CMS134v10 – Diabetes: Medical Attention for Nephropathy

Patients 18-75 years of age with diabetes with a visit during the measurement period.

– NUMERATOR

Patients with a screening for nephropathy or evidence of nephropathy during the measurement period

-DENOMINATOR EXCLUSIONS:

• Exclude patients who are in hospice care for any part of the measurement period.
• Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period.
• Exclude patients 66 and older with an indication of frailty for any part of the measurement period who meet any of the following criteria:

–   Advanced illness with two outpatient encounters during the measurement period or the year prior

–   OR advanced illness with one inpatient encounter during the measurement period or the year prior

–   OR taking dementia medications during the measurement period or the year prior

• Exclude patients receiving palliative care during the measurement period.

For Denominator:

Patients fulfilling the following criteria are included in the denominator of this measure:

• Patients aged 18-75 at the start of the measurement period with a qualifying or telehealth encounter during the measurement period. To record an encounter, navigate to Patient > Provider Note > eSuperbill. Below the ‘Procedure- CPTs’ heading, enter the encounter code.

• Patients with a diagnosis of diabetes where diabetes prevalence period overlaps the measurement period. To document the diagnosis, use the workflow Patient > Provider Note > Diagnoses and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.

For Numerator:

Include patients satisfying any of the conditions:

• Patients with active ACE or ARB medications overlapping the measurement period. To document ACEI or ARB medication, navigate to Patient > Provider Note > Medications. Click ‘Add’ and search for the medication. Enter the medication details and click ‘Save’.

• Patients with ‘Nephropathy’ diagnoses overlapping the measurement period. To document the diagnosis, use the workflow Patient > Provider Note > Diagnoses and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.

• Patients with ‘Nephropathy’ screenings during the measurement period.

1. Renal Procedures: To document a renal procedure performed, navigate to Patient > Provider Notes > Orders > Procedures. Click ‘Add’ and search for the procedure. Add the procedure details and click on ‘Save & Accept’/hover over ‘Sign & Accept’. If the user hover over ‘Sign & Accept’, then click ‘Complete’. The procedure is added to the provider note.

Note:

Please ensure that the Procedure is present in the system. For this, navigate to Settings > Billing > Procedure. If the procedure is not added then, click on the ‘Add Procedure’ button.  

Here, enter the ‘Code’ and ‘Name’ of the Procedure. Once done, click on the ‘Save’ button.

2. Renal Interventions: Navigate to Patient > Clinical > Evaluations and search for an intervention. Select ‘Performed’ from the ‘Status’ dropdown. Then click ‘Sign’ or ‘Save’.

3. End Stage Renal Disease Encounter: To record an encounter, navigate to Patient > Provider Note > eSuperbill.

4. Protein Urea Lab Test: To record a lab test, navigate to Patient > Clinical > Orders&Results > Labs and click ‘+ Add Order’ button.

Here, select a laboratory and search for the ‘Urine Protein’ test. Once done, click on the ‘Save’ or ‘Sign’ button.

Next, click on the ‘Mark As Received’ button. 

On the ‘Edit Lab Result’ screen, add the observations and click on the ‘Save’ button. The ‘Result’ field must not be null.

Note:

Please ensure that the lab code is mapped to a LOINC Code from the Settings. To map a LOINC with the lab code, navigate to Settings > EHR > Laboratory. Select the Lab and navigate to the ‘Code’ tab. Then, click on the Lab Order. Under the ‘Result Codes and LOINCS’ heading, add a Code, LOINC and Description and click on the ‘Add’ button.

Once done, click on ‘Save’. 

When a CPT code is added to a lab order, please ensure that the CPT code is present in the ‘Procedures’. 

Moreover, the CPT code should be mapped to a LOINC Code from the Settings. To map a LOINC with the CPT code, navigate to Settings > Billing > Procedure. Select the CPT code and navigate to the ‘Edit Procedure’ tab. Under the ‘Procedure Components’ heading, add a Code, LOINC and Description and click on the ‘Add’ button.

Once done, click on ‘Save’. 

For Denominator Exclusions:

Patients satisfying any of the following conditions are excluded from the denominator:

1. Patients who were in hospice care during the measurement year are included in denominator exclusion. To document that patient is receiving hospice care outside of a hospital or long term care facility, navigate to Patient > Clinical > Evaluations. Use the below mentioned codes to order or perform an intervention:
   • 385763009: Hospice Care (Regime/Therapy)
   • 385765002: Hospice Care Management (Procedure)

1. • To document an encounter inpatient, navigate to Patient > Clinical > Evaluations

2. Patients older than 65 years of age at the start of the measurement period and who spent longer than 90 consecutive days in a long term care during the measurement period. For documentation, navigate to Patient > Clinical > Evaluations.

3. Patients 65 years of age or older with two or more outpatient encounters with advanced illness and fulfilling frailty criteria. Outpatient encounters should occur two years or less prior to the end of the measurement period. To document an outpatient encounter, navigate to Patient > Provider Note > eSuperbill. To document advanced illness diagnosis, use the workflow: Patient > Clinical > Diagnoses. Workflows for recording frailty criteria:
   • Frailty device ordered/applied during the measurement period: Patient > Clinical > Evaluations
   • Frailty diagnosis during the measurement period: Patient > Clinical > Diagnoses
   • Frailty symptoms during the measurement period: Patient > Clinical > Diagnoses or Patient > Clinical > Evaluations
   • Frailty encounter during the measurement period: Patient > Provider Note > eSuperbill

4. Patients 65 years of age or older having an inpatient encounter with advanced illness and fulfilling frailty criteria. Inpatient encounters should occur two years or less prior to the end of the measurement period. To document an inpatient encounter, navigate to Patient > Provider Note > eSuperbill. To document advanced illness diagnosis, use the workflow: Patient > Clinical > Diagnoses. Workflows for recording frailty criteria:
   • Frailty device ordered/applied during the measurement period: Patient > Clinical > Evaluations
   • Frailty diagnosis during the measurement period: Patient > Clinical > Diagnoses
   • Frailty symptoms during the measurement period: Patient > Clinical > Diagnoses or Patient > Clinical > Evaluations
   • Frailty encounter during the measurement period: Patient > Provider Note > eSuperbill

5. Patients 65 years of age or older taking dementia medication one year prior to or during the measurement period and fulfilling frailty criteria. Record the medication via the workflow Patient > Clinical > Prescription. Click ‘Add’ and search for the medication. Enter the medication details and click ‘Save’. Workflows for recording frailty criteria:
   • Frailty device ordered/applied during the measurement period: Patient > Clinical > Evaluations
   • Frailty diagnosis during the measurement period: Patient > Clinical > Diagnoses
   • Frailty symptoms during the measurement period: Patient > Clinical > Diagnoses or Patient > Clinical > Evaluations
   • Frailty encounter during the measurement period: Patient > Provider Note > eSuperbill
6. Patients receiving palliative care during the measurement period.
   • To record the ‘Palliative Care Encounter’ performed, use the workflow Patient > Provider Note > eSuperbill.
   • To record the ‘Palliative Care Intervention’ performed, use the workflow Patient > Clinical > Evaluations.
   • To record the ‘Functional Assessment of Chronic Illness Therapy’ assessment performed, navigate to Patient > Clinical > Evaluations.