CDM risk factors

CDM risk factors

Common indicators for diabetes, IHD and COPD

  • Smoking cessation – discussed once per year if smoker (document smoker or nonsmoker)
  • Immunizations discussed and/or given – once per year
  • Exercise/activity – discussed, including possible referrals, once per year

Common indicators for diabetes and IHD

  • Blood pressure – 2 times per year
  • Weight/nutrition counseling – once per year
  • Lipids – once per year

Plus one, two or all three of the following as applicable:

Indicators for diabetes only

  • HbA1C – ordered 2 times per year
  • Renal function – ACR or eGFR ordered once per year
  •  Foot exam with 10-g monofilament – referred or completed once per year
  • Eye exam – discussed and/or referred once per year for routine dilated eye exam

Indicators for IHD only

  • Anti-platelet therapy – considered/reviewed once per year
  • Beta-blocker – considered/reviewed once per year
  • ACEI/ARB – considered/reviewed once per year
  • Discuss nitroglycerin – considered/reviewed once per year
  • Consider further cardiac investigations – considered/reviewed once per year

Indicator for COPD only

  • COPD Action Plan required – Develop and then review and complete once per year


Jessica Moore
Compensation manager, Physician Agreement and Fee Schedule