Comprehensive diabetes care: Improve patient health, reduce need for medical record reviews

Star rating measure

Measure description

Comprehensive diabetes care

Criteria applies to all comprehensive diabetes care measures

Definition: Patients 18 to 75 years of age with diagnosis of diabetes (Type 1 and Type 2) who have had each of the following:

• Retinal eye exam (Medicare star reporting)
• Medical attention for nephropathy (Medicare star reporting)
• Hemoglobin A1c (HbA1c) testing
• Hemoglobin A1c (HbA1c) control
• HbA1c <9% (Medicare star reporting)
• HbA1c <8%
• HbA1c <7%
• Blood pressure control (<140/90 mm Hg)

Exclusion criteria (applies to all comprehensive diabetes care measures):
If any of the following occurred any time during the member’s history on or before Dec. 31 of the measurement year:

• Gestational diabetes or steroid-induced diabetes diagnosis during the measurement year or the year prior
• Patient in hospice

Comprehensive diabetes care:
HbA1c control

Definition: Patients 18 to 75 years of age with diagnosis of diabetes and an HbA1c test performed during the measurement year:

• Control: <9% (Medicare star reporting)
• Control: <8%

How to close gaps:

• Perform or order HbA1c testing two to four times each year (optimal).
• The last HbA1c of the year determines compliance.
• Submit HbA1c claims with CPT II result codes:

• When the patient’s A1c is out of control, adjust treatment, address medication compliance and continue to bring patient in for recheck until the A1c is controlled.
• The medical record may be requested to obtain the HbA1c lab report, result and date when an A1c claim isn’t received with the CPT II result code.

Common chart deficiencies:

• An HbA1c result is noted in the medical record without a lab report or without a date the test was drawn.
• The patient has an HbA1c >9% but isn’t brought back in to have the HbA1c rechecked.

Comprehensive diabetes care:
Eye exam

Definition: Patients 18 to 75 years of age with diagnosis of diabetes. Screening or monitoring for diabetic retinal disease by an eye care professional (optometrist or ophthalmologist) where at least one of the following conditions is satisfied:

• A retinal or dilated eye exam by an eye care professional during the measurement year
• A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year. (A negative exam indicates no diabetic retinopathy is present.)
• Bilateral eye enucleation any time during the member’s history through Dec. 31 of the measurement year.

Note: Eye exams are covered as part of essential benefits under medical coverage. Not having vision coverage shouldn’t be a deterrent to receiving an eye exam for diabetics.

How to close gaps:

• Educate diabetic patients about the importance of an annual diabetic eye exam.
• Be sure the patient has his or her eyes examined yearly (or every other year if negative retinopathy).
• Refer to eye care professional for eye exam if the patient is overdue.
• When you receive an eye exam report for your diabetic patients from an eye care professional, review the report, place it in the patient’s medical record and, for all appropriate codes, submit a $0.01 claim:
• *2022F: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed
• *3072F: Low risk for retinopathy (no evidence of retinopathy in the prior year)

These CPT II codes may be billed alone or with other services.

Common chart deficiencies:

• Office receives eye exam report for a diabetic patient but doesn’t submit a claim with CPT II code *2022F or *3072F.
• Eye exam screenings aren’t consistently documented in the patient’s history. Document that a retinal eye exam was performed, as well as the date of service, result and eye care professional’s name.
• Eye exam screening is outdated but without documentation that screening was discussed or encouraged during the patient’s office visit.
• Medical record may be requested to obtain an eye exam report if CPT II code isn’t billed.

Comprehensive diabetes care:
Medical attention for nephropathy

Definition: Patients 18 to 75 years of age with diagnosis of diabetes. Screening for nephropathy or evidence of medical attention for nephropathy during the measurement year. Documentation needs to include at least one of the following, reported yearly.

How to close gaps (one or more of the below):

• Urine microalbumin or protein screening
  Include CPT code for urine protein screening (*81000, *81001, *81002, *81003, *81005, *82042, *82043, *82044 or *84156).

• Treatment with an ACE/ARB
  Submit an office visit claim with *4010F: Angiotensin Converting Enzyme, Inhibitor or Angiotensin Receptor Blocker, therapy prescribed or currently being taken.

• Evidence of CKD stage 4, ESRD, kidney transplant or a nephrology visit
  Submit an office visit claim with *3066F: Documentation of treatment for nephropathy (includes visit to nephrologist, receiving dialysis, treatment for end stage renal disease, chronic renal failure, acute renal failure or renal insufficiency).

Common chart deficiencies:

Urine microalbumin/protein screenings aren’t done or documented in the medical record, and there is no evidence of medical attention for nephropathy.

Comprehensive diabetes care:
Blood pressure control

Definition: Patients who are 18 to 75 years of age with diagnosis of diabetes. Diabetics who had their blood pressure taken during the measurement year. Documentation in the medical record must meet the following requirements:

• Blood pressure must be the last reading of the measurement year from an outpatient visit.
• For the blood pressure to be considered controlled, it must be less than 140/90 (no rounding of blood pressure numbers; document exact reading).

How to close gaps:
Include the appropriate blood pressure CPT II codes on your office visit claims:

Common chart deficiencies:

• High blood pressure readings aren’t retaken.
• The patient doesn’t have a follow-up visit after an out-of-control blood pressure is documented.