or unspecified type, not stated as
uncontrolled
250.11
Diabetes with ketoacidosis, type i [juvenile type], not stated as uncontrolled
250.12
Diabetes with ketoacidosis, type ii or unspecified type, uncontrolled
250.13
Diabetes with ketoacidosis, type i [juvenile type], uncontrolled
250.20
Diabetes with hyperosmolarity, type ii or unspecified type, not stated as
uncontrolled
250.21
Diabetes with hyperosmolarity, type i [juvenile type], not stated as
uncontrolled
250.22
Diabetes with hyperosmolarity, type ii or unspecified type, uncontrolled
250.23
Diabetes with hyperosmolarity, type i [juvenile type], uncontrolled
250.30
Diabetes with other coma, type ii or unspecified type, not stated as
uncontrolled
250.31
Diabetes with other coma, type i [juvenile type], not stated as uncontrolled
250.32
Diabetes with other coma, type ii or unspecified type, uncontrolled
250.33
Diabetes with other coma, type i [juvenile type], uncontrolled
250.40
Diabetes with renal manifestations, type ii or unspecified type, not stated as
uncontrolled
250.41
Diabetes with renal manifestations, type i [juvenile type], not stated as
uncontrolled
250.42
Diabetes with renal manifestations, type ii or unspecified type, uncontrolled
250.43
Diabetes with renal manifestations, type i [juvenile type], uncontrolled
250.50
Diabetes with ophthalmic manifestations, type ii or unspecified type, not
stated as uncontrolled
250.51
Diabetes with ophthalmic manifestations, type i [juvenile type], not stated as
uncontrolled
250.52
Diabetes with ophthalmic manifestations, type ii or unspecified type,
uncontrolled
250.53
Diabetes with ophthalmic manifestations, type i [juvenile type], uncontrolled
250.60
Diabetes with neurological manifestations, type ii or unspecified type, not
stated as uncontrolled
250.61
Diabetes with neurological manifestations, type i [juvenile type], not stated as
uncontrolled
Diabetes Care: A1c Blood Sugar Testing – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
6
WCHQ Ambulatory Measure Specification
WCHQ 1 – Diabetes Care: A1c Blood Sugar Testing
Measurement Period: 01/01/2015 – 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
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
362.0x
362.01
362.02
362.03
362.04
362.05
362.06
362.07
366.41
648.0x
648.00
648.01
648.02
648.03
648.04
Diabetes with neurological manifestations, type ii or unspecified type,
uncontrolled
Diabetes with neurological manifestations, type i [juvenile type], uncontrolled
Diabetes with peripheral circulatory disorders, type ii or unspecified type, not
stated as uncontrolled
Diabetes with peripheral circulatory disorders, type i [juvenile type], not
stated as uncontrolled
Diabetes with peripheral circulatory disorders, type ii or unspecified type,
uncontrolled
Diabetes with peripheral circulatory disorders, type i [juvenile type],
uncontrolled
Diabetes with other specified manifestations, type ii or unspecified type, not
stated as uncontrolled
Diabetes with other specified manifestations, type i [juvenile type], not stated
as uncontrolled
Diabetes with other specified manifestations, type ii or unspecified type,
uncontrolled
Diabetes with other specified manifestations, type i [juvenile type],
uncontrolled
Diabetes with unspecified complication, type ii or unspecified type, not stated
as uncontrolled
Diabetes with unspecified complication, type i [juvenile type], not stated as
uncontrolled
Diabetes with unspecified complication, type ii or unspecified type,
uncontrolled
Diabetes with unspecified complication, type i [juvenile type], uncontrolled
Polyneuropathy in diabetes
Diabetic retinopathy
Background diabetic retinopathy
Proliferative diabetic retinopathy
Nonproliferative diabetic retinopathy nos
Mild nonproliferative diabetic retinopathy
Moderate nonproliferative diabetic retinopathy
Severe nonproliferative diabetic retinopathy
Diabetic macular edema
Diabetic cataract
Complication of pregnancy, diabetes mellitus, excluding gestational diabetes
Diabetes mellitus of mother complicating pregnancy childbirth or the
puerperium unspecified as to episode of care
Diabetes mellitus of mother with delivery
Diabetes mellitus of mother with delivery with postpartum complication
Antepartum diabetes mellitus
Postpartum diabetes mellitus
Effective 10/01/2015
Diabetes Care: A1c Blood Sugar Testing – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
7
WCHQ Ambulatory Measure Specification
WCHQ 1 – Diabetes Care: A1c Blood Sugar Testing
Measurement Period: 01/01/2015 – 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
ICD-10-CM Diagnosis
Codes
Description
E11.9
Type 2 diabetes mellitus without complications
E10.9
Type 1 diabetes mellitus without complications
E11.65
Type 2 diabetes mellitus with hyperglycemia
E10.65
Type 1 diabetes mellitus with hyperglycemia
E11.69
Type 2 diabetes mellitus with other specified complication
E10.10
Type 1 diabetes mellitus with ketoacidosis without coma
E11.00
E11.01
Type 2 diabetes mellitus with hyperosmolarity without nonketotic
hyperglycemic-hyperosmolar coma (NKHHC)
Type 2 diabetes mellitus with hyperosmolarity with coma
E10.69
Type 1 diabetes mellitus with other specified complication
E11.641
Type 2 diabetes mellitus with hypoglycemia with coma
E10.11
Type 1 diabetes mellitus with ketoacidosis with coma
E10.641
Type 1 diabetes mellitus with hypoglycemia with coma
E11.65
Type 2 diabetes mellitus with hyperglycemia
E11.29
Type 2 diabetes mellitus with other diabetic kidney complication
E10.29
Type 1 diabetes mellitus with other diabetic kidney complication
E11.21
Type 2 diabetes mellitus with diabetic nephropathy
E10.21
Type 1 diabetes mellitus with diabetic nephropathy
E11.311
E11.36
Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular
edema
Type 2 diabetes mellitus with unspecified diabetic retinopathy without
macular edema
Type 2 diabetes mellitus with diabetic cataract
E11.39
Type 2 diabetes mellitus with other diabetic ophthalmic complication
E10.311
E10.39
Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular
edema
Type 1 diabetes mellitus with unspecified diabetic retinopathy without
macular edema
Type 1 diabetes mellitus with unspecified diabetic retinopathy without
macular edema
Type 1 diabetes mellitus with other diabetic ophthalmic complication
E11.40
Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E10.40
Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E11.51
Type 2 diabetes mellitus with diabetic peripheral angiopathy without
gangrene
Type 1 diabetes mellitus with diabetic peripheral angiopathy without
gangrene
Type 2 diabetes mellitus with other diabetic arthropathy
E11.319
E10.319
E10.36
E10.51
E11.618
Diabetes Care: A1c Blood Sugar Testing – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
8
WCHQ Ambulatory Measure Specification
WCHQ 1 – Diabetes Care: A1c Blood Sugar Testing
Measurement Period: 01/01/2015 – 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
E11.620
Type 2 diabetes mellitus with diabetic dermatitis
E11.621
Type 2 diabetes mellitus with foot ulcer
E11.622
Type 2 diabetes mellitus with other skin ulcer
E11.628
Type 2 diabetes mellitus with other skin complications
E11.630
Type 2 diabetes mellitus with periodontal disease
E11.638
Type 2 diabetes mellitus with other oral complications
E11.649
Type 2 diabetes mellitus with hypoglycemia without coma
E10.618
Type 1 diabetes mellitus with other diabetic arthropathy
E10.620
Type 1 diabetes mellitus with diabetic dermatitis
E10.621
Type 1 diabetes mellitus with foot ulcer
E10.622
Type 1 diabetes mellitus with other skin ulcer
E10.628
Type 1 diabetes mellitus with other skin complications
E10.630
Type 1 diabetes mellitus with periodontal disease
E10.638
Type 1 diabetes mellitus with other oral complications
E10.649
Type 1 diabetes mellitus with hypoglycemia without coma
E11.8
Type 2 diabetes mellitus with unspecified complications
E10.8
Type 1 diabetes mellitus with unspecified complications
E08.42
Diabetes mellitus due to underlying condition with diabetic polyneuropathy
E09.42
E10.42
Drug or chemical induced diabetes mellitus with neurological complications
with diabetic polyneuropathy
Type 1 diabetes mellitus with diabetic polyneuropathy
E11.42
Type 2 diabetes mellitus with diabetic polyneuropathy
E13.42
Other specified diabetes mellitus with diabetic polyneuropathy
E11.359
E08.36
Type 2 diabetes mellitus with proliferative diabetic retinopathy without
macular edema
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy
without macular edema
Type 2 diabetes mellitus with moderate nonproliferative diabetic
retinopathy without macular edema
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy
without macular edema
Diabetes mellitus due to underlying condition with diabetic cataract
E09.36
Drug or chemical induced diabetes mellitus with diabetic cataract
E10.36
Type 1 diabetes mellitus with diabetic cataract
E13.36
Other specified diabetes mellitus with diabetic cataract
O24.319
Other specified diabetes mellitus with diabetic cataract
O24.32
Unspecified pre-existing diabetes mellitus in childbirth
O24.911
Unspecified diabetes mellitus in pregnancy, first trimester
E11.329
E11.339
E11.349
Diabetes Care: A1c Blood Sugar Testing – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
9
WCHQ Ambulatory Measure Specification
WCHQ 1 – Diabetes Care: A1c Blood Sugar Testing
Measurement Period: 01/01/2015 – 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
O24.912
Unspecified diabetes mellitus in pregnancy, second trimester
O24.913
Unspecified diabetes mellitus in pregnancy, third trimester
O24.92
Unspecified diabetes mellitus in childbirth
O24.93
Unspecified diabetes mellitus in the puerperium
TABLE D-2: Office Visit Encounter Codes (Outpatient)
CPT Codes
99201-99205
99212-99215
99241-99245
99347-99350
99384-99387
99394-99397
99401-99404
99411
99412
99420
99429
99488
99495
99496
Description
Office or OPa visit E&Mb, new patient
Office or OP visit E&M, established patient
Office or other OP consultations
Home visit for evaluation and management of an established patient
Initial preventive medicine E&Mb
Periodic preventive medicine E&Mb
Preventive medicine counseling
Preventive medicine counseling, group
Preventive medicine counseling, group
Risk assessment, admin and interpretation
Unlisted preventive medicine service
Complex chronic care coordination services; first hour of clinical staff time directed
by a physician or other qualified health care professional with one face-to-face visit,
per calendar month.
Transitional Care Management Services (Moderate Complexity)
Transitional Care Management Services (High Complexity)
HCPCS Code
G0344
(deleted 12/31/08)
G0402
(Effective
01/01/09)
G0438
G0439
a
b
Description
Initial preventive physical examination; face-to-face visit services limited to new
beneficiary during the first six months of Medicare enrollment
Initial preventive physical examination; face-to-face visit, services limited to new
beneficiary during the first 12 months of Medicare enrollment
Annual wellness visit; includes a personalized prevention plan of service, initial visit
Annual wellness visit; includes a personalized prevention plan of service,
subsequent visit
outpatient
evaluation and management
TABLE D-3: Codes to Identify Hemoglobin A1c
CPT Codes
Description
83036
83037
Glycosolated Hemoglobin Test
Hemoglobin; glycosylated (A1c) by device cleared by the FDA for home use. (Used
when A1c is determined in a point-of-care environment within the clinic setting)
LOINC
4548-4
Diabetes Care: A1c Blood Sugar Testing – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
10
WCHQ Ambulatory Measure Specification
WCHQ 1 – Diabetes Care: A1c Blood Sugar Testing
Measurement Period: 01/01/2015 – 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
4549-2
17856-6
59261-8
62388-A
71875-9
CPT Category II
Codes
**3044F
**3045F
**3046F
Description
Most Recent HbA1c level less than 7.0%
Most Recent HbA1c level 7.0-9.0%
Most Recent HbA1c level greater than 9.0%
**Codes can be included at the organization’s discretion. If included, the date the
service was performed must be provided. If an 8P modifier is included with the
CPT II code, it does not qualify as numerator compliant.
Diabetes Care: A1c Blood Sugar Testing – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
11