Skip to main content
COVID-19

Diabetes Care

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.
  • 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) 2022)

  • Members who are 18-75 years of age with diabetes (type 1 or type 2)
  • Line of Business: Commercial, Medicaid, Medicare
Hemoglobin A1c Control for Patients With Diabetes (HBD)  
Description: Percentage of plan members 18-75 years of age with diabetes (type 1 or type 2) who had the following: 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.
Blood Pressure Control for Patients With Diabetes (BPD)  
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.

Eye Exam for Patients With Diabetes (EED)  
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).

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

Codes Related to Diabetes Measure

Hemoglobin A1c Testing & Control

HbA1c Lab Test

CPT 83036 83037

LOINC 17856-6 4548-4 4549-2

SNOMED CT US Edition   43396009 313835008

 

HbA1c Level Greater Than or Equal To 7.0 and Less Than 8.0

CPT-CAT-II 3051F

 

HbA1c Level Less Than 7.0

CPT-CAT-II 3044F

SNOMED CT US Edition   165679005

 

HbA1c Test Result or Finding

CPT-CAT-II 3044F 3046F 3051F 3052F

SNOMED CT US Edition   165679005 451051000124101   451061000124104

 

HbA1c Level Greater Than 9.0

CPT-CAT-II 3046F

SNOMED CT US Edition 451061000124104

 

HbA1c Level Greater Than or Equal To 8.0 and Less Than or Equal To 9.0

CPT-CAT-II 3052F

 

Diabetic Retinal Screening

Automated Eye Exam

CPT 92229  

 

Bilateral Modifier

Modifier 50

 

Diabetic Retinal Screening

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 92012 92014 92018 92019 92134 92201 92202 92225 92226 92227 92228 92230 92235 92240 92250 92260 99203 99204 99205 99213 99214 99215 99242 99243 99244 99245

HCPCS S0620 S0621 S3000

SNOMED CT US Edition  274795007 274798009 308110009 314971001 314972008 410451008 410452001 410453006 410455004 425816006 427478009 722161008

 

Diabetic Retinal Screening Negative In Prior Year

CPT-CAT-II 3072F            

 

Eye Exam With Evidence of Retinopathy

CPT-CAT-II 2022F 2024F 2026F

 

Eye Exam Without Evidence of Retinopathy

CPT-CAT-II 2023F 2025F 2033F

 

Unilateral Eye Enucleation

CPT 65091 65093 65101 65103 65105 65110 65112 65114

SNOMED CT US Edition   59590004 172132001 205336009 397800002 397994004 398031005

 

Unilateral Eye Enucleation Left

ICD10PCS 08T1XZZ

 

Unilateral Eye Enucleation Right

ICD10PCS 08T0XZZ

Blood Pressure Control (<140/90 mmHg)

Diastolic 80-89

CPT-CAT-II 3079F

 

Diastolic Blood Pressure

CPT-CAT-II 3078F 3079F 3080F

LOINC 75995-1 8453-3 8454-1 8455-8 8462-4 8496-2 8514-2 8515-9 89267-9

SNOMED CT US Edition   271650006

 

Diastolic Less Than 80

CPT-CAT-II 3078F

 

Systolic Blood Pressure

CPT-CAT-II 3074F 3075F 3077F

LOINC 75997-7 8459-0 8460-8 8461-6 8480-6 8508-4 8546-4 8547-2 89268-7

SNOMED CT US Edition   271649006

 

Systolic Less Than 140

CPT-CAT-II 3074F 3075F

 

Diastolic Greater Than or Equal To 90

CPT-CAT-II 3080F

 

Systolic Greater Than or Equal To 140

CPT-CAT-II 3077F

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

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 contact Horizon Healthy Journey: 1-844-754-2451.

Reference: NCQA HEDIS Measurement Year (MY) 2022 Technical Specs CPT® is a registered trademark of the American Medical Association.