Diabetes Care Recognition Program Guide

Transcription

Diabetes Care Recognition
Program Guide
Health Care Incentives Improvement Institute
13 Sugar Street
Newtown, CT 06470
[email protected]
http://www.hci3.org
Rev: 5/24/2016
Copyright © 2009-2016 Health Care Incentives Improvement Institute, Inc. All rights reserved.
Bridges to Excellence® is a registered trademark of the Health Care Incentives Improvement
Institute.
Table of Contents
INTRODUCTION.................................................................................................................3
Clinician Benefits of Recognition............................................................................................................................................4
Background on the Measurement Criteria...........................................................................................................................5
What Recognition Requires......................................................................................................................................................6
Eligibility for Clinician Participation....................................................................................................................................7
Minimum Submission Requirements.......................................................................................................................................7
How to Submit for Recognition..............................................................................................................................................8
CECITY..........................................................................................................................................................................................8
About CECity.................................................................................................................................................................................8
About MedConcert®..................................................................................................................................................................8
EMR Partners................................................................................................................................................................................9
BTE Diabetes Care Recognition Clinical Measures.....................................................................................................10
Diabetes Care Recognition Program Measurement Set.......................................................11
Hemoglobin A1C Control (HbA1c):..................................................................................................................................11
Hemoglobin A1C Measurement:.........................................................................................................................................13
Lipid Control:.............................................................................................................................................................................14
Blood Pressure Control:..........................................................................................................................................................16
Blood Pressure Measurement:..............................................................................................................................................18
Tobacco use and Cessation Advice and Treatment:......................................................................................................19
Podiatry Examination:.............................................................................................................................................................21
Ophthalmologic Examination:..............................................................................................................................................23
Nephropathy Assessment:......................................................................................................................................................25
ACEI/ARB Treatment:...........................................................................................................................................................28
Body Mass Index/Weight/Nutrition Counseling............................................................................................................29
Assessment of Cardiovascular Risk....................................................................................................................................31
Consider Aspirin Use..............................................................................................................................................................32
Depression Screening:.............................................................................................................................................................35
Table 2: Patient Exclusion Codes........................................................................................................................................55
Recognition Process.............................................................................................................56
Applying for Recognition......................................................................................................................................................56
Duration of Recognition..........................................................................................................................................................57
Changes in Recognition Levels...........................................................................................................................................58
Reporting Results to BTE and Its Partners..........................................................................................................................59
Terms of Recognition..............................................................................................................................................................59
Revoking Recognition..............................................................................................................................................................60
Data Use Terms.........................................................................................................................................................................60
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Relevant Medication Lists for Diabetes Care Measurement Set.........................................61
Table 1: ACE-I Medications.................................................................................................................................................61
Table 2: Angiotensin II inhibitors/angiotensin receptor blockers (ARBs)............................................................62
Table 3: Smoking Cessation medications.........................................................................................................................62
Table 4: Anticoagulants which may contraindicate aspirin use:...............................................................................63
Table 5: Antiplatelet agents which may Contraindicate Aspirin Use.....................................................................64
APPENDICES.....................................................................................................................65
Appendix A: Audit Methodology......................................................................................................................................65
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INTRODUCTION
The Health Care Incentives Improvement Institute (HCI3) is excited to offer the opportunity for
clinicians to participate in the Bridges to Excellence (BTE) recognition program and its
automated EMR/Registry performance assessment system. The BTE EMR/Registry
performance assessment system allows for rapid and independent medical record-based
clinician performance evaluations by connecting local and national medical record data sources
to a network of performance assessment organizations. HCI3’s goals are to: reduce the
reporting burden for clinicians; leverage existing reporting/data aggregation initiatives; reduce
data collection and reporting costs; facilitate the connection between quality improvement and
incentives; and speed up cycle times between reporting, improvement and reporting. Clinicians
who meet BTE performance thresholds may be eligible for BTE incentives through
participating health plans, employers and coalitions.
The Diabetes Care Recognition Program is a BTE Clinician Recognition Program intended to
identify clinicians who deliver high-value diabetes care to adult patients. The program is
designed with an understanding that adult patients may seek the care of various types of
practitioners— primary care (PCPs), endocrinologists (Endos) and others—for treatment and
management of their diabetes. Accordingly, the measures reflect that clinicians should do the
following.
§
§
Deliver high-quality care from the outset of patient contact
Understand and consider previous treatment history to help avoid
inappropriate treatment
The program comprises a set of measures, based on available clinical evidence, that promote a
model of care that includes the following criteria.
§ Comprehensive patient assessment and reassessment
§ Patient education
§ Shared decision making
HCI3’s Diabetes Care requirements assess clinical measures representing standards of care for
patients with diabetes. HCI3 believes that the BTE Diabetes Care Recognition program has the
potential to significantly improve the quality of care experienced by patients with diabetes and to
reduce the financial and human burden of unnecessary hospitalizations and complications.
To earn Diabetes Care Recognition, clinicians and medical practices voluntarily submit medical
record data documenting their delivery of care to patients with diabetes. HCI3 has partnered with
an objective third-party independent Performance Assessment Organization (PAO) to evaluate
clinician data based on standard measures to publicly recognize those that meet the BTE
Diabetes Care performance thresholds. Those clinicians not meeting the BTE Diabetes Care
performance thresholds remain anonymous to BTE and its health plan licensees. HCI3’s
Diabetes Care Recognition Program has three performance thresholds
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Clinician Benefits of Recognition
§
§
§
§
§
Clinicians can demonstrate to the public and to their professional peers that they meet
the standards of care assessed by the program by issuing a press release, as well as
having their recognition achievements posted on HCI3’s web site www.hci3.org, and
communicated to both health plans and employers.
Clinicians may use the BTE Recognition to demonstrate that they meet the standards
of care assessed by the program when contracting with health organizations and
purchasers of health services.
Clinicians can identify areas of their practice that vary from the performance
criteria and take steps to improve quality of care.
Where applicable, clinicians can establish eligibility for pay-for-performance
bonuses or differential reimbursement or other incentives from payers and health
plans.
Clinicians who achieve Diabetes Care Recognition by submitting data through a
CCHIT- certified1 electronic health record or through an electronic health record
certified to meet the federally-defined Meaningful Use criteria will also receive BTE
Level II Physician Office Link (POL) recognition.
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Background on the Measurement Criteria
Eligible clinicians and medical practices voluntarily apply for BTE Recognition by submitting
information on how they treat and manage their patients with regard to the following evidencebased, current measures.
Clinical measures1
1. Hemoglobin A1C control
2. Hemoglobin A1C measurement documented twice annually
3. LDL <70 or on moderate/high intensity statin
4. Blood pressure control
5. Blood pressure measured and documented twice annually
6. Documentation of Smoking status and cessation advice and treatment
7. Documentation of Foot exam
8. Documentation of Eye exam
9. Documentation of Nephropathy assessment
10. On ACEI/ARB if hypertensive or nephropathy
11. Documentation of calculated body mass index and nutrition counseling if appropriate
12. Documentation of use of Pooled Cohort Risk Assessment tool to calculate 10-year
ASCVD risk
13. Aspirin Use if risk >10%
14. Documentation of screening for depression with PHQ2/PHQ9
Clinicians who demonstrate high-quality performance based on these measures are awarded BTE
Diabetes Care Recognition.
1
Clinical measures evaluate performance based on care provided to a sample of individual patients and documented
in the medical records of those patients. Clinical measures are scored based on the percentage of the sample
(denominator) which meet or comply (numerator) with the measure threshold.
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What Recognition Requires
Performance Assessment Organizations (PAOs) award recognition to clinicians who achieve at
least:
Three Stars: >60%
Four Stars: >70%
Five Stars:
>80%
Measure
Total Possible
Points
20
2.5
15
Level of Evidence
Source
B
E
A
ADA
ADA
AHA
Blood Pressure <140/90
Blood Pressure measured 2x
annually
Smoking Cessation discussed and
documented
20
2.5
A
B
JNC
JNC
7.5
B
ADA
Foot Exam done annually
Eye exam annually if retinopathy,
every 2 years if no retinopathy
Nephropathy Assessment annually if
not previously diagnosed
On ACEI/ARB if hypertension or
nephropathy
5
2.5
B
B
ADA
ADA
5
B
ADA
2.5
B
ADA
BMI/Nutrition Counseling
Assess 10 year ASCVD risk annually
Give aspirin if 10 year risk >10%
Depression screening (PHQ2 or 9)
annually
5
5
5
2.5
A
C
C
B
ADA
AHA
ADA
ADA
A1C<8%
A1C measured 2x annually
LDL<70 or Mod/High intensity statin
ADA= American Diabetes Association
AHA= American Heart Association
JNC= Joint National Committee
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Eligibility for Clinician Participation
Clinicians may apply for BTE Diabetes Care Recognition as individuals or part of a medical
practice. To be eligible, applicants must meet the following criteria.
§
§
§
§
§
Applicants must be licensed as a medical doctor (M.D. or D.O.), nurse practitioner
(N.P.), or physician assistant (P.A.).
Applicants must provide continuing care for patients with diabetes and be able to
meet the minimum patient sample sizes.
Applicants must complete all application materials and agree to the terms of the
program by executing a data use agreement and authorization with a data aggregator
partner.
Applicants must submit the required data documenting their delivery of care for all
eligible patients in their full patient panel.
Applicants must use PAO-supplied or approved methods for submitting data
electronically.
Individual clinician applicant
An individual clinician applicant represents one licensed clinician practicing in any setting
who provides continuing care for patients with diabetes6.
Medical practice applicant
A medical practice applicant represents any practice with three or more licensed clinicians
who, by formal arrangement, share responsibility for a common panel of patients and
practice at the same site, defined as a physical location or street address. For purposes of this
assessment process practices of two clinicians or less must apply as individual applicants.
Minimum Submission Requirements
To be eligible for recognition, clinicians must attain a minimum score of 60%. Additionally,
clinicians must submit data on a minimum of 25 patients for the denominator of each measure
for individual clinician applicants, and a minimum of 10 patients for the denominator of each
measure for each individual clinician in a practice level applicant, with a minimum practice
average of 25 patients per clinician.
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How to Submit for Recognition
CECITY
HCI3 has partnered with CECity as the Performance Assessment Organization (PAO) for all
Bridges to Excellence (BTE) Recognition Programs submitted electronically or direct data
submission through CECity’s cloud-based MedConcert® platform. Clinicians will be provided
with real-time performance assessments, feedback reports, and access to dynamically linked
improvement tools and resources to help them close performance gaps. More information can
be found at: www.medconcert.com
About CECity
Pittsburgh, PA-based CECity is the health care industry's leading platform-as-a-service
provider of cloud-based applications and distribution networks for performance improvement,
quality reporting, and lifelong learning. Health care professionals and healthcare organizations,
including QIOs, health plans, hospitals, chain pharmacies, professional medical certifying and
licensing boards, publishers, professional societies, and academic medical centers, count on
CECity to power their solutions for continuous performance improvement, performance
assessment, clinical registries, professional development, patient safety, medication adherence,
care coordination, population health informatics, and quality reporting.
About MedConcert®
MedConcert, healthcare’s first social cloud platform for continuous performance improvement
and lifelong learning, provides one convenient, integrated solution to help all stakeholders
answer the question, “How Do We Improve?” Through MedConcert, providers, practices, and
healthcare organizations engage in building secure social networks to share best practices and
connect in meaningful ways to address a variety of critical needs driven by healthcare reform.
Through the MedConcert App Store, individuals and health systems access a wide variety of
applications for pay for performance, performance dashboards, population health management,
clinical integration, performance improvement, professional certification, patient surveys, care
coordination, patient registries, enterprise-wide benchmarking, and much more.
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EMR Partners
HCI3 has worked with many EMR Vendors to streamline the process for users wishing to submit
their data for BTE recognition. Contact information for EMR companies who have completed
certification has a Data Aggregator can be found below:
Vendor
Athena Health
eClinicalWorks
Meridios
MediTab
Contact Information
[email protected]
[email protected]
[email protected]
[email protected]
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BTE Diabetes Care Recognition Clinical Measures
Clinical Measures
Clinical measures are standard measures with a numerator and denominator that reflect
performance across a sample of eligible patients based on medical record documentation. They
are up-to-date and based on high quality evidence and guidelines.
The following items are listed for each clinical measure:
M 1: Title X points
Description: A statement of what is being measured specifically.
Data source:
A list of the data sources accepted for the clinical measure.
Explanation:
Additional information about the clinical measure.
Numerator:
A description of the applicant’s eligible patients (denominator) who meet the
measure threshold or standard.
Frequency:
Time frames associated with the numerator requirements.
Scoring:
Performance level (percentage of patients meeting or complying with the
measure) translated to points total for the clinical measure.
Information on the Domain Denominator is consistent across all of the clinical measures and is
listed under “Patient Eligibility Criteria”.
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Diabetes Care Recognition Program Measurement Set
Hemoglobin A1C Control (HbA1c):
Description:
Percentage of patients aged 18 through 75 years with with hemoglobin A1C less
than 8%.
Data source:
Electronic data (visit, lab, encounter data, or claims) and/or medical record data
(paper-based or EHR). This measure requires the use of claims/encounter,
pharmacy or medical record data for identification of patients with diabetes for
the denominator, and laboratory or medical record data for HbA1c test
information for the numerator.
Explanation:
American Diabetes Association (ADA) 2015 guidelines recommend a treatment
goal of 7% or lower for HbA1c for adult diabetic patients 65 years old and
younger with a diagnosis of diabetes without significant comorbidities. The
ADA recommends a goal hemoglobin A1C of less than 8% in older adults (over
age 65), and those with significant comorbidities, complications, and for those
who, despite best efforts, are unable to reach goal. Because this guideline
leaves significant room for interpretation, our target goal for certification will be
less than 8%. There are many patients for whom a hemoglobin A1C of less
than 7% may be a more appropriate target. It is anticipated that clinicians who
provide services for the primary management of diabetes will submit this
measure.
Numerator:
Patients in the denominator with hemoglobin A1C less than 8%. 7% is optional
for patients in which this is appropriate, but scoring reflects 8% goal.
Data Collection: The patient is numerator compliant if a hemoglobin A1C test
was administered, and the result is less than 8%, during the reporting period.
At a minimum, documentation in the medical record must include a note
indicating a result and the date on which the HbA1c test was performed.
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The following is not acceptable documentation of HbA1c results:
1.
2.
3.
4.
Fructosamine
HgB
Hemoglobin
Hb and Hg (without reference to either “glycated,” “glycosylated,” and
“A1” or “A1C”).
5. Patient self-reporting
Frequency:
Most recent test result within 12 months prior to the last day of the reporting
period.
Scoring:
(Numerator/Denominator) * Total Points available
Source and Level of Evidence: ADA, Level B
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Hemoglobin A1C Measurement:
Description:
Percentage of diabetic patients age 18-75 who have had their hemoglobin A1C
measured twice annually.
Data source:
(paper-based or EHR). This measure requires the use of claims/encounter or
medical record data for identification of patients with diabetes who have had 2
hemoglobin A1C measurements, at least 90 days apart during the last 12 months
from the reporting period
Explanation:
American Diabetes Association (ADA) 2015 guidelines recommend that all
diabetic patients age 18-75 have their hemoglobin A1C measured and
documented at least twice annually to determine control and make necessary
adjustments to lifestyle and medications.
Numerator:
Patients in the denominator who have had at least 2 hemoglobin A1C
measurements in the reporting period. The measurements must be separated by
at least 90 days. See “Patient Eligibility Criteria” for further information on
codes to identify patients with diabetes.
DATA Collection: The patient is numerator compliant if he or she has had 2
hemoglobin A1C measurements (separated by at least 90 days) documented
within the reporting period
Exclusions:
Patients with terminal illness, patients on hospice.
Frequency:
Hemoglobin A1C measurement documented twice (separated by at least 90
days) within the 12 months prior to the last day of the reporting period.
Scoring:
(Numerator/Denominator) * Max Points
Source and Level of Evidence: ADA, Level E
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Lipid Control:
Description:
Percentage of patients aged 18 through 75 years with diabetes who had most
recent LDL of 70 mg/dl or higher who are taking a moderate or high intensity
statin.
Data source:
the denominator, and laboratory or medical record data for LDL-C test
Explanation:
American Diabetes Association (ADA), AHA/ACC 2015 guidelines
recommend treatment for patients with diabetes with an LDL-C level of ≥ 70
mg/dl with a moderate to high intensity statin. It is anticipated that clinicians
who provide services for the primary management of diabetes will submit this
measure.
Numerator:
Patients in the denominator with a most recent LDL-C level <70 mg/dl and
patients in the denominator who are on a moderate or high intensity statin
medication.
DATA Collection: The patient is numerator compliant if the laboratory result of
the most recent LDL-C test is <70 or if the patient is prescribed a moderate/high
intensity statin medication
High Intensity Statins:
Atorvastatin 40 – 80mg
Rosuvastatin
20 – 40mg
Moderate Intensity Statins:
Atorvastatin 10 – 20mg
Rosuvastatin
5 – 10mg
Simvastatin
20 – 40mg
Pravastatin
40 – 80mg
Lovastatin
40mg
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At a minimum, documentation in the medical record must include a note
indicating the date on which the LDL-C test was performed and the result.If
the patient is already prescribed a moderate/high intensity statin medication, no
LDL measurement is required.
LDL-C levels may be calculated from total cholesterol, HDL-C and
triglycerides using the Friedewald equation if the triglycerides are ≤ 400 mg/dl:
LDL-C = (total cholesterol) – (HDL) – (Triglycerides/5)
If the triglycerides are > 400 mg/dl and LDL-C levels cannot be calculated
using the Friedewald equation, LDL-C levels should be entered as a value of
500 and the date of the test documented.
The following is NOT acceptable documentation of LDL-C test results:
1. LDL-to-HDL ratio
Frequency:
Most recent reading within 12 months prior to the last day of the reporting
period.
Scoring:
([Numerator 1 + Numerator 2]/Denominator) * Total Points available
Source and Level of Evidence: ADA/AHA, Level A
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Blood Pressure Control:
Description:
Percentage of patients aged 18 through 75 years with diabetes who had
appropriate control of blood pressure (less than 140/90)
Data source:
the denominator, and medical record data for blood pressure information for the
numerator.
Explanation:
American Diabetes Association (ADA) 2015 guidelines recommend blood
pressure of <140/90 mmHg as a treatment goal for all adults with diabetes. It is
anticipated that clinicians who provide services for the primary management of
diabetes will submit this measure.
Numerator:
Patients in the denominator who’s most recent systolic blood pressure
measurement of < 140 mmHg AND diastolic blood pressure of < 90 mmHg .
The steps below should be followed to determine the representative blood
pressure reading.
1. Identify the most recent visit to the doctor’s office or clinic in which a BP
reading was noted. BP reading is acceptable if the representative BP was
obtained during a visit to the clinician’s office or non-emergency outpatient
facility such as an endocrine office or urgent care center.
2. Identify the lowest systolic and lowest diastolic blood pressure reading from
the most recent blood pressure notation in the medical record. If there are
multiple BPs recorded for a single date, use the lowest systolic and lowest
diastolic BP on that date as the representative BP. The systolic and
diastolic results do not need to be from the same reading, but must be
from the same date.
The patient is numerator compliant if the most recent systolic blood pressure
measurement during the reporting period is < 140 mmHg AND the most recent
diastolic blood pressure measurement during the reporting period is < 90
mmHg. The patient is NOT numerator compliant if the most recent systolic
blood pressure measurement is ≥ 140 mmHg or missing, OR the most recent
diastolic blood pressure measurement is ≥ 90 mmHg, or if either results are
missing, OR if the BP reading was not done during the reporting period.
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The following are NOT acceptable forms of documentation of blood pressure:
1. Use of terms “VS within normal limits,” “VS WNL,” or “Vital signs
normal”
2. BP measurements obtained on the same day as a diagnostic or surgical
procedure or at an emergency room visit
Frequency:
Most recent reading within 12 months prior to the last day of the reporting
period.
Scoring:
(Numerator/Denominator) * Total Points Possible = Points awarded
Source and Level of Evidence: ADA/JNC, Level A
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Blood Pressure Measurement:
Description:
Percentage of diabetic patients age 18-75 who have had their blood pressure
measured twice annually.
Data source:
medical record data for identification of patients with diabetes who have had 2
blood pressure measurements, at least 90 days apart during the last 12 months
from the reporting period
Explanation:
diabetic patients age 18-75 have their blood pressure measured and documented
at least twice annually to determine control and make necessary adjustments to
lifestyle and medications.
Numerator:
Patients in the denominator who have had at least 2 blood pressure
measurements within the reporting period. The measurements must be
separated by at least 90 days. See “Patient Eligibility Criteria” for further
information on codes to identify patients with diabetes.
DATA Collection: The diabetic patient is numerator compliant if he or she has
had 2 blood pressure measurements (separated by at least 90 days) documented
during the reporting period
Exclusions:
Patients with terminal illness, patients on hospice.
Frequency:
Blood pressure reading documented twice and 90 days apart, within the 12
months prior to the last day of the reporting period.
Scoring:
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Tobacco use and Cessation Advice and Treatment:
Description:
Percentage of patients aged 18 through 75 years with diabetes who have
documentation of tobacco use, and if a tobacco user, received cessation
counseling or treatment.
Data source:
the denominator, and medical record data for documentation of tobacco use
status, and if a user, pharmacy or medical record data for documentation of
cessation counseling or treatment information for the numerator.
Explanation:
American Diabetes Association (ADA) guidelines recommend that diabetics do
not use tobacco products and that those who do received cessation counseling
and treatment. It is anticipated that clinicians who provide services for the
primary management of diabetes will submit this measure.
Numerator:
Patients in the denominator with documentation of tobacco use status. If patient
is a documented tobacco user then date of cessation counseling or treatment
must also be recorded for compliance to this measure. See “Patient Eligibility
Criteria” for further information on codes to identify patients with diabetes.
DATA Collection: The patient is numerator compliant if he or she has tobacco
use status documented (see Medical Record Collection below) AND if a
tobacco user has documented date of receipt of cessation counseling and/or
treatment during the reporting period, as identified by claims data. The
following codes may be used to identify smoking cessation counseling and/or
treatment:
CPT I Codes: 99406, 99407;
CPT II Codes: 1000F, 1032F, 1033F, 1034F, 1035F, 1036F
HCPCS Codes: S9453.
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Medical Record Collection: Acceptable forms of cessation counseling and treatment
methods/resources include dated documentation of patient receiving/
participating in at least one of the following:
1. 1:1 teaching
2. Written or web-based risk-based educational materials
3. Group education class focused on tobacco cessation
4. Drug therapy
For a list of numerator compliant medications, see Table 6 under “Relevant
Medication Lists for Diabetes Care Measurement Set.” The list is provided as
an example, but does not constitute an exhaustive list of appropriate
medications.
If the patient is a non-tobacco user, the patient is NOT numerator compliant if:
1. His or her tobacco use status documentation is missing
OR
2. His or her tobacco status was not asked
If the patient is a tobacco user, the patient is NOT numerator compliant if:
Frequency:
1. His or her status documentation is missing
OR
2. His or her tobacco user status was not asked
OR
3. His or her documentation on receiving cessation counseling and/or treatment
is missing
OR
4. He or she has not received cessation counseling and/or treatment
OR
5. He or she has not received cessation counseling and/or treatment during the
reporting period
OR
6. His or her documentation on receiving cessation counseling and/or treatment
is not during the reporting period
If not a tobacco user: most recent tobacco use status.
If tobacco user: most recent status and counseling/treatment within the 12
months prior to the last day of the reporting period.
Scoring:
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Podiatry Examination:
Description:
Percentage of patients aged 18 through 75 years with diabetes who had a
diabetic foot exam performed.
Data source:
the denominator, and claims/encounter and medical record data for foot exam
Explanation:
American Diabetes Association (ADA) guidelines recommend foot
examination, with shoes and socks removed, for adult patients with diabetes to
avoid lower extremity amputations, foot ulcers, infections and other foot
problems. It is anticipated that clinicians who provide services for the primary
management of diabetes will submit this measure.
Numerator:
Patients in the denominator who have documentation of having received a
diabetic foot exam (which includes visual inspection of skin integrity and
documentation of sensitivity to light touch or vibration, including monofilament
testing) or bilateral foot amputation. See “Patient Eligibility Criteria” for
further information on codes to identify patients with diabetes.
DATA Collection: The patient is numerator compliant if he or she has received
a diabetic foot exam during the reporting period, as identified by claims data.
The following codes may be used to identify a diabetic foot exam:
CPT II Codes: 2028F
Medical Record Collection: Evidence of 1 of the following is present in the
eligible patient’s health record:
1. Foot exam including visual inspection, sensory exam with monofilament,
and pulse exam (must have completed all of the 3 components) test during
the reporting period
2. Documentation of a “diabetic foot exam” during the reporting period. This
includes reports from podiatrist office
3. Bilateral foot amputation in the patient’s lifetime
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Documentation in the medical record must include test result and exam date.
The following are not acceptable documentation for diabetic foot exam:
1. Documentation of general extremity exam without mention of the foot, such
as extremities—no edema or Doppler
2. Range of motion or ROM exams
Frequency:
If patient with bilateral foot amputation: during patient lifetime.
If patient with diabetic foot exam: most recent test result within the 12 months
prior to the last day of the reporting period.
Scoring:
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Ophthalmologic Examination:
Description:
Percentage of patients aged 18 through 75 years with diabetes who had an eyescreening exam for diabetic retinal disease.
Data source:
the denominator, and claims/encounter or medical record data for eye screening
exam information for the numerator.
Explanation:
American Diabetes Association (ADA) guidelines recommend that diabetic
patients with known diabetic retinopathy have annual dilated retinal exams.
Those diabetic patients without retinopathy should be screened at least every 2
years. It is anticipated that clinicians who provide services for the primary
management of diabetes will submit this measure.
Numerator:
Patients in the denominator having received an eye screening exam for diabetic
retinal disease. See “Patient Eligibility Criteria” for further information on
.
DATA Collection: The patient is numerator compliant if he or she has an eyescreening exam for diabetic retinal disease as identified by claims data. This
includes those patients with diabetes who had one of the following:
1. A retinal or dilated eye exam by an eye care professional (optometrist or
ophthalmologist) performed and documented within 12 months prior to the
last day of the reporting period.
2. A retinal or dilated eye exam by an eye care professional (optometrist or
ophthalmologist) with a documented negative retinal exam result (no
evidence of retinopathy) within the last 24 months prior to the last day of the
reporting period.
3. Documentation of blindness, both eyes:
a. ICD-9 codes: 369.20, 369.00, 369.07, 369.08, 369.3, 369.4;
b. ICD-10 codes: H54.2, H54.0, H54.10, H54.3, H54.8
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The following codes may be used to identify that a retinal or dilated eye exam
has taken place. Note: evidence of a negative retinal exam result must be
provided through medical record collection (see below):
CPT I Codes: 67028, 67038-67040, 67101, 67105, 67107-67108, 67110,
67112, 67141, 67145, 67208, 67210, 67218, 67227, 67228, 92002, 92004,
92012, 92014, 92018, 92019, 92225, 92226, 92230, 92235, 92240, 92250,
92260; 99203-99205, 99213-99215, 99242-99245;
HCPCS Codes: S0620, S0621, S0652, S3000;
ICD-9-CM Codes: 14.1-14.5, 14.9, 95.02-95.04, 95.11, 95.12, 95.16,
V72.0.
ICD-10-PCS Codes: Z01.00, Z01.01
The following is not acceptable documentation for a retinal or dilated eye exam:
1. Referral for an eye exam or referral with no documentation that an eye exam
was completed
2. An eye exam that simply states the eyes were within normal limits (WNL)
3. A primary care clinician note that states only that the fundi were normal
without specifically stating that the eyes were dilated
4. Visit to an eye care professional where it is clear that a dilated exam was not
performed
Frequency:
If patient with positive diagnosis of retinopathy: most recent screening within
12 months prior to the last day of the reporting period.
If patient with negative retinal exam (no evidence of retinopathy): Most recent
reading within 24 months prior to the last day of the reporting period.
If patient with blindness, both eyes: patient’s lifetime.
Scoring:
Institute.
Page 24
Nephropathy Assessment:
Description:
Percentage of patients aged 18 through 75 years with diabetes who had evidence
of nephropathy or a nephropathy screening.
Data source:
the denominator, and claims/encounter, pharmacy, laboratory or medical record
data for nephropathy diagnosis, medical treatment or screening information for
the numerator.
Explanation:
American Diabetes Association (ADA) guidelines recommend routine
urinalysis and microalbuminuria testing for adult patients with diabetes to detect
nephropathy in patients with no known history of nephropathy. It is anticipated
that clinicians who provide services for the primary management of diabetes
will submit this measure.
Numerator:
Patients in the denominator with documentation of evidence of nephropathy or
nephropathy screening. See “Patient Eligibility Criteria” for further information
on codes to identify patients with diabetes.
DATA Collection: The patient is numerator compliant if he or she has evidence
of nephropathy or screening for nephropathy, as identified by claims or
pharmacy data. This includes those patients with diabetes who had one of the
following:
1. Evidence of nephropathy diagnosis or medical treatment for nephropathy
during the patient’s lifetime.
2. Nephropathy screening during the reporting period.
Evidence of Nephropathy: The following codes may be used to identify
nephropathy diagnosis or treatment:
CPT I Codes : 36145, 36800, 36810, 36815, 36818, 36819, 36821, 3683136833, 50300, 50320 50340, 50360,50365, 50370, 50380, 90920, 90921,
90924,90925, 90935, 90937, 90939. 90940, 90945,90947, 90989, 90993,
90997, 90999, 99512;
Institute.
Page 25
ICD-9-CM Codes: 38.95, 39.27, 39.42, 39.43, 39.53, 39.93-39.95, 54.98,
55.4-55.6, 250.4, 403, 404, 405.01, 405.11, 405.91, 581.81, 582.9, 583.81,
584-586,588, 753.0, 753.1, 791.0;
V-Codes: V42.0, V45.1, V56, UB-92;
Revenue Codes: 0367, 080X, 082X-085X, 088X;
DRGs: 316, 317.
ICD-10 Codes: N14.0 – N14.4, N15.0, N13.71, N07.0-N07.9, E08.21, E09.21,
E10.21, E11.21, E13.21, A36.84
Nephropathy Screening: The following codes may be used to identify
nephropathy-screening tests (microalbuminuria and/or macroalbuminuria test):
CPT I Codes:
Microalbuminuria Test: 82042, 82043, 82044, 83518, 84156, 84160*,
84166*, 84165*. Codes marked by an asterisk (*) must be accompanied by
CPT I code 81050 indicating test was a urinalysis.
Macroalbuminuria Test: 81000-81003*, 81005*. Codes marked by an asterisk
(*) must be accompanied by CPT II code 3062F indicating a positive
macroalbuminuria result.
Evidence of Nephropathy: Documentation in the medical record must include
diagnosis of or medical treatment for one of the following during the patient’s
lifetime:
-
Diabetic nephropathy
Diabetic kidney disease
Diffuse diabetic or nodular glomerularsclerosis
Kimmesstiel-Wilson lesion
Papillary necrosis
Arterionephrosclerosis
End-stage renal disease (ESRD)
Chronic renal failure (CRF)
Chronic Renal insufficiency
Chronic Kidney Disease (CKD)
Chronic renal disorder
Institute.
Page 26
-
Renal Dialysis
Acute renal failure
Proteinuria
Azotemia
Microalbuminuria
Nephropathy Screening: Documentation in the medical record must include the
date on which the screening test was performed, and the test result that has been
reviewed is within the 12 months, prior to the last day of the reporting period.
Notation of the following may count for microalbuminuria screening test:
-
24-hour urine for microalbumin
Timed urine for microalbumin
Spot urine for micro albumin
Microalbumin/Creatine ratio
24-hour urine for total protein
Random urine for protein/creatinine ratio
Notation of the following may count for macroalbuminuria screening test:
-
Positive result on urine dipstick
Note: A negative result on urine dipstick is insufficient for numerator
compliance.
The following is not acceptable documentation for nephropathy assessment:
Frequency:
If patient with diagnosis of or medical treatment for nephropathy: during patient
lifetime.
Scoring:
Institute.
Page 27
ACEI/ARB Treatment:
Description:
Denominator = number of diabetic patients age 18-75 who have diagnosis of
hypertension and/or diabetic nephropathy. Percentage of denominator that are
prescribed an ACE inhibitor or Angiotensin Receptor Blocker (ARB), or have a
documented contraindication or medication allergy.
Data source:
medical record data for identification of patients with diabetes and hypertension
and/or nephropathy for the denominator, and claims/encounter and medical
record data which states that these patients are prescribed ACEI/ARB
medication.
Explanation:
diabetic patients age 18-75 with hypertension and/or diabetic nephropathy be
prescribed an ACEI or ARB for renal protection, unless contraindicated.
Numerator:
Patients in the denominator with a diagnosis of hypertension and/or diabetic
nephropathy who are on an ACEi or ARB, unless allergy or contraindication is
recorded in chart. See “Patient Eligibility Criteria” for further information on
DATA Collection: The patient is numerator compliant if he or she has
hypertension and/or diabetic nephropathy and is prescribed an ACEi or ARB
medication.
Evidence of Hypertension: The following codes may be used to identify
hypertension diagnosis or treatment:
ICD-10 Codes : I10,
Exclusions:
ESRD, dialysis patients, ARB/ACEI allergy or documented contraindication
Frequency:
Most recent documentation of ACEI/ARB use in diabetic patients with
hypertension and/or diabetic nephropathy within the 12 months prior to the last
day of the reporting period.
Scoring:
(Numerator/Denominator) * Max Po
Institute.
Page 28
Body Mass Index/Weight/Nutrition Counseling
Description:
Percentage of patients’ aged 18 through 75 years with diabetes for whom a
documented body mass index (BMI) is calculated and nutrition counseling is
performed and documented.
Data source:
the denominator, and claims/encounter and medical record data for BMI
Explanation:
American Diabetes Association (ADA) guidelines recognized that overweight
and obesity are strongly linked to the development of type 2 diabetes and can
complicate its management. Obesity is an independent risk factor for
hypertension, dyslipidemia, and cardiovascular disease, which is the major
cause of death in persons with diabetes. Individuals with a BMI of 25 or greater
and who have diabetes or are at risk of developing diabetes should be counseled
to lose weight and improve nutrition with lifestyle changes. Counseling can be
performed by PCP, CDE, RN, dietician, or nutritionist. It is anticipated that
clinicians who provide services for the primary management of diabetes will
submit this measure.
Numerator:
Patients in the denominator with a documented BMI calculated. See “Patient
Eligibility Criteria” for further information on codes to identify patients with
diabetes.
DATA Collection: The patient is numerator compliant if he or she has a
calculation of their BMI documented during the reporting period and if BMI
>25, nutrition counseling should be provided and documented. The nutrition
counseling may take place up to 12 months prior to the reporting period. The
following codes may be used to identify a documented BMI:
CPT II Code: 3008F
HCPCS Codes: G8417-G8420
ICD-9: V-Codes: V85.0 BMI less than 19, adult; V85.1 BMI between 19-24,
adult; V85.2 BMI between 25-29, adult; V85.3 BMI between 30-39, adult;
V85.4 BMI between 40 and over, adult.
Institute.
Page 29
ICD-10: Z68.1 BMI less than 19, adult; Z68.20 – Z68.24 BMI between 2024, adult; Z68.25-Z68.29 BMI between 25-29, adult; Z68.30 – Z68.39 BMI
between 30-39, adult; Z68.4 BMI between 40 and over, adult.
Medical Record Collection: Evidence of one of the following is present in the
eligible patient’s chart:
1. Documentation of the result of a BMI calculation during the reporting
period
2. Documentation in the medical record must include BMI result and
exam date. Calculated BMI – Requires that both the height and
weight are actually measured by an eligible professional or by their
staff.
3. If BMI>25, must document that nutritional counseling around lifestyle
changes, including weight loss, has been provided.
The following are not acceptable documentation for documented BMI
calculation:
Frequency:
Most recent test result over the last 12 months from last day of the reporting
period.
Not Eligible/Not Appropriate for BMI Measurement – Patients can be
considered not eligible in the following situations:
1. If the patient has a terminal illness – life expectancy less than 6 months
2. If the patient is pregnant
3. Patient physically unable to provide weight.
Scoring:
Source and Level of Evidence: ADA, Level A
Institute.
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Assessment of Cardiovascular Risk
Description:
Denominator = number of patients aged 40 – 75 years. Percentage of patients in
the denominator, aged 40 through 75 years, who have their 10 year risk of
ASCVD assessed using the Pooled Cohort Risk Assessment Tool
Data source:
medical record data for identification of patients with diabetes for the
denominator, and claims/encounter and medical record data for Pooled Cohort
10 year risk information for the numerator.
Explanation:
American Diabetes Association (ADA) and ACC/AHA 2015 guidelines
recommend that all diabetic patients age 40-75 have their 10 year cardiovascular
risk assessed using the Pooled Cohort risk calculator. This calculator is used to
determine patient eligibility for aspirin use, statin use, and as a tool for
discussing modifiable risk factors with diabetic patients. It is anticipated that
clinicians who provide services for the primary management of diabetes will
submit this measure.
Numerator:
Patients in the denominator who are aged 40-75 years with a recorded
calculated 10-year cardiovascular risk (recorded as a percentage). See “Patient
Eligibility Criteria” for further information on codes to identify patients with
diabetes.
DATA Collection: The patient is numerator compliant if he or she is aged 40-75
and has a calculation of their 10 year cardiovascular risk documented during the
reporting period.
The following are not acceptable documentation for documented Pooled Risk
Assessment calculation:
2. Framingham Risk Score
Frequency:
Scoring:
Most recent ASCVD risk recorded within the 12 months prior to the last day of
the reporting period.
(Numerator/Denominator) * Max Points = Score
Source and Level of Evidence: AHA, Level C
Institute.
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Consider Aspirin Use
Description:
Aspirin use should be considered in diabetic patients age 40-75 based on their
10-year cardiovascular risk as calculated by the Pooled Cohort Risk Assessment
tool. If risk is greater than 10% and aspirin is not contraindicated, it should be
prescribed.
Data source:
medical record data for identification of patients with diabetes for the
denominator, and claims/encounter and medical record data which states that
aspirin use was considered information for the numerator.
Explanation:
American Diabetes Association (ADA) and ACC/AHA 2015 guidelines
recommend that all diabetic patients age 40-75 have their 10-year
cardiovascular risk assessed using the Pooled Cohort risk calculator. This
calculator is used to determine patient eligibility for aspirin use. Depending on
level of risk, aspirin may be appropriate. In patients who are lower risk, the
potential harms of aspirin may outweigh potential benefit. Thus calculating risk
and prescribing aspirin accordingly is an important component in caring for the
diabetic patient. ADA guidelines are as follows:
10 year risk
>10%
5-10%
<5%
Recommended treatment
Aspirin (81mg or 325mg)
Use clinical judgment
No aspirin (unless other indication)
Diagnosis Codes for Aspirin Use:
ICD-9 code: V58.66
ICD-10 code: Z79.82
Numerator:
Patients aged 40-75 years with a diagnosis of diabetes and a calculated 10-year
cardiovascular risk (recorded as a percentage), and notation that aspirin use was
considered. See “Patient Eligibility Criteria” for further information on codes to
identify patients with diabetes.
DATA Collection: The patient is numerator compliant if he or she has a
calculation of their 10-year cardiovascular risk documented and notation that
Institute.
Page 32
aspirin use was considered during the reporting period, as identified in the
patient’s health record or by claims data.
The following are not acceptable documentation for documented Pooled Risk
Assessment calculation:
2. Framingham Risk Score
Exclusions:
Because this is a complex decision and simple rules do not always apply, there are
many exclusionary criteria, which include the following:
1. Aspirin allergy
2. Aspirin contraindication
a. Including, but not limited to: GI intolerance, GI bleed, ulcer,
gastritis, bleeding disorder, other anticoagulation (clopridigrel,
coumadin, etc)
Anticoagulants:
Drug Name
Angiomax
argatroban
Argatroban
Arixtra
ATryn
bivalirudin
Coumadin
Eliquis
enoxaparin
fondaparinux
Fragmin
heparin
Innohep
Iprivask
Jantoven
Lovenox
Pradaxa
Refludan
Savaysa
Thrombate III
warfarin
Xarelto
generic name
bivalirudin
generic
argatroban
fondaparinux
antithrombin (recombinant)
generic
warfarin
apixaban
generic
generic
dalteparin
generic
tinzaparin
desirudin
warfarin
enoxaparin
dabigatran etexilate
lepirudin
edoxaban
antithrombin III
generic
rivaroxaban
Institute.
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Antiplatelet Agents:
Drug Name
generic name
Aggrastat
tirofiban
Aggrenox
aspirin/dipyridamole
Agrylin
anagrelide
Anagrelide
generic
Aspirin
generic
Aspirin/Dipyridamole
generic
Bayer Aspirin
aspirin
Bayer Low Dose Aspirin
aspirin
Bayer Women's Low Dose Aspirin aspirin/calcium carbonate
Brilinta
ticagrelor
Bufferin
aspirin
Cilostazol
generic
Clopidogrel
generic
Dipyridamole
generic
Ecotrin
aspirin
Ecotrin Low Strength
aspirin
Effient
prasugrel
Integrilin
eptifibatide
Kengreal
cangrelor
Persantine
dipyridamole
Plavix
clopidogrel
Pletal
cilostazol
Reopro
abciximab
St. Joseph Low Dose Aspirin
aspirin
Ticlid
ticlopidine
Zontivity
vorapaxar
Frequency:
Most recent ASCVD risk and aspirin consideration over the last 12 months from
last day of the reporting period.
Scoring:
(Numerator/Denominator) * Max Points = Score
Source and Level of Evidence: ADA, Level C
Institute.
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Depression Screening:
Description:
Percentage of diabetic patients age 18-75 who have had screening for
depression with PHQ-2 or PHQ-9 annually.
Data source:
medical record data for identification of patients with diabetes who have had
screening for depression annually.
Explanation:
Studies have demonstrated that diabetic patients have an increased risk of
depression. Conversely, depressed patients often demonstrate poor
management of their chronic diseases, including diabetes. Therefore, evidence
suggests that diabetics should have annual screening for depression.
Numerator:
Patients in the denominator who have had depression screening with PHQ-2 or
PHQ-9 within the reporting period. See “Patient Eligibility Criteria” for further
DATA Collection: The diabetic patient is numerator compliant if he or she has
had a PHQ-2 or PHQ-9 score documented in the reporting period
Exclusions:
Patients with terminal illness, patients on hospice, patients with dementia,
patients with psychosis
Frequency:
PHQ-2 or PHQ-9 measurement documented once within the 12 months prior to
the last day of the reporting period.
Scoring:
Institute.
Page 35
Patient Eligibility Criteria
An eligible diabetes patient is one who the following criteria:
1. Is between 18 and 75 years of age.2
2. Has been under the care of the applicant for at least 12 months. This is defined by
documentation of two face-to-face visits for diabetes care between the clinician and the
patient: one within 12 months prior to the last day of the reporting period and one that
predates the last day of the reporting period by at least 12 months.
There are three accepted data sources that can be used to identify patients with diabetes:
claims/encounter data, medical record data and pharmacy data.
Claims/Encounter data: Patient is denominator compliant if he or she is aged 18-75 and
has had at least two face-to-face encounters for diabetes care, in an ambulatory setting:
one within 12 months of the last day of the reporting period and one that predates the last
day of the reporting period by at least 12 months. See Table 1 below for further
Medical Record data: Patient is denominator compliant if he or she is aged 18-75 with a
documented diagnosis of diabetes listed on the problem list AND has been under the care
of the applicant for at least 12 months. See Table 1 below for further information on
diagnoses to identify patients with diabetes.
Medicare Part B Beneficiary: Is the patient a Medicare Part B Fee-For-Service (FFS)
beneficiary (includes Railroad Retirement Board, Medicare Secondary Payer, and Critical
Access Hospitals method II; does not include Medicare Advantage beneficiaries)?
a) Yes
b) No
2
As of the last date of the reporting period. Patients known to be deceased should be excluded.
Institute.
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Table 1: Codes and Descriptions to Identify Patients with a Diagnosis of
Diabetes
Diabetes Care Recognition Program Coding Conventions: Unless otherwise noted, codes are
stated to the minimum specificity required. For example, if a three-digit code is listed, it is valid
as a three-, four- or five-digit code. When necessary, a code may be specified with an "x," which
represents a required digit: for example, ICD-9-CM diagnosis code 640.0x means that a fifth
digit is required, but the fifth digit could be any number allowed by the coding manual.
ICD9
Code
3572
25003
Description
Polyneuropathy in diabetes
Diabetes mellitus without mention of complication, type II or unspecified type, not
stated as uncontrolled
Diabetes mellitus without mention of complication, type I [juvenile type], not
Diabetes mellitus without mention of complication, type II or unspecified type,
uncontrolled
Diabetes mellitus without mention of complication, type I [juvenile type],
uncontrolled
25010
Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled
25011
Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled
25012
Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
25013
25020
Diabetes with ketoacidosis, type I [juvenile type], uncontrolled
Diabetes with hyperosmolarity, type II or unspecified type, not stated as
uncontrolled
25021
Diabetes with hyperosmolarity, type I [juvenile type], not stated as uncontrolled
25022
Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
25023
Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled
25030
Diabetes with other coma, type II or unspecified type, not stated as uncontrolled
25000
25001
25002
Institute.
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ICD9
Code
Description
25031
Diabetes with other coma, type I [juvenile type], not stated as uncontrolled
25032
Diabetes with other coma, type II or unspecified type, uncontrolled
25033
25041
Diabetes with other coma, type I [juvenile type], uncontrolled
Diabetes with renal manifestations, type II or unspecified type, not stated as
uncontrolled
Diabetes with renal manifestations, type I [juvenile type], not stated as
uncontrolled
25042
Diabetes with renal manifestations, type II or unspecified type, uncontrolled
25043
25051
Diabetes with renal manifestations, type I [juvenile type], uncontrolled
Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
uncontrolled
Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as
uncontrolled
25052
Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled
25053
Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled
Diabetes with neurological manifestations, type II or unspecified type, not stated
as uncontrolled
Diabetes with neurological manifestations, type I [juvenile type], not stated as
uncontrolled
Diabetes with neurological manifestations, type II or unspecified type,
uncontrolled
25040
25050
25060
25061
25062
25063
25070
25071
25072
Diabetes with neurological manifestations, type I [juvenile type], uncontrolled
Diabetes with peripheral circulatory disorders, type II or unspecified type, not
Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as
uncontrolled
Diabetes with peripheral circulatory disorders, type II or unspecified type,
uncontrolled
Institute.
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ICD9
Code
25073
25080
25081
25082
25083
Description
Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled
Diabetes with other specified manifestations, type II or unspecified type, not stated
as uncontrolled
Diabetes with other specified manifestations, type I [juvenile type], not stated as
uncontrolled
Diabetes with other specified manifestations, type II or unspecified type,
uncontrolled
25091
Diabetes with other specified manifestations, type I [juvenile type], uncontrolled
Diabetes with unspecified complication, type II or unspecified type, not stated as
uncontrolled
Diabetes with unspecified complication, type I [juvenile type], not stated as
uncontrolled
25092
Diabetes with unspecified complication, type II or unspecified type, uncontrolled
25093
36201
36202
36203
36204
36205
36206
36207
Diabetes with unspecified complication, type I [juvenile type], uncontrolled
Background diabetic retinopathy
Proliferative diabetic retinopathy
Nonproliferative diabetic retinopathy NOS
Mild nonproliferative diabetic retinopathy
Moderate nonproliferative diabetic retinopathy
Severe nonproliferative diabetic retinopathy
Diabetic macular edema
25090
ICD10
Code
E0801
E0810
E0811
E0821
E08311
E08319
E0839
E0840
Description
Diabetes due to underlying condition w hyprosm w coma
Diabetes due to underlying condition w ketoacidosis w/o coma
Diabetes due to underlying condition w ketoacidosis w coma
Diabetes due to underlying condition w diabetic nephropathy
Diab due to undrl cond w unsp diabetic rtnop w macular edema
Diab due to undrl cond w unsp diab rtnop w/o macular edema
Diabetes due to undrl condition w oth diabetic opth comp
Diabetes due to underlying condition w diabetic neurop, unsp
Institute.
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ICD10
Code
E0841
E0842
E0843
E0844
E0849
E0851
E08610
E08618
E08620
E08621
E08622
E08628
E08630
E08638
E0869
E088
E089
E0901
E0910
E0911
E0921
E09311
E09319
E0939
E0940
E0941
E0942
E0943
E0944
E0949
E0951
E09610
E09618
E09620
E09621
Description
Diabetes due to undrl condition w diabetic mononeuropathy
Diabetes due to underlying condition w diabetic polyneurop
Diab due to undrl cond w diabetic autonm (poly)neuropathy
Diabetes due to underlying condition w diabetic amyotrophy
Diabetes due to undrl condition w oth diabetic neuro comp
Diab due to undrl cond w diab prph angiopath w/o gangrene
Diabetes due to undrl cond w diabetic neuropathic arthrop
Diabetes due to underlying condition w oth diabetic arthrop
Diabetes due to underlying condition w diabetic dermatitis
Diabetes mellitus due to underlying condition w foot ulcer
Diabetes due to underlying condition w oth skin ulcer
Diabetes due to underlying condition w oth skin comp
Diabetes due to underlying condition w periodontal disease
Diabetes due to underlying condition w oth oral comp
Diabetes due to underlying condition w oth complication
Diabetes due to underlying condition w unsp complications
Diabetes due to underlying condition w/o complications
Drug/chem diabetes mellitus w hyperosmolarity w coma
Drug/chem diabetes mellitus w ketoacidosis w/o coma
Drug/chem diabetes mellitus w ketoacidosis w coma
Drug/chem diabetes mellitus w diabetic nephropathy
Drug/chem diabetes w unsp diabetic rtnop w macular edema
Drug/chem diabetes w unsp diabetic rtnop w/o macular edema
Drug/chem diabetes w oth diabetic ophthalmic complication
Drug/chem diabetes w neuro comp w diabetic neuropathy, unsp
Drug/chem diabetes w neuro comp w diabetic mononeuropathy
Drug/chem diabetes w neurological comp w diabetic polyneurop
Drug/chem diab w neuro comp w diab autonm (poly)neuropathy
Drug/chem diabetes w neurological comp w diabetic amyotrophy
Drug/chem diabetes w neuro comp w oth diabetic neuro comp
Drug/chem diabetes w diabetic prph angiopath w/o gangrene
Drug/chem diabetes w diabetic neuropathic arthropathy
Drug/chem diabetes mellitus w oth diabetic arthropathy
Drug/chem diabetes mellitus w diabetic dermatitis
Drug or chemical induced diabetes mellitus with foot ulcer
Institute.
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ICD10
Code
E09622
E09628
E09630
E09638
E0969
E098
E099
E1010
E1011
E1021
E1029
E10311
E10319
E1039
E1040
E1042
E1051
E10618
E10620
E10621
E10622
E10628
E10630
E10638
E1069
E108
E109
E1100
E1101
E1121
E1129
E11311
E11319
E11329
E11339
Description
Drug or chemical induced diabetes mellitus w oth skin ulcer
Drug/chem diabetes mellitus w oth skin complications
Drug/chem diabetes mellitus w periodontal disease
Drug/chem diabetes mellitus w oth oral complications
Drug/chem diabetes mellitus w oth complication
Drug/chem diabetes mellitus w unsp complications
Drug or chemical induced diabetes mellitus w/o complications
Type 1 diabetes mellitus with ketoacidosis without coma
Type 1 diabetes mellitus with ketoacidosis with coma
Type 1 diabetes mellitus with diabetic nephropathy
Type 1 diabetes mellitus w oth diabetic kidney complication
Type 1 diabetes w unsp diabetic retinopathy w macular edema
Type 1 diabetes w unsp diabetic rtnop w/o macular edema
Type 1 diabetes w oth diabetic ophthalmic complication
Type 1 diabetes mellitus with diabetic neuropathy, unsp
Type 1 diabetes mellitus with diabetic polyneuropathy
Type 1 diabetes w diabetic peripheral angiopath w/o gangrene
Type 1 diabetes mellitus with other diabetic arthropathy
Type 1 diabetes mellitus with diabetic dermatitis
Type 1 diabetes mellitus with foot ulcer
Type 1 diabetes mellitus with other skin ulcer
Type 1 diabetes mellitus with other skin complications
Type 1 diabetes mellitus with periodontal disease
Type 1 diabetes mellitus with other oral complications
Type 1 diabetes mellitus with other specified complication
Type 1 diabetes mellitus with unspecified complications
Type 1 diabetes mellitus without complications
Type 2 diab w hyprosm w/o nonket hyprgly-hypros coma (NKHHC)
Type 2 diabetes mellitus with hyperosmolarity with coma
Type 2 diabetes mellitus with diabetic nephropathy
Type 2 diabetes mellitus w oth diabetic kidney complication
Type 2 diabetes w unsp diabetic retinopathy w macular edema
Type 2 diabetes w unsp diabetic rtnop w/o macular edema
Type 2 diab w mild nonprlf diabetic rtnop w/o macular edema
Type 2 diab w moderate nonprlf diab rtnop w/o macular edema
Institute.
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ICD10
Code
E11349
E11359
E1139
E1140
E1142
E1151
E11618
E11620
E11621
E11622
E11628
E11630
E11638
E1169
E118
E119
E1300
E1310
E1311
E1339
E1340
E1341
E1342
E1343
E1344
E1349
E1359
E13620
E13621
E13622
E13628
E13638
E1369
E138
E139
Description
Type 2 diab w severe nonprlf diab rtnop w/o macular edema
Type 2 diabetes w prolif diabetic rtnop w/o macular edema
Type 2 diabetes w oth diabetic ophthalmic complication
Type 2 diabetes mellitus with diabetic neuropathy, unsp
Type 2 diabetes mellitus with diabetic polyneuropathy
Type 2 diabetes w diabetic peripheral angiopath w/o gangrene
Type 2 diabetes mellitus with other diabetic arthropathy
Type 2 diabetes mellitus with diabetic dermatitis
Type 2 diabetes mellitus with foot ulcer
Type 2 diabetes mellitus with other skin ulcer
Type 2 diabetes mellitus with other skin complications
Type 2 diabetes mellitus with periodontal disease
Type 2 diabetes mellitus with other oral complications
Type 2 diabetes mellitus with other specified complication
Type 2 diabetes mellitus with unspecified complications
Type 2 diabetes mellitus without complications
Oth diab w hyprosm w/o nonket hyprgly-hypros coma (NKHHC)
Oth diabetes mellitus with ketoacidosis without coma
Oth diabetes mellitus with ketoacidosis with coma
Oth diabetes mellitus w oth diabetic ophthalmic complication
Oth diabetes mellitus with diabetic neuropathy, unspecified
Oth diabetes mellitus with diabetic mononeuropathy
Oth diabetes mellitus with diabetic polyneuropathy
Oth diabetes mellitus w diabetic autonomic (poly)neuropathy
Other specified diabetes mellitus with diabetic amyotrophy
Oth diabetes w oth diabetic neurological complication
Oth diabetes mellitus with other circulatory complications
Other specified diabetes mellitus with diabetic dermatitis
Other specified diabetes mellitus with foot ulcer
Other specified diabetes mellitus with other skin ulcer
Oth diabetes mellitus with other skin complications
Oth diabetes mellitus with other oral complications
Oth diabetes mellitus with other specified complication
Oth diabetes mellitus with unspecified complications
Other specified diabetes mellitus without complications
Institute.
Page 42
Encounter
Criteria
99201
99202
99203
99204
99205
Definition
Office or other outpatient visit for the evaluation and management of a new patient,
which requires these 3 key components: A problem focused history; A problem
focused examination; Straightforward medical decision making. Counseling and/or
coordination of care with other physicians, other qualified health care professionals,
or agencies are provided consistent with the nature of the problem(s) and the patient's
and/or family's needs. Usually, the presenting problem(s) are self limited or minor.
Typically, 10 minutes are spent face-to-face with the patient and/or family.
which requires these 3 key components: An expanded problem focused history; An
expanded problem focused examination; Straightforward medical decision making.
Counseling and/or coordination of care with other physicians, other qualified health
care professionals, or agencies are provided consistent with the nature of the
problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s)
are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the
patient and/or family.
which requires these 3 key components: A comprehensive history; A comprehensive
examination; Medical decision making of high complexity. Counseling and/or
coordination of care with other physicians, other qualified health care professionals,
or agencies are provided consistent with the nature of the problem(s) and the patient's
and/or family's needs. Usually, the presenting problem(s) are of moderate to high
severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
Institute.
Page 43
Encounter
Criteria
Definition
99211
Office or other outpatient visit for the evaluation and management of an
established patient, that may not require the presence of a physician or other
qualified health care professional. Usually, the presenting problem(s) are
minimal. Typically, 5 minutes are spent performing or supervising these services.
established patient, which requires at least 2 of these 3 key components: A
problem focused history; A problem focused examination; Straightforward
medical decision making. Counseling and/or coordination of care with other
physicians, other qualified health care professionals, or agencies are provided
consistent with the nature of the problem(s) and the patient's and/or family's
needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10
minutes are spent face-to-face with the patient and/or family.
established patient, which requires at least 2 of these 3 key components: An
expanded problem focused history; An expanded problem focused examination;
Medical decision making of low complexity. Counseling and coordination of care
with other physicians, other qualified health care professionals, or agencies are
provided consistent with the nature of the problem(s) and the patient's and/or
family's needs. Usually, the presenting problem(s) are of low to moderate
severity. Typically, 15 minutes are spent face-to-face with the patient and/or
family.
detailed history; A detailed examination; Medical decision making of moderate
complexity. Counseling and/or coordination of care with other physicians, other
qualified health care professionals, or agencies are provided consistent with the
nature of the problem(s) and the patient's and/or family's needs. Usually, the
presenting problem(s) are of moderate to high severity. Typically, 25 minutes are
spent face-to-face with the patient and/or family.
comprehensive history; A comprehensive examination; Medical decision making
of high complexity. Counseling and/or coordination of care with other physicians,
other qualified health care professionals, or agencies are provided consistent with
the nature of the problem(s) and the patient's and/or family's needs. Usually, the
presenting problem(s) are of moderate to high severity. Typically, 40 minutes are
spent face-to-face with the patient and/or family.
99212
99213
99214
99215
Institute.
Page 44
Encounter
Criteria
Definition
99217
Observation care discharge day management (This code is to be utilized to report
all services provided to a patient on discharge from "observation status" if the
discharge is on other than the initial date of "observation status." To report
services to a patient designated as "observation status" or "inpatient status" and
discharged on the same date, use the codes for Observation or Inpatient Care
Services [including Admission and Discharge Services, 99234-99236 as
appropriate.])
Initial observation care, per day, for the evaluation and management of a patient
which requires these 3 key components: A detailed or comprehensive history; A
detailed or comprehensive examination; and Medical decision making that is
straightforward or of low complexity. Counseling and/or coordination of care
family's needs. Usually, the problem(s) requiring admission to "observation
status" are of low severity. Typically, 30 minutes are spent at the bedside and on
the patient's hospital floor or unit.
Initial observation care, per day, for the evaluation and management of a patient,
which requires these 3 key components: A comprehensive history; A
comprehensive examination; and Medical decision making of moderate
problem(s) requiring admission to "observation status" are of moderate severity.
Typically, 50 minutes are spent at the bedside and on the patient's hospital floor
or unit.
Initial observation care, per day, for the evaluation and management of a patient,
comprehensive examination; and Medical decision making of high complexity.
Counseling and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the nature of
the problem(s) and the patient's and/or family's needs. Usually, the problem(s)
requiring admission to "observation status" are of high severity. Typically, 70
minutes are spent at the bedside and on the patient's hospital floor or unit.
99218
99219
99220
Institute.
Page 45
Encounter
Criteria
Definition
99221
Initial hospital care, per day, for the evaluation and management of a patient,
which requires these 3 key components: A detailed or comprehensive history; A
detailed or comprehensive examination; and Medical decision making that is
family's needs. Usually, the problem(s) requiring admission are of low severity.
or unit.
problem(s) requiring admission are of moderate severity. Typically, 50 minutes
are spent at the bedside and on the patient's hospital floor or unit.
requiring admission are of high severity. Typically, 70 minutes are spent at the
bedside and on the patient's hospital floor or unit.
Subsequent hospital care, per day, for the evaluation and management of a
patient, which requires at least 2 of these 3 key components: A problem focused
interval history; A problem focused examination; Medical decision making that is
family's needs. Usually, the patient is stable, recovering or improving. Typically,
15 minutes are spent at the bedside and on the patient's hospital floor or unit.
99222
99223
99231
Institute.
Page 46
Encounter
Criteria
Definition
99232
99238
patient, which requires at least 2 of these 3 key components: An expanded
problem focused interval history; An expanded problem focused examination;
Medical decision making of moderate complexity. Counseling and/or
coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of the
problem(s) and the patient's and/or family's needs. Usually, the patient is
responding inadequately to therapy or has developed a minor complication.
or unit.
patient, which requires at least 2 of these 3 key components: A detailed interval
history; A detailed examination; Medical decision making of high complexity.
the problem(s) and the patient's and/or family's needs. Usually, the patient is
unstable or has developed a significant complication or a significant new
problem. Typically, 35 minutes are spent at the bedside and on the patient's
hospital floor or unit.
Hospital discharge day management; 30 minutes or less.
99239
Hospital discharge day management; more than 30 minutes.
99281
Emergency department visit for the evaluation and management of a patient,
which requires these 3 key components: A problem focused history; A problem
focused examination; and Straightforward medical decision making. Counseling
and/or coordination of care with other physicians, other qualified health care
problem(s) and the patient's and/or family's needs. Usually, the presenting
problem(s) are self limited or minor.
which requires these 3 key components: An expanded problem focused history;
An expanded problem focused examination; and Medical decision making of low
presenting problem(s) are of low to moderate severity.
99233
99282
Institute.
Page 47
Encounter
Criteria
99283
99284
99285
99291
99304
Definition
which requires these 3 key components: An expanded problem focused history;
An expanded problem focused examination; and Medical decision making of
moderate complexity. Counseling and/or coordination of care with other
needs. Usually, the presenting problem(s) are of moderate severity.
which requires these 3 key components: A detailed history; A detailed
examination; and Medical decision making of moderate complexity. Counseling
problem(s) are of high severity, and require urgent evaluation by the physician or
other qualified health care professionals but do not pose an immediate significant
threat to life or physiologic function.
which requires these 3 key components within the constraints imposed by the
urgency of the patient's clinical condition and/or mental status: A comprehensive
history; A comprehensive examination; and Medical decision making of high
presenting problem(s) are of high severity and pose an immediate significant
threat to life or physiologic function.
Critical care, evaluation and management of the critically ill or critically injured
patient; first 30-74 minutes.
Initial nursing facility care, per day, for the evaluation and management of a
patient, which requires these 3 key components: A detailed or comprehensive
history; A detailed or comprehensive examination; and Medical decision making
that is straightforward or of low complexity. Counseling and/or coordination of
care with other physicians, other qualified health care professionals, or agencies
are provided consistent with the nature of the problem(s) and the patient's and/or
family's needs. Usually, the problem(s) requiring admission are of low severity.
Typically, 25 minutes are spent at the bedside and on the patient's facility floor or
unit.
Institute.
Page 48
Encounter
Criteria
99305
99306
99307
99308
Definition
patient, which requires these 3 key components: A comprehensive history; A
problem(s) requiring admission are of moderate severity. Typically, 35 minutes
are spent at the bedside and on the patient's facility floor or unit.
requiring admission are of high severity. Typically, 45 minutes are spent at the
bedside and on the patient's facility floor or unit.
Subsequent nursing facility care, per day, for the evaluation and management of a
patient, which requires at least 2 of these 3 key components: A problem focused
interval history; A problem focused examination; Straightforward medical
decision making. Counseling and/or coordination of care with other physicians,
other qualified health care professionals, or agencies are provided consistent with
the nature of the problem(s) and the patient's and/or family's needs. Usually, the
patient is stable, recovering, or improving. Typically, 10 minutes are spent at the
bedside and on the patient's facility floor or unit.
patient, which requires at least 2 of these 3 key components: An expanded
problem focused interval history; An expanded problem focused examination;
Medical decision making of low complexity. Counseling and/or coordination of
care with other physicians, other qualified health care professionals, or agencies
are provided consistent with the nature of the problem(s) and the patient's and/or
family's needs. Usually, the patient is responding inadequately to therapy or has
developed a minor complication. Typically, 15 minutes are spent at the bedside
and on the patient's facility floor or unit.
Institute.
Page 49
Encounter
Criteria
Definition
99309
99315
patient, which requires at least 2 of these 3 key components: A detailed interval
history; A detailed examination; Medical decision making of moderate
patient has developed a significant complication or a significant new problem.
Typically, 25 minutes are spent at the bedside and on the patient's facility floor or
unit.
patient, which requires at least 2 of these 3 key components: A comprehensive
interval history; A comprehensive examination; Medical decision making of high
nature of the problem(s) and the patient's and/or family's needs. The patient may
be unstable or may have developed a significant new problem requiring
immediate physician attention. Typically, 35 minutes are spent at the bedside and
on the patient's facility floor or unit.
Nursing facility discharge day management; 30 minutes or less.
99316
Nursing facility discharge day management; more than 30 minutes.
99318
Evaluation and management of a patient involving an annual nursing facility
assessment, which requires these 3 key components: A detailed interval history;
A comprehensive examination; and Medical decision making that is of low to
needs. Usually, the patient is stable, recovering, or improving. Typically, 30
minutes are spent at the bedside and on the patient's facility floor or unit.
Domiciliary or rest home visit for the evaluation and management of a new
patient, which requires these 3 key components: A problem focused history; A
problem focused examination; and Straightforward medical decision making.
the problem(s) and the patient's and/or family's needs. Usually, the presenting
problem(s) are of low severity. Typically, 20 minutes are spent with the patient
and/or family or caregiver.
99310
99324
Institute.
Page 50
Encounter
Criteria
Definition
99325
patient, which requires these 3 key components: An expanded problem focused
history; An expanded problem focused examination; and Medical decision
making of low complexity. Counseling and/or coordination of care with other
needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30
minutes are spent with the patient and/or family or caregiver.
patient, which requires these 3 key components: A detailed history; A detailed
problem(s) are of moderate to high severity. Typically, 45 minutes are spent with
the patient and/or family or caregiver.
presenting problem(s) are of high severity. Typically, 60 minutes are spent with
the problem(s) and the patient's and/or family's needs. Usually, the patient is
unstable or has developed a significant new problem requiring immediate
physician attention. Typically, 75 minutes are spent with the patient and/or family
or caregiver.
99326
99327
99328
Institute.
Page 51
Encounter
Criteria
Definition
99334
Domiciliary or rest home visit for the evaluation and management of an
problem focused interval history; A problem focused examination;
Straightforward medical decision making. Counseling and/or coordination of care
family's needs. Usually, the presenting problem(s) are self-limited or minor.
Typically, 15 minutes are spent with the patient and/or family or caregiver.
established patient, which requires at least 2 of these 3 key components: An
expanded problem focused interval history; An expanded problem focused
examination; Medical decision making of low complexity. Counseling and/or
problem(s) are of low to moderate severity. Typically, 25 minutes are spent with
detailed interval history; A detailed examination; Medical decision making of
needs. Usually, the presenting problem(s) are of moderate to high severity.
Typically, 40 minutes are spent with the patient and/or family or caregiver.
comprehensive interval history; A comprehensive examination; Medical decision
making of moderate to high complexity. Counseling and/or coordination of care
family's needs. Usually, the presenting problem(s) are of moderate to high
severity. The patient may be unstable or may have developed a significant new
problem requiring immediate physician attention. Typically, 60 minutes are spent
with the patient and/or family or caregiver.
99335
99336
99337
Institute.
Page 52
Encounter
Criteria
Definition
99341
Home visit for the evaluation and management of a new patient, which requires
these 3 key components: A problem focused history; A problem focused
examination; and Straightforward medical decision making. Counseling and/or
problem(s) are of low severity. Typically, 20 minutes are spent face-to-face with
the patient and/or family.
these 3 key components: An expanded problem focused history; An expanded
problem focused examination; and Medical decision making of low complexity.
problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face
with the patient and/or family.
these 3 key components: A detailed history; A detailed examination; and Medical
decision making of moderate complexity. Counseling and/or coordination of care
family's needs. Usually, the presenting problem(s) are of moderate to high
severity. Typically, 45 minutes are spent face-to-face with the patient and/or
family.
these 3 key components: A comprehensive history; A comprehensive
problem(s) are of high severity. Typically, 60 minutes are spent face-to-face with
the patient and/or family.
99342
99343
99344
Institute.
Page 53
Encounter
Criteria
Definition
99345
these 3 key components: A comprehensive history; A comprehensive
examination; and Medical decision making of high complexity. Counseling
problem(s) and the patient's and/or family's needs. Usually, the patient is unstable
or has developed a significant new problem requiring immediate physician
attention. Typically, 75 minutes are spent face-to-face with the patient and/or
family.
Home visit for the evaluation and management of an established patient, which
requires at least 2 of these 3 key components: A problem focused interval history;
A problem focused examination; Straightforward medical decision making.
problem(s) are self limited or minor. Typically, 15 minutes are spent face-to-face
with the patient and/or family.
requires at least 2 of these 3 key components: An expanded problem focused
interval history; An expanded problem focused examination; Medical decision
making of low complexity. Counseling and/or coordination of care with other
needs. Usually, the presenting problem(s) are of low to moderate severity.
Typically, 25 minutes are spent face-to-face with the patient and/or family.
requires at least 2 of these 3 key components: A detailed interval history; A
detailed examination; Medical decision making of moderate complexity.
problem(s) are moderate to high severity. Typically, 40 minutes are spent face-toface with the patient and/or family.
99347
99348
99349
Institute.
Page 54
Encounter
Criteria
Definition
99350
requires at least 2 of these 3 key components: A comprehensive interval history;
A comprehensive examination; Medical decision making of moderate to high
presenting problem(s) are of moderate to high severity. The patient may be
unstable or may have developed a significant new problem requiring immediate
physician attention. Typically, 60 minutes are spent face-to-face with the patient
and/or family.
Work related or medical disability examination by the treating physician that
includes: Completion of a medical history commensurate with the patient's
condition; Performance of an examination commensurate with the patient's
condition; Formulation of a diagnosis, assessment of capabilities and stability,
and calculation of impairment; Development of future medical treatment plan;
and Completion of necessary documentation/certificates and report.
Work related or medical disability examination by other than the treating
physician that includes: Completion of a medical history commensurate with the
patient's condition; Performance of an examination commensurate with the
patient's condition; Formulation of a diagnosis, assessment of capabilities and
stability, and calculation of impairment; Development of future medical treatment
plan; and Completion of necessary documentation/certificates and report.
99455
99456
Table 2: Patient Exclusion Codes
Exclusions
Gestational Diabetes
ICD-9: 648.8
ICD-10: O24.4
Hospice and Palliative Care
ICD-9: V66.7
ICD-10: Z51.5
CPT: 99377, 99378
Institute.
Page 55
Recognition Process
Applying for Recognition
Clinician applicants opt to voluntarily submit their data to a PAO for performance assessment through the
Diabetes Care Recognition program. Participating clinicians must execute a data use agreement with the
data aggregator partner through which they plan to submit data for HCI3’s automated performance
assessment process. All data aggregator partners have data use agreements executed with their partnering
PAO. All necessary steps will be taken by the data aggregator and PAO to protect the confidentiality of
patient data, as required by The Health Insurance Portability and Accountability Act of 1996 (HIPAA).
To assist with clinician compliance with HIPAA, the data aggregator partner provides a Business
Associate addendum referenced in the data use agreement, which states that both the data aggregator and
the clinician applicant will comply with HIPAA requirements.
Clinicians considering applying for recognition should:
1. Determine eligibility. See “Eligibility for Clinician Participation” for more information.
2. Familiarize themselves with the BTE Diabetes Care measures and specifications. See “What
Recognition Requires”.
3. Determine whether to apply as an individual clinician or medical practice.
Clinicians submitting through a data aggregator partner are required to submit medical record data for
all eligible patients across their full patient population on a quarterly calendar schedule. Clinicians are
required to continue submitting data for all eligible patients each quarter unless they cease using the
data aggregator’s electronic system.
Clinicians that are new to an electronic data aggregator partner’s system, where the system is not yet fully
integrated in the clinicians’ office and patient records have not been backloaded, are required to
prospectively enter all eligible patients from their full patient panel into the data aggregator’s electronic
system. For individual applicants, clinician assessment will automatically be triggered after all required
data is submitted through the data aggregator’s electronic system for the minimum requirement of 25
eligible patients. For practice level applicants, assessment will automatically be triggered after all required
data is submitted through the data aggregator’s electronic system for 10 patients per individual clinician
and a practice average of 25 patients per clinician. It is assumed that after one full year of usage of the data
aggregator’s electronic system that all eligible patients will be included.
Completed applications are processed for compliance with performance requirements, and applicantspecific reports with results for all Diabetes Care measures are produced within 30 days. The begin
recognition date is calculated based on the date that the applicant’s data is scored. BTE issues an official
certificate to each recognized clinician or medical practice.
Copyright © 2009-2016 Health Care Incentives Improvement Institute, Inc. All rights reserved. Bridges to
Excellence® is a registered trademark of the Health Care Incentives Improvement Institute.
Page 56
Additionally, BTE reserves the right to complete an audit of any individual or practice application for
Recognition. PAO or specified local organization subcontractors conduct audits of at least 5 percent of
the recognized clinicians from each data aggregator partner each year. Audits may be completed by fax,
mail, electronically or on site, as determined by the PAO. The remainder of the five percent will be
identified by a single methodology that randomizes the medical groups who submit to the data aggregator
and then sequentially selecting medical groups. The number of medical groups selected is dependent on
the total number of recognized clinicians in each medical group, enough groups will be selected to
account for 5% of total recognized clinicians submitted by the data aggregator.
The PAO will notify the data aggregator which will notify the applicant if their application is chosen for
audit, ascertain that audit personnel have no conflict of interest with the audited organization and provide
instructions on audit requirements. Obtaining final Recognition results takes longer than usual for
applicants chosen for audit. For those applicants selected for audit, final Recognition determination will
be made within 60 days of the date of data submission. Upon passing an audit, the applicant’s recognition
dates are assigned retroactively to the date the applicant’s data was scored. Failure to pass an audit or
failure to respond to an audit request and complete the audit within 30 days results in no further
consideration for the program for six months to two years (depending on the audit score) from the date of
submission of the application.
Duration of Recognition
The Chronic Care Recognition Programs have duration of two years from the date on which the
recognition was awarded; regardless of the pathway the clinician achieved the recognition – electronic
data submission, direct data manual submission or NCQA. Patient Centered Medical Home
Recognitions achieved through the NCQA have a three-year duration.
For continuously assessed applicants who maintain their current level of recognition, new begin and end
recognition dates will be assigned at the time of the most recent assessment. Recognition determinations
are made on the basis of a specific patient population. Recognition status remains in effect for the
duration of recognition as long as the clinician maintains his or her current practice and patient base.
Clinicians are responsible for informing the data aggregator within 30 days who will inform the PAO
if they move or change practices.
Page 57
Changes in Recognition Levels
Continuous data submission applicants are eligible for changes in recognition level. Clinicians who
achieve at least Three Star Diabetes Care Recognition will maintain their Diabetes Care Recognition for
the duration of recognition outlined above. However, during this time it is possible for the recognition
status to move between program levels (3, 4, or 5 Stars) based on changes in clinical data from quarter to
quarter. Changes to program level and recognition dates occur according to the following rules:
§
§
§
§
Clinicians who achieve a higher level of recognition for two consecutive assessment
periods will have their recognition level changed effective the date of the most recent
assessment.
Clinicians recognized at Four Stars or Five Stars can drop in levels of recognition based on
lower scoring results for two consecutive assessment periods.
Each time a clinician’s recognition status changes levels in either direction a new begin
recognition date is assigned for the date of the most recent assessment and a new end
recognition date is calculated.
Clinicians who drop below Three Stars for two consecutive quarterly assessments will be
assigned or maintain Three Star Diabetes Care Recognition status and maintain their current
begin and end recognition dates.
Example 1: Clinician A assessment history
Assessment
period
10/1/079/30/08
1/1/0812/31/08
4/1/083/31/09
7/1/086/30/09
10/1/089/30/09
Assessment
date
10/22/08
Assessed
(Scored)
7
Five
LevelStars
Recognition
Level8
Five Stars
1/21/09
Five Stars
Five Stars
4/18/09
Five Stars
Five Stars
7/25/09
Four Stars
Five Stars
10/16/09
Four Stars
Four Stars
Recognition
Dates
10/22/0810/22/10
1/21/091/21/11
4/18/094/18/11
4/18/094/18/11
10/16/0910/16/11
Page 58
Example 2: Clinician B assessment history
Assessment
period
10/1/089/30/09
1/1/0912/31/09
4/1/093/31/10
7/1/096/30/10
Assessment
date
10/22/09
Assessed
(Scored) Level
Not Pass
Recognition
Level
N/A
Recognitio
n Dates
N/A
1/21/10
Four Stars
N/A
N/A
4/18/10
Four Stars
Four Stars
7/25/10
Not Pass
Four Stars
4/18/104/18/12
4/18/104/18/12
Reporting Results to BTE and Its Partners
As part of HCI3’s mission to identify and promote quality, the PAO report results to the following:
§
§
To the data aggregator partner through which the recognition application was submitted. The
data aggregator is required to share results reports with the clinician applicant to facilitate
quality improvement.
To BTE: Only Recognized statuses are reported to BTE for display on HCI3’s web site:
www.hci3.org and transmission to BTE-licensed health plans for associated rewards payments.
Once the final decision is made, the PAO will reveal the identity, program name and program
level of the recognized clinicians only. No clinical data is shared with BTE at any point in the
process.
Terms of Recognition
When communicating with patients, third-party payers, managed care organizations (MCOs) and others,
clinicians or practices who receive BTE Diabetes Care Recognition may represent themselves as BTErecognized and meeting NQF/AQA quality measure requirements; however, clinicians or practices may
not characterize themselves as “NQF/AQA-Approved” or “NQF/AQA- Endorsed.” The use of this
mischaracterization or other similarly inappropriate statements will be grounds for revocation of status.
Page 59
Revoking Recognition
PAO may revoke a Recognition decision if any of the following occurs:
§
§
§
§
§
§
§
The clinician or practice submits false data or does not collect data according to the
procedures outlined in this manual, as determined by discussion with the clinician or
practice or audit of application data and materials.
The clinician or practice misrepresents the credentials of any of its clinicians.
The clinician or practice misrepresents its Recognition status.
The clinician or any of the practice's clinicians experience a suspension or revocation of
medical licensure.
The clinician or practice has been placed in receivership or rehabilitation and is being
liquidated.
State, federal or other duly authorized regulatory or judicial action restricts or limits the
clinician or practice’s operations.
BTE identifies a significant threat to patient safety or care.
Data Use Terms
Data use terms are outlined in the data use agreement that the applicant signs with the selected
data aggregator partner.
Page 60
Relevant Medication Lists for Diabetes Care Measurement Set
Table 1: ACE-I
Medications
Accupril
Captopril/hydrochlorothiazide
Mavik
Quinapril Hydrochloride/
hydrochlorothiazide
Quinapril/hydrochlorothiaz
ide
Ramipril
Tarka
Teczem
Trandolapril
Trandolapril/verapamil
Trandolapril/verapamil
hydrochloride
Accuretic
Enalapril
Moexipril
Aceon
Altace
Benazepril
Benazepril Hydrochloride
Benazepril/amlodipine
Benazepril/hydrochlorothiazide
Enalapril Maleate/diltiazem
Enalapril Maleate/hydrochlorothiazide
Enalapril/diltiazem
Enalapril/felodipine
Enalapril/hydrochlorothiazide
Enalaprilat
Moexipril Hydrochloride
Moexipril Hydrochloride/
hydrochlorothiazide
Moexipril/hydrochlorothiazide
Monopril
Monopril HCT
Capoten
Capozide
Capozide 25/15
Epaned (enalapril)
Fosinopril
Fosinopril Sodium/hydrochlorothiazide
Lexxel
Monopril HCT 10/12.5
Perindopril
Perindopril erbumine (added 12/10/04)
Uniretic
Univasc
Vaseretic
Capozide 25/25
Capozide 50/15
Capozide 50/25
Captopril
Captopril HCT
Lisinopril
Lisinopril/hydrochlorothiazide
Lotensin
Lotensin HCT
Lotrel
Prinivil
Prinzide
Quinapril
Quinapril HCl
Quinapril HCl/HCT
Vasotec
Zestoretic
Zestril
Copyright © 2009-2016 Health Care Incentives Improvement Institute, Inc. All rights reserved. Bridges to Excellence® is a registered
trademark of the Health Care Incentives Improvement Institute.
Page 61
Table 2: Angiotensin II inhibitors/angiotensin receptor
blockers (ARBs)
Atacand
Atacand HCT
Diovan
Diovan HCT
Irbesartan/hydrochlorothiazide
Losartan
Avalide
Avapro
Benicar
Candesartan
Candesartan/ hydrochlorothiazde
Cozaar
Eprosartan
Eprosartan/ hydrochlorothiazide
Exforge (amlodopine/valsartan)
Hydrochlorothiazideolmesartan
Hyzaar
Irbesartan
Losartan/hydrochlorothiazide
Micardis
Micardis HCT
Olmesartan
Olmesartan/hydrochlorothiazide
Tasosartan
Telmisartan
Telmisartan/
hyodrochlorothiazide
Teveten
Teveten HCT
Valsartan
Valsartan/hydrochlorothiazide
Table 3: Smoking Cessation medications
Aplenzin
Buproban Oral
Bupropion SR
Bupropion XL
Chantix (varenicline)
Commit
CVS NTS Step 1 TD
CVS NTS Step 2 TD
CVS NTS Step 3 TD
Furtive XL
Habitrol (PDR)
Habitrol (TD)
INTS Step 3 TD
Medic Nicotine TD
NicoDerm CQ
Nicoderm CQ TD
Nicoderm TD
Nicotine Nasl
Nicotine Patches (PDR)
Nicorelief
Nicotine TD
Nicotine Transdermal TD
Nicotrol (PDR)
Nicotrol Inhaler (PDR)
Nicotrol NS (PDR)
Nicotrol NS Nasl
Nicotrol TD
Nicotrol Td TD
Buproban
Nicorette
NTS Step 1 TD
NTS Step 2 TD
NTS Step 3 TD
Prostep TD
Wellbutrin
Wellbutrin XL or SR
Zyban (PDR)
Zyban Oral
Page 62
Table 4: Anticoagulants which may contraindicate aspirin use:
Drug Name
Angiomax
Argatroban
Argatroban
Arixtra
ATryn
Generic Name
bivalirudin
generic
argatroban
fondaparinux
antithrombin (recombinant)
Bivalirudin
Coumadin
Eliquis
Enoxaparin
Fondaparinux
Fragmin
Heparin
Innohep
Iprivask
Jantoven
Lovenox
Pradaxa
Refludan
Savaysa
Thrombate III
Warfarin
Xarelto
generic
warfarin
apixaban
generic
generic
dalteparin
generic
tinzaparin
desirudin
warfarin
enoxaparin
dabigatran etexilate
lepirudin
edoxaban
antithrombin III
generic
rivaroxaban
Page 63
Table 5: Antiplatelet agents which may Contraindicate Aspirin Use
Drug Name
Aggrastat
Aggrenox
Agrylin
Anagrelide
Aspirin
Aspirin/dipyridamole
Bayer Aspirin
Bayer Low Dose Aspirin
Bayer Women's Low Dose Aspirin
Brilinta
Bufferin
Cilostazol
Clopidogrel
Dipyridamole
Ecotrin
Ecotrin Low Strength
Effient
Integrilin
Kengreal
Persantine
Plavix
Pletal
Reopro
St. Joseph Low Dose Aspirin
Ticlid
Zontivity
Generic Drug Name
tirofiban
aspirin/dipyridamole
anagrelide
generic
generic
generic
aspirin
aspirin
aspirin/calcium carbonate
ticagrelor
aspirin
generic
generic
generic
aspirin
aspirin
prasugrel
eptifibatide
cangrelor
dipyridamole
clopidogrel
cilostazol
abciximab
aspirin
ticlopidine
vorapaxar
Page 64
APPENDICES
Appendix A: Audit Methodology
The PAO is responsible for conducting three levels of audit pertaining to applicant submission
for BTE Diabetes Care Recognition:
§
Level 1: Data Aggregator (DA) Data Extraction code review
§
Level 2: Data Validation (Load Summary) see table below
§
Level 3: Clinician Chart Audit
Detailed audit policies are included in the BTE Clinician Assessment Policy and Procedures
Manual.
The following data validation checks are used in creating the load summary provided to the da
aggregator after each data file submission to identify any missing or invalid data values:
DataValidationChecksforClinicalMeasuresDataFields
Data field
ResponsibleProviderID
ChartID
lastVisitDate
PatientDOB
medicarePartB
Data field specifications
InternalproviderIDthat
matcheswiththeIDinthe
physicianfile
Acceptable Data Value
Anyuniquecombination
charactersandnumbers
Alphanumericvalueupt
charactersinlength
MM/DD/YYYY-cannotb
theendofthereporting
MM/DD/YYYY-orYYYY18-75yearsold
UniquepatientorchartID
Thedateofthelastvisitfor
thatpatient
Thedateofbirth,oryearof
birth,ofthepatient
IsthepatientaMedicare
PartBFee-For-Service(FFS)
beneficiary(includes
RailroadRetirementBoard,
MedicareSecondaryPayer,
andCriticalAccessHospitals
methodII;doesnotinclude "YES","NO",-blankwilld
MedicareAdvantage
NOandgenerateaWAR
beneficiaries)?
whenuploading.
Pag
Data field
HbA1c1
HbA1cDate1
HbA1c2
HbA1cDate2
systolic1
diastolic1
bloodPressureDate1
systolic2
diastolic2
bloodPressureDate2
MostRecentHbA1cblood
sugarvalue
DateofmostrecentHbA1C
screening
PriorHbA1cbloodsugar
value
DateofpriorHbA1C
screening
MostrecentSystolicblood
pressurevalue
MostrecentDiastolicblood
pressurevalue
DateofmostrecentBlood
Pressurereading
PriorSystolicbloodpressure
value
PriorDiastolicblood
pressurevalue
DateofpriorBloodPressure
reading
retinalExamDate
Doesthepatienthavea
diagnosisofretinopathy?
Dateofmostrecentretinal
exam
blindness
Isthepatientblind?
retinopathy
Isthepatientatobacco
tobaccoStatus
user?
Datethepatient'stobacco
usestatuswasmost
tobaccoStatusAssessmentDate
recentlyassessed
Datethepatientwasmost
recentlygiventobacco
cessationcounselingor
tobaccoCessationAdviceOrTreatmentDate treatment
MostrecentLDLcholesterol
LDLLevel
value
MostrecentLDLcholesterol
LDLDate
date
Acceptable Data Value Range
Numericvaluebetween4and16
MM/DD/YYYY
Numericvaluebetween4and16
MM/DD/YYYY
Numericvaluebetween60and
300
150
MM/DD/YYYY
300
150
MM/DD/YYYY
YES,"NO","NOTKNOWN"-blank
willdefaulttoNOTKNOWNand
generateaWARNINGwhen
uploading
MM/DD/YYYY-cannotbeafter
theendofthereportingperiod
YES,"NO"-blankwilldefaultto
NO
1-TobaccoFree,"2"-Current
TobaccoUser,"3"-No
Documentation(BLANKorMissing
valuewilldefaulttoNo
Documentation)
500
MM/DD/YYYY
Page 66
Data field
statinStatus
Isthepatientcurrently
takingamoderateorhigh
intensitystatin?
nephropathyDiagnosis
Doesthepatienthavea
diagnosisofnephropathy?
aceiArbTherapy
Doesthepatienthave
evidenceoftheuseofACEI
ARBtherapy?
hypertensionDiagnosis
microalbuminDate
amputation
footExamDate
bmi
bmiDate
bmiCounseling
bmiCounselingDate
ascvd
aspirin
ascvdDate
depression
depressionDate
Doesthepatienthavea
diagnosisofhypertension?
Mostrecentnephropathy
screeningdate
Didthepatienthavea
bilateralamputation?
Mostrecentfootexamdate
MostrecentBodyMass
Index
DateofmostrecentBody
MassIndex(BMI)
Calculation-ifany
Didthepatientreceive
BMI/NutritionCounseling?
DateofBMI/Nutrition
Counseling-ifany
Wasthepatientassessedon
their10yearASCVDrisk?
Wasaspirinprescribedif10
yearASCVDrisk>10%?
DateofmostrecentASCVD
riskassessment.
Didthepatientreceive
Depressionscreening?
Dateofmostrecent
Depressionscreening?
Acceptable Data Value Range
"YES","NO","NOTKNOWN"-
blankwilldefaulttoNOTKNOWN
uploading
"YES","NO","NO-Patient
Exclusionpresent","NOT
KNOWN"-blankwilldefaultto
NOTKNOWN
uploading
YES,"NO"-blankwilldefaultto
NO
Numericvaluebetween15.0and
50.0
MM/DD/YYYY
"YES"or"NO"(BLANKorMissing
valuewilldefaultto"NO")
MM/DD/YYYY
"YES"or"NO"(BLANKorMissing
"1"-Yes,"2"-No,patienthas
documentedcontraindicationor
allergy,"3"-No,patient'srisk
<10%,"4"-No(BLANKorMissing
valuewilldefaultto"4")
MM/DD/YYYY
"YES","NO-PatientExclusion
present","NO"(BLANKorMissing
MM/DD/YYYY
Page 67
Data Validation Checks for Clinician Identifier Data Fields
Data field
Resp. Clinician
ID
(Required field)
Alphanumeric value up to
26 characters in length
(Required field)
Numeric value 10
characters in length
Alphanumeric value 9
Alphanumeric value up to
10 characters in length
NPI
DEA Number
Medical
License
Number
Clinician Last
Name
Clinician First
Name
Clinician
Middle Name
Clinician
Degree
Clinician/
Practice
Address 1
Clinician/
Practice
Address 2
Clinician/
Practice City
Clinician/
Practice State
Acceptable Data
Value Range
First letter must be “A”,
“B”, “F” or “M”.
(Required field)
Alpha value up to 50
(Required field)
(Required field)
Numeric value
(Required field)
Alphanumeric value up
to 100 characters in
length
Alphanumeric value up
to 100 characters in
length
(Required field)
(Required field)
Alpha value 2 characters
in length
Notes
Leading abbreviations like “DR” or
“Dr” must be dropped.
Generational suffixes (e.g., Sr, Jr, II,
III, etc.) should be included in the Last
Name field without any punctuation.
Suffix should be separated from the last
name by a blank (e.g., Smith Jr).
“01”, “02”, “03”, “04”
01 = M.D.
02 = D.O.
03 = N.P.
04 = P.A.
Should include the street name and
number only.
Should include additional information
such as suite, room, floor, building, etc.
U.S. Postal Service
abbreviation
representing the state of
the clinician’s or
practice’s address
Page 68
Data field
Clinician/
Practice Zip
Code
Clinician email
address
Clinician/
Practice Phone
Clinician Date
of Birth
Clinician
Gender
Clinician
Specialty
Data field
specifications
(Required field)
Numeric value 5
(#####), 9
(#########) or 10
characters (#########) in length
Example
[email protected]
Range
Notes
Must be a valid email address
Alphanumeric value
up to 30 characters in
length
Numeric value:
MM/DD/YYYY
Alpha value
The email address of the provider.
This is required if provider would
like access to their scores in the
MedConcert platform. This is only
for the provider email, if an
administrator account needs set up
this will be provided in a
supplemental file.
Area code is required.
Telephone number may be entered
with or without punctuation.
“F”, “M”, “U”
Numeric value
“01”-“29”
F = Female
M = Male
U = Unknown
01 = Allergy/Immunology
02 = Cardiology
03 = Critical Care Services
04 = Dermatology
05 = Endocrinology
06 = Gastroenterology
07 = Gen/Fam Practice
08 = Geriatric Medicine
09 = Hematology
10 = Infectious Disease
11 = Internal Medicine
12 = Nephrology
13 = Neurology
14 = Neurosurgery
15 = Obstetrics/Gynecology
16 = Occ. Medicine
17 = Oncology
18 = Ophthalmology
19 = Orthopedics
20 = Otolaryngology
21 = Pediatrics
22 = Phys/Rehab Medicine
23 = Psychiatry
24 = Psychopharmacology
25 = Pulmonary Medicine
26 = Rheumatology
27 = Surgery
28 = Urology
29 = Other – not listed
Page 69
Data field
Data field
specifications
Range
Provider_Practice
ID
(Required field)
Alphanumeric value
up to 26 characters in
length
Practice Name
(Required field)
Alpha value up to
100 characters in
length
(Required Field)
Alpha value
"I" - Individual Scoring
or "G" - Group Scoring
Alpha value
“Y”, “N”
Alpha value
“Y”, “N”
Individual_Group
Data Submission
through CCHIT
/Meaningful Use
certified System
Full Patient Panel
Notes
The practice ID is the unique identifier for the
practice. This is how the practices and users
are assigned to a network.
Flag to say whether the provider is
submitting as an individual or group for
scoring.
Y = Yes
N = No
Blank fields will default to “N”.
Y = Yes
N = No
Blank fields will default to “N”.
Page 70

Diabetes Care Recognition Program Guide

Transcription

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