Due to an error found in the logic, the Centers for Medicare & Medicaid Services (CMS) is providing guidance on measure CMS122 (Diabetes: Hemoglobin A1c Poor Control), which is included in the 2014 measure set for the Electronic Health Record (EHR) Incentive Program for eligible professionals (EPs). Version CMS122v3 of the measure was posted on the CMS website in May 2014. A subsequent posting of this measure in 2015 (CMS122v4) resolved this issue for the 2016 program year.
CMS122 measures the percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement year. A patient meets the numerator condition if any of the following are true:
- The most recent HbA1c reading is > 9.0%;
- The most recent HbA1c result is missing; or
- If there are no HbA1c tests performed and results documented during the measurement period.
CMS122 is an inverse measure, meaning that lower scores indicate better performance. In 2014, this measure was updated as CMS122v3 to include logic and specifications for numerator condition (2), where there is evidence of a laboratory test’s having been performed, but the result of the test was not recorded. This logic introduced an error, which results in patients with HbA1c laboratory results of less than 9.0% as being numerator compliant, artificially inflating the (inverse) performance score.
What should you do if you report this measure?
Version CMS122v3 affects the 2015 program year and 2017 payment year for several programs including the Physician Quality Reporting System (PQRS), the Medicare EHR Incentive Program, the Value-Based Payment Modifier (VM) and the Comprehensive Primary Care (CPC) initiative. Guidance for each program is provided below.
Reporting CMS122v3 will count as one of the nine measures required to satisfactorily report for the PQRS program. For PQRS questions regarding CMS122v3, please contact the QualityNet Help Desk at Qnetsupport@hcqis.org or 1-866-288-8912, TTY: 1-877-715-6222.
- EHR Incentive Programs
Reporting CMS122v3 will count as one of the nine measures required to satisfactorily report for the EHR Incentive Programs. For questions regarding CMS122v3, please contact the EHR Incentive Programs Information Center at 1-888-734-6433 or TTY 1-888-734-6563.
- Value Modifier (VM) Program
Based on this logic error, CMS will not include CMS122v3 in the calculation of the Quality Composite for the CY 2017 Value Modifier. For VM questions regarding CMS122v3, please contact the Physician Value Help Desk at email@example.com or 1-888-734-6433 (press option 3).
- Comprehensive Primary Care Initiative (CPC)
All practices are required to report 9 measures from the 13 CPC eCQM measures. If a practice is unable to report on a different CPC eCQM, then they should report this measure to meet the 9 measure reporting requirement for the CPC program. For 2015 CPC Medicare shared savings, CMS will not include this measure in performance calculations for quality scoring purposes. Practices that report on CMS122v3 will still be eligible to receive any Medicare shared savings based on their other reported eCQMs. For CPC questions regarding CMS122v3, please contact the CPC Support at: firstname.lastname@example.org or 1-800-381-4724.
For more information on eCQMs, visit the eCQM Library.