2014 Diabetes Mellitus Physician Quality Reporting System Template

American Board of Family Medicine Performance in Practice Registry

( please keep this form for your records and for audit purposes - do not send to the ABFM )

Provider Identification Data

Physician's Name:

Physician's Individual NPI Number*: (as submitted in line item 24-J of the CMS 1500 Claim Form
as the Rendering Provider ID.)

Taxpayer Identification Number (TIN)*: (as submitted in line item 25 of the CMS 1500 Claim
Form as the Federal Tax I.D. Number.)
*Important: The same NPI and TIN must be used for all patients included in this registry.

REMINDER! - Please be certain that this form is completely filled out and that you keep all forms for audit purposes.

Patient Name:

Patient Medical Record Number:

Date of Birth:

Date of Service*:

*Note: You must collect data on 20 unique, separate and distinct Diabetes Mellitus patients that are between the ages 18 and 75
years old, of which 11 must be Medicare Part B beneficiaries, and the date of service must be between 1/1/2014 - 12/31/2014.

As of the date of service, is the patient between the ages of 18 - 75 years old? Yes No
If no, stop and move on to the next unique Diabetic patient. Only record patients between 18 - 75 years old.
Does the patient have Diabetes Mellitus? Yes No
If no, stop and move on to the next unique Diabetic patient. Only record unique patients with Diabetes Mellitus.

As you enter this patient into the online Physician Quality Reporting System registry, please write the
patient number in this box. (e.g., 12, 13, 14, etc.)

Medicare Part B
1. Is this patient covered by Part B of Medicare. Yes No

A majority (11) patients must be Medicare Part B beneficiaries in your total sample. If you submit the minimum 20 patients or more than 20
total patients, there still only needs to be 11 Medicare Part B beneficiaries. Only record unique patients with Diabetes Mellitus.

High Blood Pressure Control in Type 1 or 2 Diabetes Mellitus

2. Within the last 12 months of this encounter, does the patient's record include documentation of Yes No
a blood pressure measurement?
2a. If yes to #2, what was the patient's most recent blood pressure? Systolic

Diastolic

IMPORTANT: In the following diabetes measure group questions, you must have a performance rate greater than zero (less than 100%
for inverse measures) for the patient sample provided. Notes are provided with each question to indicate what is required to meet the
performance rate requirement.

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 2014 Diabetes Physician Quality Reporting System Template (continued)

Measure Number 1 - Diabetes: Hemoglobin A1c Poor Control

3. Within the last 12 months of this encounter, does the patient's record include documentation of Yes No
a hemoglobin A1c value?
3a. If yes to #3, is the patient's most recent hemoglobin A1c value greater than 9%? Yes No
(NOTE: You must have at least one patient with "yes" for item 3 and "no" for item 3a for performance requirement.)

Measure Number 2 - Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dL)
4. Within the last 12 months of this encounter, does the patient's record include documentation of Yes No
an LDL or lipid panel?
(NOTE: You must have at least one patient with "yes" for item 4 and "yes" for item 4a for performance requirement.)
4a. If yes to #4, is the patient's most recent LDL level less than 100mg/dl? Yes No

Measure Number 117 - Diabetes: Eye Exam

5. Does the patient's record include documentation of a dilated retinal examination performed by Yes No
an optometrist or ophthalmologist between January 1, 2014 and December 31, 2014?
5a. If no to #5, is there electronic results of a negative retinal or dilated eye exam (negative for Yes No
retinopathy) performed by an eye care professional between January 1, 2013 and December
31, 2013?
(NOTE: You must have at least one patient with "yes" for item 5 or 5a.)

Measure Number 119 - Diabetes: Medical Attention for Nephropathy

6. Between January 1, 2014 and December 31, 2014, does the patient's record include documentation
of nephropathy screening test or evidence of nephropathy? Indicate below:
(NOTE: You must have at least one patient with "yes" for 6a, 6b, 6c, 6d or 6e.)

6a. Positive microalbuminuria test result documented and reviewed Yes No N/A

6b. Negative microalbuminuria test result documented and reviewed Yes No N/A

6c. Positive macroalbuminuria test result documented and reviewed Yes No N/A
(NOTE: For items 6a, 6b & 6c, mark "N/A" if the patient is without kidneys or is on regular maintenance dialysis.)

6d. Documentation of treatment for nephropathy (eg, patient receiving dialysis; patient Yes No N/A
being treated for ESRD, CRF, ARF, or renal insufficiency; any visit to a nephrologist)
6e. Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) Yes No N/A
therapy prescribed in the last 12 months?

Measure Number 163 - Foot Exam

7. Within the last 12 months of this encounter, does the patient's record include foot examination documentation of:
(NOTE: You must have at least one patient with "yes" for item 7a, 7b and 7c.)

7a. A visual inspection? Yes No N/A

7b. A monofilament exam? Yes No N/A

7c. An examination of the pulses? Yes No N/A

(NOTE: For items 7b & 7c, mark "N/A" if the patient is without feet.)

REMINDER! - Please be certain that this form is completely filled out and that you keep all forms. If you are randomly selected
for the audit your completed forms will need to be provided for the audit. This document provides the only link to the de-identified
data that you have provided to the ABFM Registry and the patient from whom it was collected.

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