eCQM Title

Kidney Health Evaluation for People with Diabetes and/or Hypertension

CMS ID

1337

eCQM Version Number

Draft based on 0.0.001

CBE Number

Not Applicable

GUID

3d2419ab-966d-4cfe-9961-e7b8e903c71c

Measurement Period

January 1, 2027 through December 31, 2027

Measure Steward

National Kidney Foundation

Measure Developer

National Kidney Foundation

Endorsed By

None

Description

Percentage of patients aged 18-85 years with a diagnosis of diabetes and/or hypertension who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within the measurement period.

Disclaimer

Physician Performance Measures (Measures) and related data specifications developed by the National Kidney Foundation (NKF) are intended to facilitate quality improvement activities by health care professionals.

These Measures are intended to assist health care professionals in enhancing quality of care. These Measures are not clinical guidelines and do not establish a standard of medical care and have not been tested for all potential applications. NKF encourages testing and evaluation of its Measures.

Measures are subject to review and may be revised or rescinded at any time by NKF. The measures may not be altered without prior written approval from NKF. The measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes. Commercial use is defined as the sale, license, or distribution of the measures for commercial gain, or incorporation of the measures into a product or service that is sold, licensed, or distributed for commercial gain. Commercial uses of the measures require a license agreement between the user and NKF. Neither NKF nor its members shall be responsible for any use of the measures.

THESE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets.

CPT(R) contained in the Measure specifications is copyright 2004-2025 American Medical Association. LOINC(R) is copyright 2004-2025 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2025 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2025 World Health Organization. All Rights Reserved.

The PCPI's and American Medical Association (AMA)'s significant past efforts and contributions to the development and updating of the measure are acknowledged.

Due to technical limitations, registered trademarks are indicated by (R) or [R].

Measure Scoring

Proportion

Measure Type

Process

Stratification

None

Risk Adjustment

None

Rate Aggregation

None

Rationale

Chronic Kidney Disease (CKD) is a major driver of morbidity, mortality and high healthcare costs in the United States. Currently, 35.5 million American adults have CKD and millions of others are at increased risk (CDC, 2023), with an estimated population prevalence growing to nearly 17% among Americans aged 30 years and older by the year 2030 (Hoerger, 2015; USRDS, 2025). Total Medicare spending in 2023 on both CKD and End-Stage Kidney Disease (ESKD) was over $196 billion, comprising 36% of total Medicare FFS spending overall with costs increasing exponentially with advancing CKD (Nichols, 2020; USRDS, 2025). In the US from 2002-2016, the burden of CKD, defined as years of life lost, years living with disability, disability-adjusted life years, and deaths, outpaced changes in the burden of disease for other conditions (Bowe, 2018). Patients with CKD experience hospitalization and readmissions more frequently than those without diagnosed CKD (USRDS, 2025). CKD is the 9th leading cause of death in the US and is the fastest growing non-communicable disease in terms of in burden largely due to death (Hoerger, 2015; Bowe, 2018). This public health issue is driven largely by the impact of diabetes and hypertension, the most common comorbid risk factors for CKD (Hoerger, 2015; Bowe, 2018).

The intent of this process measure is to improve rates of guideline-concordant kidney health evaluation in patients with diabetes and/or hypertension to more consistently identify and potentially treat or delay progression of CKD in this high-risk population. Annual kidney health evaluation in patients with diabetes and/or hypertension to determine risk of CKD using estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (uACR) is recommended by clinical practice guidelines (Diabetes ADAPPCf, 2025; Writing Committee M, 2025; Stevens, 2024; Ndumele, 2023; de Boer, 2022; KDOQI, 2007; KDOQI, 2012) and has been a focus of various local and national health care quality improvement initiatives, including Healthy People 2020 (Healthy People 2020, 2020; Ndumele, 2023). There is variability in the performance of these tests in patients with diabetes and/or hypertension. Rates of testing vary by payer type and by comorbidity. Medicare Advantage members with diabetes are tested most frequently (59.6%) whereas Medicare FFS members with hypertension only are tested least (8.0%) (USRDS, 2024; Stempniewicz, 2021). 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, 2014). Indeed, 90% of individuals with CKD are unaware of their condition due to under-recognition and under-diagnosis (CDC, 2023). Currently, an individual's lifetime probability of developing CKD is relatively high, reaching 54% for someone currently aged 30-49 years (Hoerger, 2015). As CKD is associated with an elevated risk of cardiovascular events and mortality even in its earliest stages, eGFR and uACR are strong predictors of adverse cardiovascular events (Khan, 2024). Regular kidney health evaluations, utilizing both eGFR and uACR, provide an opportunity to improve identification of CKD and reduce progression of CKD and its associated cardiovascular risk, particularly in high-risk populations, such as those with diabetes and/or hypertension.

Clinical Recommendation Statement

The following evidence statements are quoted verbatim from the referenced clinical guidelines and other sources, where applicable:

American Diabetes Association, Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes-2026:

Assess kidney function with random urine albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) at least annually in people with type 1 diabetes with duration of >= 5 years and in all people with type 2 diabetes regardless of treatment. Level of Evidence: B

KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease, 2007 and 2012 Update:

Patients with diabetes should be screened annually for Diabetic Kidney Disease (DKD). Initial screening should commence:
- 5 years after the diagnosis of type 1 diabetes; (Quality of Evidence: A) or
- From diagnosis of type 2 diabetes. (Quality of Evidence: B)
Screening should include:
- Measurements of urinary albumin-creatinine ratio (ACR) in a spot urine sample; (Quality of Evidence: B)
- Measurement of serum creatinine and estimation of GFR. (Quality of Evidence: B)

KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease:

Practice Point 1.1.1.1: Test people at risk for and with chronic kidney disease (CKD) using both urine albumin measurement and assessment of glomerular filtration rate (GFR).

AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults, 2025:

For adults who are diagnosed with hypertension, laboratory tests (i.e., complete blood count, serum electrolytes, serum creatinine, lipid profile, glucose or hemoglobin A1c [HbA1c], thyroid-stimulating hormone, urinalysis, and urine albumin-to-creatinine ratio) and diagnostic procedures (12-lead ECG) should be performed to optimize management. (Class of Recommendation 1; Level of Evidence: C)

Improvement Notation

Increased score indicates improvement

Reference

Reference Type: Citation

Reference Text:

Bowe B, Xie Y, Li T, et al. Changes in the US Burden of Chronic Kidney Disease From 2002 to 2016: An Analysis of the Global Burden of Disease Study. JAMA Netw Open. Nov 2 2018;1(7):e184412. doi:10.1001/jamanetworkopen.2018.4412

Reference

Reference Type: Citation

Reference Text:

Centers for Disease Control & Prevention (CDC). Chronic Kidney Disease in the United States, 2023. Accessed March 30, 2026 https://www.cdc.gov/kidney-disease/php/data-research/index.html

Reference

Reference Type: Citation

Reference Text: de Boer IH, Khunti K, Sadusky T, et al. Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care. 2022;45(12):3075-3090. doi:10.2337/dci22-0027

Reference

Reference Type: Citation

Reference Text:

Diabetes* ADAPPCf. 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes-2026. Diabetes Care. 2025;49(Supplement_1):S246-S260. doi:10.2337/dc26-S011

Reference

Reference Type: Citation

Reference Text:

Healthy People 2020. Chronic Kidney Disease. U.S. Department of Health and Human Services,. Accessed March 30, 2026. https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/chronic-kidney-disease

Reference

Reference Type: Citation

Reference Text:

Hoerger TJ, Simpson SA, Yarnoff BO, et al. The future burden of CKD in the United States: a simulation model for the CDC CKD Initiative. Am J Kidney Dis. Mar 2015;65(3):403-11. doi:10.1053/j.ajkd.2014.09.023

Reference

Reference Type: Citation

Reference Text:

KDOQI Clinical Practice Guideline for Diabetes and CKD: 2012 Update. American Journal of Kidney Diseases. 2012;60(5):850-886. doi:10.1053/j.ajkd.2012.07.005

Reference

Reference Type: Citation

Reference Text:

KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. Am J Kidney Dis. Feb 2007;49(2 Suppl 2):S12-154. doi:10.1053/j.ajkd.2006.12.005

Reference

Reference Type: Citation

Reference Text:

Khan SS, Matsushita K, Sang Y, et al. Development and Validation of the American Heart Association's PREVENT Equations. Circulation. 2024/02/06 2024;149(6):430-449. doi:10.1161/CIRCULATIONAHA.123.067626

Reference

Reference Type: Citation

Reference Text:

Ndumele CE, Rangaswami J, Chow SL, et al. Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association. Circulation. 2023;148(20):1606-1635. doi:doi:10.1161/CIR.0000000000001184

Reference

Reference Type: Citation

Reference Text:

Nichols, G. A., Ustyugova, A., Deruaz-Luyet, A., O'Keeffe-Rosetti, M., & Brodovicz, K. G. (2020). Health care costs by type of expenditure across eGFR stages among patients with and without diabetes, cardiovascular disease, and heart failure. Journal of the American Society of Nephrology, 31(7), 1594-1601. https://doi.org/10.1681/ASN.2019121308

Reference

Reference Type: Citation

Reference Text:

Stempniewicz N, Vassalotti JA, Cuddeback JK, et al. Chronic Kidney Disease Testing Among Primary Care Patients With Type 2 Diabetes Across 24 U.S. Health Care Organizations. Diabetes Care. Sep 2021;44(9):2000-2009. doi:10.2337/dc20-2715

Reference

Reference Type: Citation

Reference Text:

Stevens PE, Ahmed SB, Carrero JJ, et al. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International. 2024;105(4):S117-S314. doi:10.1016/j.kint.2023.10.018

Reference

Reference Type: Citation

Reference Text:

Szczech LA, Stewart RC, Su H-L, et al. Primary Care Detection of Chronic Kidney Disease in Adults with Type-2 Diabetes: The ADD-CKD Study (Awareness, Detection and Drug Therapy in Type 2 Diabetes and Chronic Kidney Disease). PLOS ONE. 2014;9(11):e110535. doi:10.1371/journal.pone.0110535

Reference

Reference Type: Citation

Reference Text:

United States Renal Data System. 2024 USRDS Annual Data Report: Epidemiology of kidney disease in the United States, 2024. Accessed March 30, 2026. https://usrds-adr.niddk.nih.gov/2024

Reference

Reference Type: Citation

Reference Text:

United States Renal Data System. 2025 USRDS Annual Data Report: Epidemiology of kidney disease in the United States, 2025. Accessed March 30, 2026 https://usrds-adr.niddk.nih.gov/2025

Reference

Reference Type: Citation

Reference Text:

Writing Committee M, Jones DW, Ferdinand KC, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025/09/16 2025;152(11):e114-e218. doi:10.1161/CIR.0000000000001356

Definition

None

Guidance

This measure assesses the performance of a comprehensive kidney evaluation in adults aged 18-85. This measure does not preclude or discourage regular laboratory testing for CKD in patients outside of the age range (patients under 18 years and those over 85 years of age).

This measure includes patients with diabetes and/or hypertension, which includes those with only diabetes, only hypertension and those with both diabetes and hypertension.

The Urine Albumin-Creatinine Ratio (uACR) requirement can be met with a Urine Albumin and Urine Creatinine tests resulted less than or equal to four days apart; the four day window serves as a proxy to accommodate for laboratory processing times. These tests are typically performed on a single urine sample. A calculation of uACR is not required to meet this measure, but it is intended for the uACR to be calculated for the purposes of kidney health evaluation. If the Urine Albumin and Urine Creatinine tests have different units of measure, they should be converted to the same unit of measure for the purposes of calculating uACR. The uACR, Urine Albumin or Urine Creatinine test requirements can be met if the lab result is received as a quantitative value or as an undetectable result. Undetectable results can be coded using values in the "Undetectable Lab Result Value" value set.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Transmission Format

TBD

Initial Population

All patients aged 18-85 years with a diagnosis of diabetes and/or hypertension at the start of the measurement period with a visit during the measurement period.

Denominator

Equals Initial Population

Denominator Exclusions

Patients who meet the following criteria during the measurement period are excluded from the measure:

Patients with a diagnosis of ESRD active during the measurement period.
Patients with a diagnosis of CKD Stage 5 active during the measurement period.
Patients who have an order for or are receiving hospice or palliative care.

Numerator

Patients who received a kidney health evaluation during the measurement period. A kidney health evaluation includes:

an eGFR AND uACR resulted within the measurement period

an eGFR resulted within the measurement period AND both a Urine Albumin and Urine Creatinine resulted less than or equal to four days apart within the measurement period.

Numerator Exclusions

None

Denominator Exceptions

None

Supplemental Data Elements

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Population Criteria
Definitions
Functions
Terminology
Data Criteria (QDM Data Elements)
Supplemental Data Elements
Risk Adjustment Variables

Population Criteria

Initial Population

  AgeInYearsAt(date from start of "Measurement Period") in Interval[18, 85]
    and "Has Outpatient Visit During Measurement Period"
    and (("Has Active Diabetes At The Start Of The Measurement Period" and not "Has Active Hypertension At The Start Of The Measurement Period")
or ("Has Active Hypertension At The Start Of The Measurement Period" and not "Has Active Diabetes At The Start Of The Measurement Period")
or ("Has Active Diabetes At The Start Of The Measurement Period" and "Has Active Hypertension At The Start Of The Measurement Period"))

- Denominator
  - "Initial Population"

Denominator Exclusions

     exists "Has CKD Stage 5 Or ESRD Diagnosis Overlaps Measurement Period"
      or Hospice."Has Hospice Services"
      or PalliativeCare."Has Palliative Care In The Measurement Period"

Numerator

  "Has Kidney Panel Resulted During Measurement Period"

- Numerator Exclusions
  - None

- Denominator Exceptions
  - None

- Stratification
  - None

Definitions

Denominator
- - "Initial Population"

Denominator Exclusions

     exists "Has CKD Stage 5 Or ESRD Diagnosis Overlaps Measurement Period"
      or Hospice."Has Hospice Services"
      or PalliativeCare."Has Palliative Care In The Measurement Period"

Has Active Diabetes At The Start Of The Measurement Period

  exists ( ["Diagnosis": "Diabetes"] DiabetesDiagnosis
      where DiabetesDiagnosis.prevalencePeriod overlaps before day of "Measurement Period"
  )

Has Active Hypertension At The Start Of The Measurement Period

  exists ( ["Diagnosis": "Essential Hypertension"] HTNDiagnosis
      where HTNDiagnosis.prevalencePeriod overlaps before day of "Measurement Period"
  )

Has CKD Stage 5 Or ESRD Diagnosis Overlaps Measurement Period

  ( ["Diagnosis": "Chronic Kidney Disease, Stage 5"]
    union ["Diagnosis": "End Stage Renal Disease"] ) CKDOrESRD
    where CKDOrESRD.prevalencePeriod overlaps day of "Measurement Period"

Has Estimated Glomerular Filtration Rate Resulted During Measurement Period

  exists ( ["Laboratory Test, Performed": "Estimated Glomerular Filtration Rate"] eGFRTest
      where Global."NormalizeInterval" ( eGFRTest.relevantDatetime, eGFRTest.relevantPeriod ) during day of "Measurement Period"
        and eGFRTest.result is not null)

Has Kidney Panel Resulted During Measurement Period

    "Has Estimated Glomerular Filtration Rate Resulted During Measurement Period" 
   and ("Has Urine Albumin Creatinine Ratio Test Resulted During Measurement Period" 
   or "Has Urine Albumin Test And Urine Creatinine Test Less Than Or Equal To Four Days Apart")

Has Outpatient Visit During Measurement Period

  exists ( ( ["Encounter, Performed": "Annual Wellness Visit"]
      union ["Encounter, Performed": "Home Healthcare Services"]
      union ["Encounter, Performed": "Office Visit"]
      union ["Encounter, Performed": "Outpatient Consultation"]
      union ["Encounter, Performed": "Preventive Care Services Established Office Visit, 18 and Up"]
      union ["Encounter, Performed": "Preventive Care Services Initial Office Visit, 18 and Up"]
      union ["Encounter, Performed": "Telephone Visits"] ) ValidEncounter
      where ValidEncounter.relevantPeriod during "Measurement Period"
  )

Has Urine Albumin Creatinine Ratio Test Resulted During Measurement Period

    exists ( ["Laboratory Test, Performed": "Urine Albumin Creatinine Ratio"] uACRTest
        where Global."NormalizeInterval" ( uACRTest.relevantDatetime, uACRTest.relevantPeriod ) during day of "Measurement Period"
          and uACRTest.result is not null
          and (uACRTest.result is Quantity 
          or uACRTest.result as Code in "Undetectable Lab Result Value"))

Has Urine Albumin Test And Urine Creatinine Test Less Than Or Equal To Four Days Apart

     exists from
    "Has Urine Albumin Test Resulted During The Measurement Period" UrineAlbuminTest,
    "Has Urine Creatinine Test Resulted During The Measurement Period" UrineCreatinineTest
    let UrineAlbuminDocumentedTime: Global."NormalizeInterval"(UrineAlbuminTest.relevantDatetime, UrineAlbuminTest.relevantPeriod),
        UrineCreatinineDocumentedTime: Global."NormalizeInterval"(UrineCreatinineTest.relevantDatetime, UrineCreatinineTest.relevantPeriod)
    where UrineAlbuminDocumentedTime during Interval[start of UrineCreatinineDocumentedTime - 4 days, end of UrineCreatinineDocumentedTime + 4 days]

Has Urine Albumin Test Resulted During The Measurement Period

  ["Laboratory Test, Performed": "Urine Albumin"] AlbuminTest
    where Global."NormalizeInterval" ( AlbuminTest.relevantDatetime, AlbuminTest.relevantPeriod ) during day of "Measurement Period"
    and AlbuminTest.result is not null
    and (AlbuminTest.result is Quantity 
          or AlbuminTest.result as Code in "Undetectable Lab Result Value")

Has Urine Creatinine Test Resulted During The Measurement Period

  ["Laboratory Test, Performed": "Urine Creatinine"] CreatinineTest
     where Global."NormalizeInterval" ( CreatinineTest.relevantDatetime, CreatinineTest.relevantPeriod ) during day of "Measurement Period"
         and CreatinineTest.result is not null
    and (CreatinineTest.result is Quantity 
          or CreatinineTest.result as Code in "Undetectable Lab Result Value")

Hospice.Has Hospice Services

  exists ( ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
      where ( InpatientEncounter.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
          or InpatientEncounter.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
      )
        and InpatientEncounter.relevantPeriod ends during day of "Measurement Period"
  )
    or exists ( ["Encounter, Performed": "Hospice Encounter"] HospiceEncounter
        where HospiceEncounter.relevantPeriod overlaps day of "Measurement Period"
    )
    or exists ( ["Assessment, Performed": "Hospice care [Minimum Data Set]"] HospiceAssessment
        where HospiceAssessment.result ~ "Yes (qualifier value)"
          and Global."NormalizeInterval" ( HospiceAssessment.relevantDatetime, HospiceAssessment.relevantPeriod ) overlaps day of "Measurement Period"
    )
    or exists ( ["Intervention, Order": "Hospice Care Ambulatory"] HospiceOrder
        where HospiceOrder.authorDatetime during day of "Measurement Period"
    )
    or exists ( ["Intervention, Performed": "Hospice Care Ambulatory"] HospicePerformed
        where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps day of "Measurement Period"
    )
  or exists ( ["Diagnosis": "Hospice Diagnosis"] HospiceCareDiagnosis
        where HospiceCareDiagnosis.prevalencePeriod overlaps day of "Measurement Period"
    )

Initial Population

  AgeInYearsAt(date from start of "Measurement Period") in Interval[18, 85]
    and "Has Outpatient Visit During Measurement Period"
    and (("Has Active Diabetes At The Start Of The Measurement Period" and not "Has Active Hypertension At The Start Of The Measurement Period")
or ("Has Active Hypertension At The Start Of The Measurement Period" and not "Has Active Diabetes At The Start Of The Measurement Period")
or ("Has Active Diabetes At The Start Of The Measurement Period" and "Has Active Hypertension At The Start Of The Measurement Period"))

Numerator

  "Has Kidney Panel Resulted During Measurement Period"

PalliativeCare.Has Palliative Care In The Measurement Period

  exists ( ["Assessment, Performed": "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"] PalliativeAssessment
      where Global."NormalizeInterval" ( PalliativeAssessment.relevantDatetime, PalliativeAssessment.relevantPeriod ) overlaps day of "Measurement Period"
  )
    or exists ( ["Diagnosis": "Palliative Care Diagnosis"] PalliativeDiagnosis
        where PalliativeDiagnosis.prevalencePeriod overlaps day of "Measurement Period"
    )
    or exists ( ["Encounter, Performed": "Palliative Care Encounter"] PalliativeEncounter
        where PalliativeEncounter.relevantPeriod overlaps day of "Measurement Period"
    )
    or exists ( ["Intervention, Performed": "Palliative Care Intervention"] PalliativeIntervention
        where Global."NormalizeInterval" ( PalliativeIntervention.relevantDatetime, PalliativeIntervention.relevantPeriod ) overlaps day of "Measurement Period"
    )

SDE Ethnicity

  ["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

  ["Patient Characteristic Payer": "Payer Type"]

SDE Race

  ["Patient Characteristic Race": "Race"]

SDE Sex

  ["Patient Characteristic Sex": "Federal Administrative Sex"]

Functions

Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

  if pointInTime is not null then Interval[pointInTime, pointInTime]
    else if period is not null then period 
    else null as Interval<DateTime>

Terminology

code "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)")
code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)")
code "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" ("LOINC Code (71007-9)")
code "Hospice care [Minimum Data Set]" ("LOINC Code (45755-6)")
code "Yes (qualifier value)" ("SNOMEDCT Code (373066001)")
valueset "Annual Wellness Visit" (2.16.840.1.113883.3.526.3.1240)
valueset "Chronic Kidney Disease, Stage 5" (2.16.840.1.113883.3.526.3.1002)
valueset "Diabetes" (2.16.840.1.113883.3.464.1003.103.12.1001)
valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
valueset "End Stage Renal Disease" (2.16.840.1.113883.3.526.3.353)
valueset "Essential Hypertension" (2.16.840.1.113883.3.464.1003.104.12.1011)
valueset "Estimated Glomerular Filtration Rate" (2.16.840.1.113883.3.6929.3.1000)
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "Federal Administrative Sex" (2.16.840.1.113762.1.4.1021.121)
valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016)
valueset "Hospice Care Ambulatory" (2.16.840.1.113883.3.526.3.1584)
valueset "Hospice Diagnosis" (2.16.840.1.113883.3.464.1003.1165)
valueset "Hospice Encounter" (2.16.840.1.113883.3.464.1003.1003)
valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
valueset "Outpatient Consultation" (2.16.840.1.113883.3.464.1003.101.12.1008)
valueset "Palliative Care Diagnosis" (2.16.840.1.113883.3.464.1003.1167)
valueset "Palliative Care Encounter" (2.16.840.1.113883.3.464.1003.101.12.1090)
valueset "Palliative Care Intervention" (2.16.840.1.113883.3.464.1003.198.12.1135)
valueset "Payer Type" (2.16.840.1.114222.4.11.3591)
valueset "Preventive Care Services Established Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1025)
valueset "Preventive Care Services Initial Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1023)
valueset "Race" (2.16.840.1.114222.4.11.836)
valueset "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)
valueset "Undetectable Lab Result Value" (2.16.840.1.113762.1.4.1248.272)
valueset "Urine Albumin" (2.16.840.1.113762.1.4.1178.88)
valueset "Urine Albumin Creatinine Ratio" (2.16.840.1.113883.3.6929.3.1007)
valueset "Urine Creatinine" (2.16.840.1.113762.1.4.1178.87)

Data Criteria (QDM Data Elements)

"Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" using "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal) (LOINC Code 71007-9)"
"Assessment, Performed: Hospice care [Minimum Data Set]" using "Hospice care [Minimum Data Set] (LOINC Code 45755-6)"
"Diagnosis: Chronic Kidney Disease, Stage 5" using "Chronic Kidney Disease, Stage 5 (2.16.840.1.113883.3.526.3.1002)"
"Diagnosis: Diabetes" using "Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001)"
"Diagnosis: End Stage Renal Disease" using "End Stage Renal Disease (2.16.840.1.113883.3.526.3.353)"
"Diagnosis: Essential Hypertension" using "Essential Hypertension (2.16.840.1.113883.3.464.1003.104.12.1011)"
"Diagnosis: Hospice Diagnosis" using "Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165)"
"Diagnosis: Palliative Care Diagnosis" using "Palliative Care Diagnosis (2.16.840.1.113883.3.464.1003.1167)"
"Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240)"
"Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
"Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016)"
"Encounter, Performed: Hospice Encounter" using "Hospice Encounter (2.16.840.1.113883.3.464.1003.1003)"
"Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
"Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008)"
"Encounter, Performed: Palliative Care Encounter" using "Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090)"
"Encounter, Performed: Preventive Care Services Established Office Visit, 18 and Up" using "Preventive Care Services Established Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1025)"
"Encounter, Performed: Preventive Care Services Initial Office Visit, 18 and Up" using "Preventive Care Services Initial Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1023)"
"Encounter, Performed: Telephone Visits" using "Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080)"
"Intervention, Order: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
"Intervention, Performed: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
"Intervention, Performed: Palliative Care Intervention" using "Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135)"
"Laboratory Test, Performed: Estimated Glomerular Filtration Rate" using "Estimated Glomerular Filtration Rate (2.16.840.1.113883.3.6929.3.1000)"
"Laboratory Test, Performed: Urine Albumin Creatinine Ratio" using "Urine Albumin Creatinine Ratio (2.16.840.1.113883.3.6929.3.1007)"
"Laboratory Test, Performed: Urine Albumin" using "Urine Albumin (2.16.840.1.113762.1.4.1178.88)"
"Laboratory Test, Performed: Urine Creatinine" using "Urine Creatinine (2.16.840.1.113762.1.4.1178.87)"
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer Type" using "Payer Type (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: Federal Administrative Sex" using "Federal Administrative Sex (2.16.840.1.113762.1.4.1021.121)"

Supplemental Data Elements

SDE Ethnicity

  ["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

  ["Patient Characteristic Payer": "Payer Type"]

SDE Race

  ["Patient Characteristic Race": "Race"]

SDE Sex

  ["Patient Characteristic Sex": "Federal Administrative Sex"]

Risk Adjustment Variables

None

Measure Set