Measure description

The percentage of members 18-75 years of age with diabetes (Type 1 or Type 2) during the measurement year or the year prior to the measurement year identified with diabetes by claim/encounter data and/or by pharmacy data.

Events/diagnosis that include the member in the denominator

  • At least one acute inpatient encounter with a diagnosis of diabetes without telehealth.
  • At least one acute inpatient discharge with a diagnosis of diabetes on the discharge claim.
  • At least two of the following:
    • Outpatient visits, observation visits, telephone visits, online or virtual check-ins, emergencyvisits, nonacute inpatient encounters1 or nonacute inpatient discharges, on different dates of service, with a diagnosis of diabetes. Visit type does not need to be the same for the two encounters.

A full listing of diagnoses that will exclude the member from the denominator can be found in the performance measures guide available in the Theon® Welcome Kit on Care Collaborator® or Care Optimizer®.

Medications that include the member in the denominator

Members who were dispensed insulin or hypoglycemic/ anti-hyperglycemic drugs on an ambulatory basis during the measurement year or the year prior to the measurement.

Drug name(s)

Acarbose

Alogliptin

Alogliptin-metformin

Alogliptin-pioglitazone

Albiglutide

Canagliflozin

Canagliflozin-metformin

Chlorpropamide

Dapagliflozin (excluding Farxiga®)

Dapagliflozin-metformin

Dulaglutide

Empagliflozin

Empagliflozin-linagliptin

Empagliflozin-metformin

Exenatide

Glimepiride

Glimepiride-pioglitazone

Glipizide

Glipizide-metformin

Glyburide

Glyburide-metformin

Insulin aspart

Insulin aspart-insulin aspart protamine

Insulin degludec

Insulin detemir

Insulin glargine

Insulin glulisine

Insulin isophane human

Insulin isophane-insulin regular

Insulin lispro

Insulin lispro-insulin lispro protamine

Insulin regular human

Insulin human inhaled

Linagliptin

Linagliptin-metformin

Liraglutide (excluding Saxenda®)

Miglitol

Metformin-pioglitazone

Metformin-repaglinide

Metformin-rosiglitazone

Metformin-saxagliptin

Metformin-sitagliptin

Nateglinide

Pioglitazone

Pramlintide

Repaglinide

Rosiglitazone

Saxagliptin

Semaglutide

Sitagliptin

Tolazamide

Tolbutamide

 

 

Note: Glucophage/metformin as a solo agent is not included because it can be used to treat conditions other than diabetes. Members with diabetes on these medications are identified through diagnosis codes only.

Events/diagnosis that exclude the member from the denominator

  • Members receiving palliative care. For supplemental data, medical record must show documentation of member receiving palliative care.
  • Members in hospice.
  • Members who do not have a diagnosis of diabetes, in any setting, during the measurement year or the year prior to the measurement year and who had a diagnosis of polycystic ovarian syndrome, gestational diabetes, or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year. For supplemental data submission proof of these exclusions, additional documentation will be needed.

Exclusions for supplemental and medical record data that may not be used

Medicare members 66 years of age and older as of December 31 of the measurement year who meet either of the following:

  • Enrolled in an Institutional SNP any time during the measurement year.
  • Living long-term in an institution any time during the measurement year.

Members 66 years of age and older as of December 31 of the measurement year (all product lines) with frailty and advanced illness.

Members must meet both of the following frailty and advanced illness criteria to be excluded:

  1. At least one claim/encounter for frailty during the measurement year.
  2. Any of the following during the measurement year or the year prior to the measurement year (count services that occur over both years):
    • At least two of the following: outpatient visits, observation visits, emergency visits, telephone visits, online or virtual check-ins, non-acute inpatient encounters or non-acute inpatient discharges on different dates of service, with an advanced illness diagnosis. Visit type need not be the same for the two visits.
    • At least one acute inpatient encounter with an advanced illness diagnosis.
    • At least one acute inpatient discharge with an advanced illness diagnosis on the discharge claim.
    • A dispensed dementia medication:
      • Donepezil
      • Donepezil-memantine
      • Galantamine
      • Memantine
      • Rivastigimine

A full listing of diagnoses that will exclude the member from the denominator can be found in the performance measures guide available in the Theon® Welcome Kit on Care Collaborator® or Care Optimizer®.


1Only include nonacute inpatient encounters without telehealth.