Diabetes Care Recognition Program Guide
Transcription
Diabetes Care Recognition Program Guide
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 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 1 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 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 2 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 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 3 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. 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 4 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. 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 5 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 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 6 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. 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 7 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. 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 8 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] 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 9 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”. 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 10 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. 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 11 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 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 12 Hemoglobin A1C Measurement: Description: Percentage of diabetic patients age 18-75 who have had their hemoglobin A1C measured twice annually. 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 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 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 13 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: 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 LDL-C test information for the numerator. 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 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 14 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 2. Patient self-reporting 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 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 15 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: 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 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. 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 16 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 3. Patient self-reporting 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 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 17 Blood Pressure Measurement: Description: Percentage of diabetic patients age 18-75 who have had their blood pressure measured twice annually. 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 or 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: American Diabetes Association (ADA) 2015 guidelines recommend that all 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. (Numerator/Denominator) * Max Points Scoring: Source and Level of Evidence: ADA, Level B 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 18 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: 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 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. 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 19 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: (Numerator/Denominator) * Total Points Possible = Points awarded Source and Level of Evidence: ADA, Level B 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 20 Podiatry Examination: Description: Percentage of patients aged 18 through 75 years with diabetes who had a diabetic foot exam performed. 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 claims/encounter and medical record data for foot exam information for the numerator. 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 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 21 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 3. Patient self-reporting 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: (Numerator/Denominator) * Total Points Possible = Points awarded Source and Level of Evidence: ADA, Level B 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 22 Ophthalmologic Examination: Description: Percentage of patients aged 18 through 75 years with diabetes who had an eyescreening exam for diabetic retinal disease. 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 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 codes to identify patients with diabetes. . 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 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 23 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 5. Patient self-reporting 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: (Numerator/Denominator) * Total Points Possible = Points awarded Source and Level of Evidence: ADA, Level B 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 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: 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 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; 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 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 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 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: 1. Patient self-reporting Frequency: If patient with diagnosis of or medical treatment for nephropathy: during patient lifetime. Scoring: (Numerator/Denominator) * Total Points Possible = Points awarded Source and Level of Evidence: ADA, Level B 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 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: 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 or 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: American Diabetes Association (ADA) 2015 guidelines recommend that all 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 codes to identify patients with diabetes. 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 Source and Level of Evidence: ADA, Level B 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 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: 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 claims/encounter and medical record data for BMI information for the numerator. 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. 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 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: 1. Patient self-reporting 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: (Numerator/Denominator) * Total Points Possible = Points awarded Source and Level of Evidence: ADA, Level A 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 30 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: 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 or 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: 1. Patient self-reporting 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 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 31 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: 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 or 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 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 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: 1. Patient self-reporting 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 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 33 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 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 34 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: 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 or 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 information on codes to identify patients with diabetes. 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: (Numerator/Denominator) * Max Points Source and Level of Evidence: ADA, Level B 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 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 information on codes to identify patients with diabetes. 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. 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 36 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 stated as uncontrolled 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 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 37 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 stated as uncontrolled Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled Copyright © 2009-2016 Health Care Incentives Improvement Institute, Inc. 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Page 38 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 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 39 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 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 40 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 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 41 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 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 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. Office or other outpatient visit for the evaluation and management of a new patient, 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. Office or other outpatient visit for the evaluation and management of a new patient, 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. Office or other outpatient visit for the evaluation and management of a new patient, 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. Office or other outpatient visit for the evaluation and management of a new patient, 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. 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 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. Office or other outpatient visit for the evaluation and management of an 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. Office or other outpatient visit for the evaluation and management of an 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. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A 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. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of 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, 40 minutes are spent face-to-face with the patient and/or family. 99212 99213 99214 99215 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 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 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 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 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 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, which requires these 3 key components: A comprehensive history; A 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 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 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 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, 30 minutes are spent at the bedside and on the patient's hospital floor or unit. Initial hospital 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 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 moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. Initial hospital 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 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 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 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 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 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 46 Encounter Criteria Definition 99232 99238 Subsequent hospital care, per day, for the evaluation and management of a 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. Typically, 25 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 detailed interval history; A detailed 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 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 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. Emergency department visit for the evaluation and management of a 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 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. 99233 99282 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 47 Encounter Criteria 99283 99284 99285 99291 99304 Definition Emergency department visit for the evaluation and management of a patient, 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 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 severity. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and 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 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. Emergency department visit for the evaluation and management of a patient, 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 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 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. 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 48 Encounter Criteria 99305 99306 99307 99308 Definition Initial nursing facility 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 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 moderate severity. Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit. Initial nursing facility 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 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 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. Subsequent nursing facility care, per day, for the evaluation and management of a 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. 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 49 Encounter Criteria Definition 99309 99315 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 detailed interval 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 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. 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 comprehensive interval 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. 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 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 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. 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 severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. 99310 99324 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 50 Encounter Criteria Definition 99325 Domiciliary or rest home visit for the evaluation and management of a new 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 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 severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and 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, 45 minutes are spent with the patient and/or family or caregiver. Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and 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 high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A 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 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 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 51 Encounter Criteria Definition 99334 Domiciliary or rest 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. 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, 15 minutes are spent with the patient and/or family or caregiver. Domiciliary or rest home visit for the evaluation and management of an 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 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, 25 minutes are spent with the patient and/or family or caregiver. Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval 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, 40 minutes are spent with the patient and/or family or caregiver. Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to 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. 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 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 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 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 severity. Typically, 20 minutes are spent face-to-face with the patient and/or family. Home visit for the evaluation and management of a new 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 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 severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and 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, 45 minutes are spent face-to-face with the patient and/or family. Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and 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 high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. 99342 99343 99344 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 53 Encounter Criteria Definition 99345 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A 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 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. 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, 15 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: 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 presenting problem(s) are of low to moderate severity. Typically, 25 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 detailed interval 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 moderate to high severity. Typically, 40 minutes are spent face-toface with the patient and/or family. 99347 99348 99349 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 54 Encounter Criteria Definition 99350 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to 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. 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 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 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. 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 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 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 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. 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 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. 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 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 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 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 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 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 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 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 Data field specifications 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 Numericvaluebetween40and 150 MM/DD/YYYY Numericvaluebetween60and 300 Numericvaluebetween40and 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) MM/DD/YYYY-cannotbeafter theendofthereportingperiod MM/DD/YYYY-cannotbeafter theendofthereportingperiod Numericvaluebetween15and 500 MM/DD/YYYY Page 66 Data field Data field specifications 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 YES,"NO","NOTKNOWN"-blank willdefaulttoNOTKNOWNand generateaWARNINGwhen uploading "YES","NO","NO-Patient Exclusionpresent","NOT KNOWN"-blankwilldefaultto NOTKNOWN YES,"NO","NOTKNOWN"-blank willdefaulttoNOTKNOWNand generateaWARNINGwhen uploading MM/DD/YYYY-cannotbeafter theendofthereportingperiod YES,"NO"-blankwilldefaultto NO MM/DD/YYYY-cannotbeafter theendofthereportingperiod Numericvaluebetween15.0and 50.0 MM/DD/YYYY "YES"or"NO"(BLANKorMissing valuewilldefaultto"NO") MM/DD/YYYY "YES"or"NO"(BLANKorMissing valuewilldefaultto"NO") "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 valuewilldefaultto"NO") MM/DD/YYYY Page 67 Data Validation Checks for Clinician Identifier Data Fields Data field Data field specifications Resp. Clinician ID (Required field) Alphanumeric value up to 26 characters in length (Required field) Numeric value 10 characters in length Alphanumeric value 9 characters in length 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 characters in length (Required field) Alpha value up to 50 characters in length Alpha value up to 30 characters in length (Required field) Numeric value (Required field) Alphanumeric value up to 100 characters in length Alphanumeric value up to 100 characters in length (Required field) Alpha value up to 100 characters in length (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] Acceptable Data Value 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 Acceptable Data Value 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