Measure Description
Percentage of patients aged 18-75 years with a diagnosis of diabetes who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within the measurement period.
Instructions
This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of diabetes seen during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
*NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.
Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
Denominator
All patients aged 18-75 years with a diagnosis of diabetes at the start of the measurement period with a visit during the measurement period
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged 18-75 years on the date of the encounter
AND
Diagnosis of Diabetes (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.36, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.10, E11.11, E11.21, E11.22, E11.29, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319, E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.36, E13.37X1, E13.37X2, E13.37X3, E13.37X9, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83
AND
Patient encounter during the performance period (CPT): 98966, 98967, 98968, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99441, 99442, 99443, G0438, G0439
AND NOT
DENOMINATOR EXCLUSION:
Patients with a diagnosis of End Stage Renal Disease (ESRD): M1187
OR
Patients with a diagnosis of Chronic Kidney Disease (CKD) Stage 5: M1188
OR
Patients who have an order for or are receiving hospice or palliative care: M1186
Numerator
Patients who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within the measurement period.
Numerator Options:
Performance Met: Documentation of a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) performed (M1189)
OR
Performance Not Met: Documentation of a kidney health evaluation was not performed or defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) (M1190)
Rational
Chronic Kidney Disease (CKD) is a major driver of morbidity, mortality, and healthcare costs in the United States. Approximately 9 percent of American adults currently have CKD (NKF, 2019), and it is projected that by 2030 approximately 17 percent of Americans aged 30 years and older will have CKD (Saran et al., 2019; Hoerger et al., 2015). Furthermore, CKD stemming from diabetes specifically occurs in almost 30 percent of patients with diabetes (Afkarian et al., 2016). In 2017 total Medicare spending on CKD patients was over $84 billion (CDC, 2020). CKD patients are readmitted to the hospital more frequently than those with other diagnoses (Saran et al., 2019) and CKD is the 9th leading cause of death in the U.S. (Hoerger et al., 2015). If left untreated, CKD can progress to kidney failure and early cardiovascular disease (CDC, 2020). The most common risk factor for CKD is diabetes (Saran et al., 2019; Bowe et al., 2018). The intent of this process measure is to improve rates of guideline-concordant kidney health evaluation in patients with diabetes to more consistently identify and potentially treat or delay progression of CKD in this high-risk population.
Clinical Recommendation Statements
Annual kidney health evaluation using estimated glomerular filtration rate (eGFR) and urine albumin creatinine ratio (uACR) to determine risk of CKD in patients diagnosed with diabetes is recommended by clinical practice guidelines (ADA, 2018; NKF, 2007; NKF, 2012) and has been a focus of various local and national health care quality improvement initiatives, including Healthy People 2020 (United States Renal Data System, 2018). However, performance of these tests in patients with diabetes remains low, with rates that vary across Medicare (41.8 percent) and private insurers (49.0 percent) (Saran et al., 2019). Low rates of detection of CKD in a population of patients with diabetes have been demonstrated to be associated with low patient awareness of their own kidney health status (Szczech et al., 2014). Regular kidney health evaluations, utilizing both eGFR and uACR, provide an opportunity to improve identification and potential reversal of worsening kidney function, particularly in high risk populations, such as those with diabetes. Kidney health evaluation in patients with diabetes, in accordance with clinical guidelines, leads to the identification of CKD patients and the potential treatment and delay of progression of CKD.
The following evidence statements are quoted from the referenced clinical guidelines:
- At least once a year, assess urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and eGFR in patients with type 1 diabetes with duration of ≥5 years and in all patients with type 2 diabetes regardless of treatment. (Evidence Grade = B) (American Diabetes Association, 2020)
- Patients with diabetes should be screened annually for chronic kidney disease. Initial screening should commence: 5 years after the diagnosis of type 1 diabetes; (Evidence Grade = A) or from diagnosis of type 2 diabetes. (Evidence Grade = B) Screening should include measurements of urinary albumin-creatinine ratio (ACR) in a spot urine sample; (Evidence Grade = B) measurement of serum creatinine and estimation of GFR. (Evidence Grade = B) (National Kidney Foundation, 2007 and 2012)