BCBSRI is committed to making it easier for your practice to be successful in all areas of quality improvement. Together, we can achieve our shared goal of improving health outcomes by identifying and addressing open care gaps. Hints for HEDIS (and more) is a reference tool to help better understanding of:
- Definitions, specifications, and exclusions of the many quality measures
- Billing codes used to report gap closure
- Collection and reporting methodologies
- Tips and best practices to maximize gap closure
Our Quality Concierge Team (QCT) is also available to answer questions, provide updates, assist in the interpretation of monthly gaps in care (GIC) reports and detail summaries, research member attribution issues, and provide overall HEDIS support to you and your practice. Our QCT nurses can be reached at QualityHEDIS@bcbsri.org or at (401) 459-1005.
Below are some general tips and information that can be applied to the Comprehensive Diabetes Care (CDC) HEDIS measure:
The HEDIS Comprehensive Diabetes Care (CDC) measure set includes screening rates for:
- HbA1c control in patients with type 1 and type 2 diabetes
- Retinal eye exams
- Blood pressure
- Nephropathy screening
Please note: HEDIS excludes Medicare members age 66 and older as of December 31 of the measurement year who are:
- Diagnosed with frailty and advanced illness during the measurement year
- Enrolled in an institutional SNP (I-SNP) any time during the measurement year
- Living long-term in an institution (LTI) any time during the measurement year (Organizations may use the LTI flag in the Medicare Part C monthly membership file.)
Tips for success
Hemoglobin A1c testing
- Pre-visit planning may be useful. For members with upcoming appointments, medical assistants can mail a reminder letter and a lab slip to those due for HbA1c screening and other tests to help improve performance in this measure.
- Reinforce with members the importance of routine HbA1c testing as an indicator of diabetes control and to help guide treatment planning.
- Obtain testing on an acute visit for patients who are non-compliant for routine screenings.
- Take advantage of in-office testing for those that have the equipment.
- Consider diabetes disease management for patients with HbA1c > 8.
- Consider a referral to a PCMH pharmacist or the BCBSRI pharmacy program for assistance with medication management for patients with HbA1c >8.
- Consider endocrinology referral for complex or refractory cases.
- Reinforce and recognize members’ achievement of target HbA1c and its association with lower rates of complications.
Eye exam (retinal) performed
A retinal eye exam by an optometrist or ophthalmologist in the measurement year OR a “negative for retinopathy” retinal exam by one of the above specialists in the year prior to the measurement year.
- PCPs and optometrists/ophthalmologists should collaborate by sharing medical record information on their mutual patient.
- The retinal eye exam may include (but does not require) dilation.
- Remind patients that diabetic eye disease can be asymptomatic, so routine exams are important for finding and treating problems early.
- Utilize CPT Category 2 code (3072F) to identify diabetic eye exams negative for retinopathy in the year prior.
Medical attention for nephropathy
A nephropathy screening test done annually OR evidence of nephropathy.
- At least one ACE-I or ARB medication dispensing event in the measurement year counts as evidence of treatment for nephropathy.
- Remind patients that, like eye disease, diabetic kidney disease may be asymptomatic. Regular tests can detect issues early, when treatment may help delay disease progression.
- Pre-visit planning may be useful when screening tests are due. For members with upcoming appointments, have medical assistants note (schedules or records) that a urine test for albumin or protein is needed.
- Obtain testing* on an acute visit for patients who are non-compliant for routine screenings.
*Includes spot urine tests for albumin or protein
BP control (<140/90 mm Hg)
The most recent blood pressure reading taken during an outpatient visit or a non-acute in-patient encounter.
- Discuss the importance of BP control, especially given the additional cardiovascular risks for people with diabetes.
- It is very important to obtain and document two readings upon visit if initial reading is elevated. We are able to combine multiple readings on the same visit to show the lowest representative BP for systolic and diastolic. Any reading ≥140 systolic or ≥90 diastolic should be rechecked and documented.
CDC – Comprehensive diabetes care
Hybrid measures - The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had the following during the measurement period (1/1-12/31 of the current year):
*Excludes members 65 years of age and older living in long-term institutional settings, with advanced illness, and/or with frailty from all of this measure.
*Excludes members 65 years of age and older living in long-term institutional settings, with advanced illness, and/or with frailty from all of this measure.
HEDIS QUALITY MEASURE
CLINICAL GOAL
CRITERIA TO MEET THE GOAL
CDC – HbA1c
Three rates are reported:
Three rates are reported:
- HbA1c Testing
- HbA1c Poor Control > 9%
- HbA1c Good Control < 8%
Members will have an HbA1c test performed during the measurement year.
HbA1c value – poor control ≥9% (reported as inverted rate <9%)
HbA1c value good control <8%
MA patients – goal HbA1c <9
Commercial patients – goal HbA1c <8%
HbA1c value – poor control ≥9% (reported as inverted rate <9%)
HbA1c value good control <8%
MA patients – goal HbA1c <9
Commercial patients – goal HbA1c <8%
Claims:
Submit a claim identifying the results of the HbA1c utilizing one of the following three CPT II codes:
3046F – HbA1c greater than 9%
3045F – HbA1c between 7.0 – 9.0%*
3044F – HbA1c less than 7.0%
**CPTII code 3045F (HbA1c 7.0–9.0%) is not specific enough to denote numerator compliance. BCBSRI will need to use other sources (laboratory value, chart reviews) to identify if the HbA1c was <8%.
Medical record documentation of:
Submit a claim identifying the results of the HbA1c utilizing one of the following three CPT II codes:
3046F – HbA1c greater than 9%
3045F – HbA1c between 7.0 – 9.0%*
3044F – HbA1c less than 7.0%
**CPTII code 3045F (HbA1c 7.0–9.0%) is not specific enough to denote numerator compliance. BCBSRI will need to use other sources (laboratory value, chart reviews) to identify if the HbA1c was <8%.
Medical record documentation of:
- Date and value of most recent HbA1c result during the measurement year.
CDC – Medical attention for nephropathy
Annual screening test or evidence of treatment for nephropathy with ACE/ARB therapy.
Annual screening test or evidence of treatment for nephropathy with ACE/ARB therapy.
Members will have an annual urine screen for albumin/ protein done during the measurement year.
OR
Evidence of treatment for nephropathy.
OR
ACE/ARB therapy.
OR
Evidence of treatment for nephropathy.
OR
ACE/ARB therapy.
Claims:
Submit a claim for appropriate nephropathy screening test or evidence of nephropathy during the measurement year. Also can accomplish by utilizing one of the following CPTII codes:
3060F or 3061F – Screening tests for nephropathy
3062F – Positive macroalbuminuria
3066F – Documentation of treatment for nephropathy
4010F – Patient prescribed or taking ACE or ARB
Medical record documentation of:
NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org in November of the measurement year.
Submit a claim for appropriate nephropathy screening test or evidence of nephropathy during the measurement year. Also can accomplish by utilizing one of the following CPTII codes:
3060F or 3061F – Screening tests for nephropathy
3062F – Positive macroalbuminuria
3066F – Documentation of treatment for nephropathy
4010F – Patient prescribed or taking ACE or ARB
Medical record documentation of:
- Results of nephropathy screen during the measurement year
- Evidence of nephropathy during the measurement year
- ACE/ARB therapy prescribed during the measurement year
NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org in November of the measurement year.
CDC – BP control <140/90
Members with diabetes will have blood pressure control of <140/90 mm Hg.
Claims:
Submit a claim with the two appropriate CPTII codes to report results of the BP at each office visit:
Medical record documentation not applicable.
Please note – When submitting any CPTII codes, do not use the modifiers 1P, 2P, 3P, or 8P. These modifiers indicate that the service was not done and will exclude the CPTII code from care gap calculations.
Submit a claim with the two appropriate CPTII codes to report results of the BP at each office visit:
Systolic BP greater than/equal to 140 mm Hg
CPT II – 3077F
Not controlled
Diastolic BP greater than/equal to 90 mm Hg
CPT II – 3080F
Not controlled
Systolic BP 130–139 mg Hg
CPT II – 3075F
Controlled
Systolic BP less than 130 mg Hg
CPT II – 3074F
Controlled
Diastolic BP 80–89 mm Hg
CPT II – 3079F
Controlled
Diastolic BP less than 80 mm Hg
CPT II – 3078F
Controlled
Please note – When submitting any CPTII codes, do not use the modifiers 1P, 2P, 3P, or 8P. These modifiers indicate that the service was not done and will exclude the CPTII code from care gap calculations.
CDC – Annual Eye Exam
Member will have:
A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year.
A negative retinal or dilated eye exam(negative for retinopathy) by an eye care professional in the year prior to the measurement year.
Bilateral eye enucleation anytime during the member’s history through December 31 of the measurement year.
A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year.
A negative retinal or dilated eye exam(negative for retinopathy) by an eye care professional in the year prior to the measurement year.
Bilateral eye enucleation anytime during the member’s history through December 31 of the measurement year.
Claims:
If you have or reviewed a report from the patient’s ophthalmologist or optometrist:
Submit a claim with the appropriate CPTII code:
2022F – Dilated eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed.
2024F – Seven (7) standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed.
2026F – Eye imaging validated to match diagnosis from seven (7) standard field stereoscopic photos results documented and reviewed.
3072F – Low risk for retinopathy (no evidence of retinopathy in the prior year).
Medical record documentation of:
Results of most recent eye exam by an eye care professional within the measurement year or within two years if documented low risk of retinopathy or evidence of bilateral eye enucleation/acquired absence in both eyes anytime in member’s history.
Please note – When submitting any CPTII codes, do not use the modifiers 1P, 2P, 3P, or 8P. These modifiers indicate that the service was not done and will exclude the CPTII code from care gap calculations.
If you have or reviewed a report from the patient’s ophthalmologist or optometrist:
Submit a claim with the appropriate CPTII code:
2022F – Dilated eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed.
2024F – Seven (7) standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed.
2026F – Eye imaging validated to match diagnosis from seven (7) standard field stereoscopic photos results documented and reviewed.
3072F – Low risk for retinopathy (no evidence of retinopathy in the prior year).
Medical record documentation of:
Results of most recent eye exam by an eye care professional within the measurement year or within two years if documented low risk of retinopathy or evidence of bilateral eye enucleation/acquired absence in both eyes anytime in member’s history.
Please note – When submitting any CPTII codes, do not use the modifiers 1P, 2P, 3P, or 8P. These modifiers indicate that the service was not done and will exclude the CPTII code from care gap calculations.