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Comprehensive Diabetes Care (CDC)

Your TO-DO LIST for members diagnosed with diabetes should include:

  • Order a hemoglobin A1c test (HbA1c) at least once per calendar year.
  • Appropriately treat and control member’s diabetes
  • Refer member to eye care professional for eye exam (retinal) every year.
  • Perform testing for nephropathy, or indicate member has nephropathy every year.
  • Measure and manage member’s blood pressure.
  • Ensure members are taking their diabetic medications.

Why should you complete your TO-DO LIST?

It is an evidence-based, best practice and these actions are used to measure your quality performance.

Diabetic Population Definition:

(NCQA HEDIS guidelines, Measurement Year (MY) 2020 & MY 2021)

  • Members who are 18-75 years of age with diabetes (type 1 or type 2)
  • Line of Business: Commercial, Medicaid, Medicare

Diabetes Care-Blood Glucose Testing & Control

DiabetesCare-Hemoglobin A1c Testing & Control  
Description: Percentage of plan members 18-75 years of age with diabetes (type 1 or type 2) who had each of the following: Hemoglobin A1c (HbA1c) testing HbA1c control (<8.0%) HbA1c poor control (>9.0%)
Requirement: HbA1c The Most Recent HbA1c test performed during the measurement year, as identified by claim/encounter or automated laboratory data. HbA1c Poor Control(>9%) Most recent HbA1c test more than 9% (a lower rate indicates better performance). The member is numerator compliant if the most recent HbA1c level is >9.0% or is missing a result, or if an HbA1c test was not done during the measurement year. HbA1c control(<8.0%) Most recent HbA1c result less than 8%. The member is numerator compliant if the most recent HbA1c level is <8.0%. Appropriately treat and control member’s diabetes.
Documentation: At a minimum, documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result. Ranges and thresholds do not meet criteria for this indicator. A distinct numeric result is required for numerator compliance.
Diabetes Care-Controlling Blood Pressure  
Description: Percentage of plan members 18-75 years of age with diabetes (type 1 or type 2) who had a blood pressure (BP) reading taken during an outpatient visit or a nonacute inpatient encounter, or remote monitoring event during the measurement year, meeting compliance if the most recent BP reading is <140/90 mmHg
Requirement: The most recent BP reading during an outpatient visit or nonacute inpatient encounter, or remote monitoring event or telephone visits, e-visits and virtual checks-ins during the measurement year The most recent BP reading is <140/90 mmHg during the most recent visit Do not use the following sources for BP readings: Taken by the member using a non-digital device such as with a manual blood pressure cuff and a stethoscope BP taken on the same day as a diagnostic test or therapeutic procedure that requires a change in diet (NPO), a colonoscopy or a change in a medication regimen (Dialysis, infusions and chemotherapy) on or one day before the procedure, with the exception of fasting blood tests. - A nebulizer treatment with albuterol is considered a therapeutic procedure that requires a medication regimen (albuterol). BP taken during an acute inpatient stay or an ED visit.

The member is not compliant if the BP is ≥140/90 mmHg, if there is no BP reading during the measurement year or if the reading is incomplete (e.g., the systolic or diastolic level is missing). If there are multiple BPs on the same date of service, use the lowest systolic and lowest diastolic BP on that date as the representative BP.

Diabetes Care-EyeExam  
Description: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had an eye exam (retinal) performed. Screening or monitoring for diabetic retinal disease as identified by administrative data. This includes diabetics who had one of the following: 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
Requirement: Any of the following meet criteria: Any code in the Diabetic Retinal Screening Value Set billed by an eye care professional (optometrist or ophthalmologist) during the measurement year Any code in the Diabetic Retinal Screening Value Set billed by an eye care professional (optometrist or ophthalmologist) during the year prior to the measurement year, with a negative result (negative for retinopathy) Any code in the Diabetic Retinal Screening Value Set billed by an eye care professional (optometrist or ophthalmologist) during the year prior to the measurement year, with a diagnosis of diabetes without complications (Diabetes Mellitus Without Complications Value Set) Any code in the Eye Exam With Evidence of Retinopathy Value Set or Eye Exam Without Evidence of Retinopathy Value Set billed by any provider type during the measurement year Any code in the Eye Exam Without Evidence of Retinopathy Value Set billed by any provider type during the year prior to the measurement year Any code in the Diabetic Retinal Screening Negative In Prior Year Value Set billed by an provider type during the measurement year Unilateral eye enucleation (Unilateral Eye Enucleation Value Set) with a bilateral modifier (Bilateral Modifier Value Set) Two unilateral eye enucleations (Unilateral Eye Enucleation Left Value Set) with service dates 14 days or more apart Left unilateral eye enucleation (Unilateral Eye Enucleation Left Value Set) and right unilateral eye enucleation (Unilateral Eye Enucleation Right Value Set) on the same or different dates of service A unilateral eye enucleation (Unilateral Eye Enucleation Value Set) and a left unilateral eye enucleation (Unilateral Eye Enucleation Left Value Set) with service dates 14 days or more apart. A unilateral eye enucleation (Unilateral Eye Enucleation Value Set) and a right unilateral eye enucleation (Unilateral Eye Enucleation Right Value Set) with service dates 14 days or more apart.
Documentation: Ataminimum,documentation in the medical record must include one of the following: A note or letter prepared by an ophthalmologist, optometrist, PCP or other health care professional indicating that an ophthalmoscopic exam was completed by an eye care professional (optometrist or ophthalmologist), including the date of exam and results. A chart or photograph indicating the date when the fundus photography was performed and evidence that an eye care professional (optometrist or ophthalmologist) reviewed the results. Alternatively, results may be read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist; or results may be read by a system that provides an artificial intelligence (AI) interpretation. Documentation does not have to state specifically “no diabetic retinopathy” to be considered negative for retinopathy; however, it must be clear that the patient had a dilated or retinal eye exam by an eye care professional (optometrist or ophthalmologist) and that retinopathy was not present. Notation limited to a statement that indicates “diabetes without complications” does not meet criteria. Evidence that the member had bilateral eye enucleation or acquired absence of both eyes. Look as far back as possible in the member’s history through December 31 of the measurement year. Documentation of a negative retinal or dilated exam by an eye care professional (optometrist or ophthalmologist) in the year prior to the measurement year, where results indicate retinopathy was not present (e.g., documentation of normal findings).
Diabetes Care-Medical Attention for Nephropathy**Applicable to Medicare Line of Business only  
Description: Percentage of plan members 18-75 years of age with diabetes (type 1 or type 2) who had medical attention for nephropathy, a nephropathy screening or monitoring test, or evidence of nephropathy as documented through administrative data during the measurement year
Requirement: A nephropathy screening or monitoring test (Urine Protein Tests Value Set) Evidence of treatment for nephropathy or ACE/ARB therapy (Nephropathy Treatment Value Set) Evidence of stage 4 chronic kidney disease (CKD Stage 4 Value Set) Evidence of ESRD (ESRD Diagnosis Value Set) or dialysis (Dialysis Procedure Value Set). Evidence of nephrectomy (Nephrectomy Value Set) or kidney transplant (Kidney Transplant Value Set). A visit with a nephrologist, as identified by the organization’s specialty provider codes (no restriction on the diagnosis or procedure code submitted) At least one ACE inhibitor or ARB dispensing event (Table CDC-L)
Documentation: Any of the following during the measurement year meet criteria for an ephropathy screening or monitoring test or evidence of nephropathy: A urine test for albumin or protein. At a minimum, documentation must include a note indicating the date when a urine test was performed, and the result or finding. Any of the following meet the criteria: 24-hour urine for albumin or protein Timed urine for albumin or protein Spot urine (e.g., urine dipstick or test strip) for albumin or protein - Urine for albumin/creatinine ratio - 24-hour urine for total protein - Random urine for protein/creatinine ratio Documentation of a visit to a nephrologist Documentation of a renal transplant Documentation of medical attention for any of the following (no restriction on provider type): Diabetic nephropathy ESRD Chronic renal failure (CRF) Chronic kidney disease (CKD) - Renal insufficiency Proteinuria Albuminuria Renal dysfunction Acute renal failure (ARF) Dialysis, hemodialysis or peritoneal dialysis Evidence of ACE inhibitor/ARB therapy. Documentation in the medical record must include evidence that the member received ACE inhibitor/ARB therapy during the measurement year. Any of the following meet criteria: Documentation that a prescription for an ACE inhibitor/ARB was written during the measurement year Documentation that a prescription for an ACE inhibitor/ARB was filled during the measurement year Documentation that the member took an ACE inhibitor/ARB during the measurement year

Table CDC-L ACE Inhibitors/ARBs

Description: Prescription:
Angiotensin converting enzyme inhibitors
  • Benazepril
  • Moexipril
  • Captopril
  • Perindopril
  • Enalapril
  • Quinapril
  • Fosinopril
  • Ramipril
  • Lisinopril
  • Trandolapril
Angiotensin II inhibitors
  • Candesartan
  • Valsartan
  • Eprosartan
  • Azilsartan
  • Irbesartan
  • Olmesartan
  • Losartan
  • Telmisartan
Antihypertensive combinations
  • Amlodipine-benazepril
  • Amlodipine-valsartan
  • Benazepril-hydrochlorothiazide
  • Captopril-hydrochlorothiazide
  • Fosinopril-hydrochlorothiazide
  • Hydrochlorothiazide-lisinopril
  • Hydrochlorothiazide-quinapril
  • Hydrochlorothiazide-valsartan
  • Amlodipine-olmesartan
  • Azilsartan-chlorthalidone
  • Hydrochlorothiazide-olmesartan
  • Trandolapril-verapamil
  • Amlodipine-perindopril
  • Amlodipine-hydrochlorothiazide-valsartan
  • Candesartan-hydrochlorothiazide
  • Enalapril-hydrochlorothiazide
  • Hydrochlorothiazide-irbesartan
  • Hydrochlorothiazide-losartan
  • Hydrochlorothiazide-telmisartan
  • Amlodipine-hydrochlorothiazide-olmesartan
  • Amlodipine-telmisartan
  • Hydrochlorothiazide-moexipril
  • Sacubitril-valsartan
  • Nebivolol-valsartan

 

How does your completion of the TO-DO LIST get recorded?

Codes Related to Diabetes Measure

Hemoglobin A1c Testing & Control

CPT®: LOINC:
83036, 83037 17856-6, 4548-4, 4549-2
SNOMED:
43396009, 313835008

HbA1c Testing

Result: CPT-CAT-II: SNOMED:
HbA1c Result Less Than 7 3044F 165679005
HbA1c Level Greater Than 9.0 3046F 451061000124104
HbA1c Level Greater Than or Equal to 7.0% and Less Than 8.0% 3051F  
HbA1c Level Greater Than or Equal to 8.0% and Less Than or Equal to 9.0% 3052F  

Diabetic Retinal Screening

SNOMED CT:
6615001, 252779009, 252780007, 252781006, 252782004, 252783009, 252784003, 252788000, 252789008, 252790004, 274795007, 274798009, 308110009, 314971001, 314972008, 410451008, 410452001, 410453006, 410455004, 420213007, 425816006, 427478009, 722161008
CPT®:
67028, 67030, 67031, 67036, 67039, 67040, 67041, 67042, 67043, 67101, 67105, 67107, 67108, 67110, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92201, 92202, 92012, 92014, 92018, 92019, 92134, 92225, 92226, 92227, 92228, 92230, 92235, 92240, 92250, 92260, 99203, 99204, 99205, 99213, 99214, 99215, 99242, 99243, 99244, 99245
HCPCS:
S0620, S0621, S3000

Diabetic Retinal Screening Negative In Prior Year

CPT-CAT-II:
3072F

Unilateral Eye Enucleation Value Set

CPT®:
65091, 65093, 65101, 65103, 65105, 65110, 65112, 65114
SNOMED CT:
59590004, 172132001, 205336009, 397800002, 397994004, 398031005

Bilateral Modifier Value Set

CPT®:
50

Unilateral Eye Enucleation Left Value Set

ICD10PCS:
08T1XZZ

Unilateral Eye Enucleation Right Value Set

ICD10PCS:
08T0XZZ

Eye Exam With Evidence of Retinopathy

CPT®:
2022F, 2024F, 2026F

Eye Exam Without Evidence of Retinopathy

CPT®:
2023F, 2025F, 2033F

Nephropathy Screening or Monitoring Test – Urine Protein Tests

CPT®: CPT-CAT-II: LOINC:
81000, 81001, 81002, 81003, 81005, 82042, 82043, 82044, 84156, 3060F, 3061F, 3062F 11218-5, 12842-1, 13705-9, 13801-6, 13986-5, 13992-3, 14956-7, 14957-5, 14958-3, 14959-1, 1753-3, 1754-1, 1755-8, 1757-4, 17819-4, 18373-1, 20454-5,20621-9, 21059-1, 21482-5, 26801-1, 27298-9, 2887-8, 2888-6, 2889-4, 2890-2, 29946-1, 30000-4, 30001-2, 30003-8, 32209-9, 32294-1, 32551-4, 34366-5, 35663-4, 40486-3, 40662-9, 40663-7, 43605-5, 43606-3, 43607-1, 44292-1, 47558-2, 49002-9, 49023-5, 50209-6, 50561-0, 50949-7, 51190-7, 53121-0, 53525-2, 53530-2, 53531-0, 53532-8, 56553-1, 57369-1, 57735-3, 5804-0, 58448-2, 58992-9, 59159-4, 60678-0, 63474-1, 6941-9, 6942-7, 76401-9, 77253-3, 77254-1, 77940-5, 89998-9, 89999-7, 90000-1, 9318-7, 93746-6, 95232-5; 95233-3
SNOMEDCT:
19518008, 29809003, 45590004, 46716003, 57378007, 104486009, 104819000, 104820006, 171247004, 270999004, 271000000, 271346009, 313502007, 391410005, 412902007, 417187008

Nephropathy Treatment or ACE/ARB therapy

ICD10CM: CPT-CAT-II:
E08.21, E08.22,E08.29,E09.21, E09.22, E09.29,E10.21, E10.22, E10.29, E11.21, E11.22, E11.29, E.13.21, E13.22, E13.29, I12.0, I12.9, I13.0, I13.10, I13.11, I13.2, I15.0, I15.1, N00.0, N00.1, N00.2, N00.3, N00.4, N00.5, N00.6, N00.7, N00.8, N00.9, N01.0, N01.A, N01.1, N01.2, N01.3, N01.4, N01.5, N01.6, N01.7, N01.8, N01.9, N02.0, N02.A, N02.1, N02.2, N02.3, N02.4, N02.5, N02.6, N02.7, N02.8, N02.9, N03.0, N03.A, N03.1, N03.2, N03.3, N03.4, N03.5, N03.6, N03.7, N03.8, N03.9, N04.0, N04.A, N04.1, N04.2, N04.3, N04.4, N04.5, N04.6, N04.7, N04.8, N04.9, N05.0, N05.A, N05.1, N05.2, N05.3, N05.4, N05.5, N05.6, N05.7, N05.8, N05.9, N06.0, N06.A, N06.1, N06.2, N06.3, N06.4, N06.5, N06.6, N06.7, N06.8, N06.9, N07.0, N07.A, N07.1, N07.2, N07.3, N07.4, N07.5, N07.6, N07.7, N07.8, N07.9, N08,N14.0, N14.1, N14.2, N14.3, N14.4, N17.0, N17.1, N17.2, N17.8, N17.9, N18.1, N18.2, N18.3, N18.4, N18.5, N18.6, N18.9, N18.30, N18.31, N18.32, N19, N25.0, N25.1, N25.81, N25.89, N25.9,N26.1, N26.2, N26.9,Q60.0, Q60.1, Q60.2, Q60.3, Q60.4, Q60.5, Q60.6, Q61.00, Q61.01, Q61.02, Q61.11, Q61.19, Q61.2, Q61.3, Q61.4, Q61.5, Q61.8, Q61.9, R80.0, R80.1, R80.2, R80.3, R80.8, R80.9 3066F, 4010F
SNOMED CT:
1426004, 2657005, 2663001, 2740001, 3704008, 4390004, 7724006, 7725007, 8022000, 8199003, 8875000, 11480007, 12178007, 13335004, 13886001, 13889008, 14669001, 15859004, 16147005, 16751003, 17121006, 17928001, 19351000, 20917003, 22352007, 22702000, 22794007, 22846003, 23697004, 23754003, 23891001, 25821008, 26121002, 26367008, 27366005, 27810000, 28637003, 28689008, 29738008, 31005002, 32093003, 32482005, 32599008, 33461007, 33763006, 34993002, 35546006, 35727008, 36171008, 36225005, 36689008, 37061001, 37085009, 38046004, 38898003, 40233000, 41962002, 42399005, 42827006, 43258006, 43820004, 44785005, 45646000, 45816000, 45927004, 46177005, 47330001, 48160003, 48713002, 49220004, 49708008, 50581000, 51292008, 52254009, 52845002, 53556002, 54879000, 55006001, 55652009, 55662002, 57009009, 57557005, 57965003, 58574008, 59400006, 59479006, 60926001, 61135002, 61503006, 62853008, 63302006, 63510008, 64168005, 64212008, 66993009, 68544003, 68779003, 69718008, 73014008, 73305009, 73630001, 73883007, 75888001, 77182004, 77250007, 78209002, 80321008, 82112005, 83866005, 85223007, 86235003, 86249007, 87865005, 88380005, 89238002, 90688005, 91003006, 91195006, 95889002, 109477002, 110996009, 111404004, 111406002, 111407006, 123609007, 123610002, 123611003, 123612005, 123752003, 123753008, 123754002, 123755001, 127013003, 186796004, 190407009, 190829000, 194780003, 194781004, 197579006, 197580009, 197582001, 197583006, 197584000, 197585004, 197589005, 197590001, 197591002, 197593004, 197594005, 197595006, 197596007, 197597003, 197598008, 197599000, 197600002, 197603000, 197604006, 197605007, 197606008, 197607004, 197613008, 197616000, 197617009, 197618004, 197619007, 197626007, 197629000, 197660000, 197661001, 197679002, 197683002, 197684008, 197685009, 197686005, 197688006, 197692004, 197693009, 197694003, 197695002, 197697005, 197707007, 197708002, 197709005, 197712008, 197713003, 197714009, 197715005, 197716006, 197717002, 197719004, 197720005, 197721009, 197722002, 197723007, 197724001, 197725000, 197738008, 197739000, 197753000, 197760006, 197761005, 197764002, 197768004, 197769007, 197782004, 200118004, 204942005, 213231008, 230970001, 234485006, 236373001, 236374007, 236378005, 236379002, 236380004, 236381000, 236382007, 236385009, 236392004, 236393009, 236394003, 236395002, 236397005, 236398000, 236399008, 236400001, 236401002, 236402009, 236403004, 236404005, 236405006, 236406007, 236407003, 236409000, 236410005, 236411009, 236412002, 236413007, 236414001, 236415000, 236416004, 236417008, 236418003, 236422008, 236423003, 236424009, 236428007, 236429004, 236430009, 236431008, 236432001, 236433006, 236434000, 236435004, 236436003, 236452000, 236453005, 236454004, 236455003, 236456002, 236457006, 236458001, 236479001, 236480003, 236481004, 236495001, 236496000, 236499007, 236500003, 236504007,236505008, 236506009, 236508005, 236511006, 236514003, 236515002, 236516001, 236517005, 236518000, 236520002, 236521003, 236523000, 236524006, 236525007, 236528009, 236535001, 236538004, 236556004, 236586006, 236587002, 236588007, 236589004, 236590008, 236720004, 237612000, 237888005, 239932005, 251869004, 254149007, 263808002, 264867001, 266549004, 269257004, 269301005, 274769005, 274771005, 275408006, 276883000, 278904002, 278905001, 282364005, 292761003, 292762005, 301814009, 307309005, 309426007, 310387003, 310647000, 311366001, 312975006, 324046003, 324984006, 325955007, 326915002, 359694003, 363233007, 363234001, 363287001, 364756009, 370494002, 373421000, 373422007, 401110002, 402458002, 402762007, 403732009, 403733004, 404813001, 408667000, 418839003, 420279001, 420514000, 420715001, 421305000, 421893009, 421986006, 422593004, 423322005, 423533009, 424188009, 425369003, 425384007, 425455002, 425879009, 426598005, 427555000, 428255004, 428720002, 428937001, 428982002, 429224003, 429489008, 430332005, 430535006, 431855005, 431856006, 431857002, 433144002, 433146000, 438783006, 439990003, 440018001, 440663004, 441815006, 442326005, 443143006, 443596009, 445170001, 445236007, 445258009, 446923008, 449288005, 698591006, 698757009, 699235009, 700378005, 700379002, 702634004, 702635003, 702718005, 704055002, 704203009, 704204003, 704205002, 704206001, 704308002, 704377006, 704667004, 707090004, 707221002, 707324008, 707332000, 707751009, 708127008, 709044004, 709978007, 710565001, 711531007, 712487000, 713313000, 713453003, 713695001, 713696000, 713720009, 713721008, 713724000, 713727007, 713886006, 713887002, 714152005, 714153000, 714813000, 714814006, 714815007, 714816008, 714817004, 714818009, 714819001, 714820007, 714821006, 714822004, 714825002, 714826001, 716864001, 717191005, 717760006, 717770008, 718192000, 720519003, 721175003, 721297008, 722078002, 722081007, 722082000, 722086002, 722088001, 722089009, 722095005, 722096006, 722098007, 722119002, 722120008, 722139003, 722147003, 722149000, 722150000,
SNOMED CT:(continued)
722168002, 722278006, 722433005, 722467000, 722758004, 722759007, 722760002, 722761003, 723074006, 723188008, 723189000, 723190009, 723363009, 723449004, 723995003, 724093004, 726082003, 733089005, 733097003, 733116005, 733137002, 733138007, 733139004, 733342000, 733472005, 733839001, 735430007, 735623008, 735624002, 736992003, 736993008, 762907005, 762908000, 762909008, 762910003, 765779008, 765780006, 766249007, 767577006, 771447009, 773280009, 773647007, 776416004, 782738008, 783157004, 783159001, 783187005, 783787000, 788613004 789660001, 792926007, 816069008, 816212004, 818952002, 331000124109, 341000124104, 361000124100, 431000124102, 441000124107, 451000124109, 461000124106, 471000124104, 571000124100, 601000124107, 631000124104, 641000124109, 711000119100, 721000119107, 731000119105, 741000119101, 751000119104, 771000119108, 1801000119106, 4181000119109, 7011000119105, 8501000119104, 12491000132101, 12511000132108, 15911000119103, 18521000119106, 28191000119109, 40371000119105, 40391000119106, 42231000009109, 50411000119108, 71421000119105, 71441000119104, 71701000119105, 71721000119101, 85381000119105, 89681000119101, 90721000119101, 90731000119103, 90741000119107, 90751000119109, 90761000119106, 90771000119100, 90781000119102, 90791000119104, 90971000119103, 96441000119101, 96701000119107, 96711000119105, 96721000119103, 96731000119100, 96741000119109, 96751000119106, 101711000119105, 104931000119100, 106911000119102, 111411000119103, 117681000119102, 120241000119100, 120261000119101, 126551000119103, 127901000119107, 127911000119105, 127991000119101, 128001000119105, 129151000119102, 129161000119100, 129171000119106, 129181000119109, 129561000119108, 129721000119106, 133031000119106, 140031000119103, 140101000119109, 140111000119107, 140121000119100, 140131000119102, 145681000119101, 149941000119100, 153851000119106, 153891000119101, 157141000119108, 195791000119101, 243421000119104, 284961000119106, 284971000119100, 284981000119102, 284991000119104, 285001000119105, 285011000119108, 285041000119107, 285061000119106, 285081000119102, 285101000119109, 285831000119108, 285841000119104, 285851000119102, 285861000119100, 285871000119106, 285881000119109, 285911000119109, 285921000119102, 286371000119107, 320681000119102, 368871000119106, 368881000119109, 368901000119106, 368911000119109, 368921000119102, 368931000119104, 368951000119105, 433991000124108, 434061000124103, 434431000124103, 449631000124102, 691421000119108, 1081801000112104, 1086071000119103, 1092371000119103, 1092831000119109, 10757401000119104, 11000731000119102, 11000771000119104, 16320631000119104

Chronic Kidney Disease – Stage 4

ICD10CM:
N18.4
SNOMED CT US Edition:
129151000119102, 140111000119107, 285001000119105, 285101000119109, 285881000119109, 431857002, 691401000119104, 721000119107, 90751000119109, 96721000119103,

End Stage Renal Disease (ESRD)

ICD10CM:
N18.5, N18.6, Z99.2
SNOMED CT:
46177005, 236434000, 236435004, 236436003, 428937001, 428982002, 429075005, 433146000, 698810000, 704667004, 707324008, 712487000, 714152005, 714153000, 711000119100, 90761000119106, 90771000119100, 90791000119104, 96711000119105, 111411000119103, 120261000119101, 127991000119101, 128001000119105, 129161000119100, 140101000119109, 153851000119106, 153891000119101, 285011000119108, 285841000119104, 286371000119107, 434431000124103

Kidney Transplant

CPT®: HCPCS: ICD10PCS:
50360, 50365, 50380 S2065 0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY10Z2
SNOMED CT US Edition:
175899003, 175901007, 175902000, 236138007, 313030004, 52213001, 6471000179103, 70536003, 711411006, 711413009, 765478004, 765479007, 782655004

Dialysis Procedure

CPT®: HCPCS: ICD10PCS:
90935, 90937, 90945, 90947, 90997, 90999, 99512 G0257, S9339 3EM39Z, 5A1D00Z, 5A1D60Z, 5A1D70Z, 5A1D80Z, 5A1D90Z, 39.95, 54.98

Nephrectomy

CPT®: SNOMED CT US Edition: ICD10PCS:
50340, 50370 88930008 OTB00ZX, OTB00ZZ, OTB03ZX, OTB03ZZ, OTB 04ZX, OTB04ZZ, OTB07ZX, OTB07ZZ, OTB08ZX, OTB08ZZ, OTB10ZX, OTB10ZZ, OTB13ZX, Otb13ZZ, OTB14ZX, OTB14ZZ, OTB17ZX, OTB17ZZ, OTB18ZX, OTB18ZZ

Blood Pressure Control (<140/90 mmHg)

CPT-CAT-II:
3079F Diastolic 80-89
3078F Diastolic Less Than 80
3074F, 3075F Systolic Less Than 140
3077F Systolic Greater Than or Equal to 140
3080F Diastolic Greater Than or Equal to 90

Remote Blood Pressure Monitoring

CPT®:
93784, 93788, 93790, 99091, 99453, 99454, 99457, 99473, 99474
SNOMEDCT:
448678005, 725956001

Supplemental Data Requirements

HbA1C Testing:

  • HbA1C test in the measurement year
  • Dated progress note documenting the date and result of HbA1C test
  • When lab results are imported into the EHR by interface, a dated medical record documentation of the HbA1c test and result in measurement year
  • In-office, point-of-care testing performed with date and result during the measurement year

HbA1C Control:

  • Dated progress note documenting the date and result of most recent HbA1C test
  • Lab report with results or reported date and result
  • When lab results are imported into the EHR by interface, a dated medical record documentation of the most recent HbA1c test and result in measurement year
  • In-office, point-of-care testing performed with date and result of most recent HbA1C during the measurement year

EyeExam:

  • A signed and dated report/progress note with a result (negative or positive for diabetic retinopathy) from an eye care professional indicating eye exam was completed in measurement year. A negative eye exam from the prior year is also acceptable.
  • A dated progress note from the Primary Care Physician indicating that the patient had a retinal eye exam with date, eye care professional’s name and result of exam.
  • Fundoscopic photo that is read by an eye care professional is also eligible if signed and dated with result

Medical Attention for Nephropathy:

  • A dated progress note documenting laboratory test and result for nephropathy can be submitted. In-office urine tests also meet this metric. (ie. Urine for Microalbumin, Protein)
  • A dated progress note indicating that an ACE or ARB was ordered within the measurement year and the ACE or ARB is on the current medication list. The prescription for the ACE/ARB must be written within the measurement year.
  • A dated progress note indicating documentation of nephropathy (example: ARF, RI, CKD, CRF, ESRD, renal transplant)

A dated progress note from a nephrologist can be submitted

Blood Pressure Control

  • A dated progress note documenting the most recent BP in the measurement year
  • A vital sign flowsheet with name, date of birth, date of service

General Notes

The most accurate method to submit data for clinical quality gap closure is through correct coding. Supplemental data submission can be used for gap closure when information is not received through coding. All supplemental data must be signed and dated by a treating physician, nurse practitioner or physician assistant. All dates must include month, day and year.

Patient name and birthdate needs to be on all supplemental documentation. If birthdate is not officially on a report, it needs to be either written on the document and signed by the physician, or a demographic cover sheet should be included as an additional page with the submission.

Resources available for you and your patients:

American Diabetes Association

Centers for Disease Control and Prevention (CDC)

To learn more about your practice’s current HEDIS performance for this or other measures, or for assistance in compliance with the HEDIS guidelines, please call 1-844-754-2451.

Reference: NCQA HEDIS Measurement Year (MY) 2020 & MY 2021 Technical Specs CPT® is a registered trademark of the American Medical Association.