Comprehensive Diabetes Care
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Comprehensive Diabetes Care CDC
Description
The percentage of members 1875 years of age with diabetes type 1 and type 2 who had each of the following Hemoglobin A1c HbA1c testing HbA1c poor control 90 HbA1c control 80 first-year indicator HbA1c control 70 first-year indicator Eye exam retinal performed LDL-C screening LDL-C control 100 mg/dL Medical attention for nephropathy Blood pressure control 130/80 mm Hg Blood pressure control 140/90 mm Hg
Additional exclusion criteria are required for this indicator
Eligible Population
Product lines Ages Continuous enrollment Allowable gap Commercial, Medicaid, Medicare report each product line separately 1875 years as of December 31 of the measurement year The measurement year No more than one gap in enrollment of up to 45 days during the measurement year To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage ie, a member whose coverage lapses for 2 months [60 days] is not considered continuously enrolled December 31 of the measurement year Medical Two methods identify members with diabetes:
pharmacy data and claim/encounter data The organization must use both to identify the eligible population, but a member only needs to be identified in one to be included in the measure Members may be identified as having diabetes during the measurement year or the year prior to the measurement year Pharmacy data Members who were dispensed insulin or oral hypoglycemics/ antihyperglycemics during the measurement year or year prior to the measurement year on an ambulatory basis Table CDC-A
Anchor date Benefit Event/diagnosis
_____________ CPT codes copyright 2008 American Medical Association All rights reserved CPT is a trademark of the AMA No fee schedules, basic units, relative values or related listings are included in CPT The AMA assumes no liability for the data contained herein Applicable FARS/DFARS restrictions apply to government use
October 1, 2008
HEDIS 2009 Volume 2 Technical Update
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Comprehensive Diabetes Care
Table CDC-A: Prescriptions to Identify Members With Diabetes
Description
Alpha-glucosidase inhibitors Amylin analogs Antidiabetic combinations
Prescription
acarbose pramlinitide glimepiride-pioglitazone glimepiride-rosiglitazone
glipizide-metformin glyburide-metformin insulin aspart insulin aspart-insulin aspart protamine insulin detemir insulin glargine insulin glulisine insulin inhalation insulin isophane beef-pork insulin isophane human insulin isophane pork insulin isophane-insulin regular nateglinide exenatide acetohexamide chlorpropamide pioglitazone
miglitol metformin-pioglitazone metformin-rosiglitazone metformin-sitagliptin
insulin lispro insulin lispro-insulin lispro protamine insulin regular beef-pork insulin regular human insulin regular pork insulin zinc beef-pork insulin zinc extended human insulin zinc human insulin zinc pork
Insulin
Meglitinides Miscellaneous antidiabetic agents Sulfonylureas Thiazolidinediones
repaglinide pramlintide glimepiride glipizide rosiglitazone
sitagliptin glyburide tolazamide
tolbutamide
Note: Glucophage/metformin is not included because it is used to treat conditions other than diabetes; members with diabetes on these medications are identified through diagnosis coding only NCQA will provide a complete list of medications and NDC codes on its Web site wwwncqaorg by November 14, 2008 Claim/encounter data Members who had two
face-to-face encounters with a diagnosis of diabetes Table CDC-B on different dates of service in an outpatient setting or nonacute inpatient setting, or one face-to-face encounter in an acute inpatient or ED setting during the measurement year or the year prior to the measurement year The organization may count services that occur over both years Refer to Table CDC-C for codes to identify visit type
Table CDC-B: Codes to Identify Diabetes
Description
Diabetes
ICD-9-CM Diagnosis
250, 3572, 3620, 36641, 6480
HEDIS 2009 Volume 2 Technical Update
October 1, 2008
Comprehensive Diabetes Care
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Table CDC-C: Codes to Identify Visit Type
Description
Outpatient
CPT
92002, 92004, 92012, 92014, 99201-99205, 9921199215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 9940199404, 99411, 99412, 99420, 99429, 99455, 99456 99301-99313, 99315, 99316, 99318, 99321-99328, 99331-99337 99221-99223, 99231-99233, 99238, 99239, 9925199255, 99261-99263, 99291 99281-99285
UB Revenue
051x, 0520-0523, 0526-0529, 057x-059x, 077x, 082x-085x, 088x, 0982, 0983
Nonacute inpatient Acute inpatient
0118, 0128, 0138, 0148, 0158, 019x, 0524, 0525, 055x, 066x 010x, 0110-0114,
0119, 0120-0124, 0129, 01300134, 0139, 0140-0144, 0149, 0150-0154, 0159, 016x, 020x-022x, 072x, 080x, 0987 045x, 0981
ED
Administrative Specification
Denominator Required exclusions for the HbA1c control 7 indicator The eligible population For the HbA1c control 7 indicator, exclude members who meet any of the following criteria 6575 years of age as of December 31 of the measurement year Coronary artery bypass graft CABG or percutaneous transluminal coronary angioplasty PTCA Members discharged alive for CABG or PTCA in the measurement year or the year prior to the measurement year Use the codes listed in Table CMC-A to identify PTCA and CABG CABG cases should be from inpatient claims only Include all cases of PTCA, regardless of setting eg, inpatient, outpatient, ED Ischemic vascular disease IVD Members who met at least one of the following criteria during both the measurement year and the year prior to the measurement year Criteria need not be the same across both years At least one outpatient visit Table CMC-C with an IVD diagnosis Table CMC-B, or At least one acute inpatient visit Table CMC-C with an IVD diagnosis Table CMC-B Chronic heart failure CHF Members who had at
least one encounter, in any setting, with any code to identify Chronic Heart Failure Table RCA-A Look as far back as possible in the members history through December 31 of the measurement year Prior myocardial infarction MI Members who had at least one encounter, in any setting, with any code to identify MI Table CDC-P Look as far back as possible in the members history through December 31 of the measurement year Chronic renal failure CRF/end-stage renal disease ESRD Members who had at least one encounter, in any setting, with any code to identify ESRD Table CDC-P Look as far back as possible in the members history through December 31 of the measurement year
_____________ Current Procedural Terminology 2008 American Medical Association All rights reserved
October 1, 2008
HEDIS 2009 Volume 2 Technical Update
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Comprehensive Diabetes Care Dementia Members who had at least one encounter, in any setting, with any code to identify dementia Table DDE-E Look as far back as possible in the members history through December 31 of the measurement year Blindness Members who had at least one encounter, in any setting, with any code to identify blindness Table CDC-P Look as far back as
possible in the members history through December 31 of the measurement year Amputation lower extremity Members who had at least one encounter, in any setting, with any code to identify lower extremity amputation Table CDC-P Look as far back as possible in the members history through December 31 of the measurement year
Table CDC-P: Codes to Identify Required Exclusions
Description
Myocardial infarction ESRD including renal dialysis 36145, 3680036821, 3683136833, 9091990921, 9092390925, 90935, 90937, 90939, 90940, 90945, 90947, 90989, 90993, 90997, 90999, 99512 G0257, G0311-G0319, G0321-G0323, G0325-G0327, G0392, G0393, S9339
CPT
HCPCS
ICD-9-CM Diagnosis
410, 412 5854, 5855, 5856, V420, V451, V56
ICD-9-CM Procedure
UB Revenue
UB Type of Bill
POS
3895, 3927, 3942, 3943, 3953, 3993, 3994, 3995, 5498
080x, 082×085x, 088x
72x
65
Blindness Amputation lower extremity 27290, 27295, 27590-27592, 27594, 27596, 27598, 27880, 27881, 27882, 27884, 27886, 27888, 27889, 28800, 28805, 28810, 28820, 28825
3690, 3691, 3692, 3694, 3696, 3697 841
Numerators HbA1c testing An HbA1c test performed during the measurement year, as identified by claim/ encounter or automated laboratory data
Use any code listed in Table CDC-D
Table CDC-D: Codes to Identify HbA1c Tests
CPT
83036, 83037
CPT Category II
3044F, 3045F, 3046F, 3047F
LOINC
4548-4, 4549-2, 17856-6
_____________ Current Procedural Terminology 2008 American Medical Association All rights reserved
HEDIS 2009 Volume 2 Technical Update
October 1, 2008
Comprehensive Diabetes Care HbA1c poor control 9 Use automated laboratory data to identify the most recent HbA1c test during the measurement year The member is numerator compliant if the most recent automated HbA1c level is 90 or is missing a result or if an HbA1c test was not done during the measurement year The member is not numerator compliant if the automated result for the most recent HbA1c test during the measurement year is 90 An organization that uses CPT Category II codes to identify numerator compliance for this indicator must search for all codes in Table CDC-E and use the most recent code during the measurement year to evaluate whether the member is numerator compliant 3046F indicates the member is numerator compliant; 3044F, 3045F, 3047F indicate the member is not numerator compliant Note: For this indicator, a lower rate indicates better
performance ie, low rates of poor control indicate better care
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Table CDC-E: Codes to Identify HbA1c Levels 9
Description
Numerator compliant HbA1c 90 Not numerator compliant HbA1c 90
CPT Category II
3046F 3044F, 3045F, 3047F
HbA1c control 8
Use automated laboratory data to identify the most recent HbA1c test during the measurement year The member is numerator compliant if the most recent automated HbA1c level is 80 The member is not numerator compliant if the automated result for the most recent HbA1c test is 80 or is missing a result, or if an HbA1c test was not done during the measurement year An organization that uses CPT Category II codes to identify numerator compliance for this indicator must search for all codes in Table CDC-Q and use the most recent code during the measurement year to evaluate whether the member is numerator compliant
Table CDC-Q: Codes to Identify HbA1c Levels 8
Description
Numerator compliant HbA1c 80 Not numerator compliant HbA1c 80
CPT Category II
3044F 3045F, 3046F, 3047F
CPT Category II code 3045F indicates most recent hemoglobin A1c HbA1c level 70 - 90 and is not specific enough to denote
numerator compliance for this indicator For
members with this code, the organization may elect to use other sources laboratory data, hybrid reporting method to determine if the HbA1c result was less than 8
CPT Category II code 3047F indicates HbA1c 9 and is not specific enough to denote numerator compliance for this indicator For members with this code, the organization may elect to use other sources laboratory data, hybrid reporting method to determine if the HbA1c result was less than 8
_____________ Current Procedural Terminology 2008 American Medical Association All rights reserved
October 1, 2008
HEDIS 2009 Volume 2 Technical Update
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Comprehensive Diabetes Care HbA1c control 7 Use automated laboratory data to identify the most recent HbA1c test during the measurement year The member is numerator compliant if the most recent automated HbA1c level is 70 The member is not numerator compliant if the automated result for the most recent HbA1c test is 70 or is missing a result, or if an HbA1c test was not done during the measurement year An organization that uses CPT Category II codes to identify numerator compliance for this indicator must search for all codes in Table CDC-F and use the most recent code during the
measurement year to evaluate whether the member is numerator compliant 3044F indicates the member is numerator compliant; 3045F, 3046F, 3047F indicate the member is not numerator compliant Note: This indicator uses the eligible population with additional eligible population criteria ie, removing members with comorbid conditions
Table CDC-F: Codes to Identify HbA1c Levels 7
Description
Numerator compliant HbA1c 70 Not numerator compliant HbA1c 70
CPT Category II
3044F 3045F, 3046F, 3047F
CPT Category II code 3047F indicates HbA1c 9 and is not specific enough to denote numerator compliance for this indicator For
members with this code, the organization may elect to use other sources laboratory data, hybrid reporting method to determine if the HbA1c result was less than 7
Eye exam
An eye screening for diabetic retinal disease as identified by administrative data This includes diabetics who had one of the following A retinal or dilated eye exam by an eye care professional optometrist or ophthalmologist in the measurement year, or A negative retinal exam no evidence of retinopathy by an eye care professional in the year prior to the measurement year Refer to Table CDC-G for
codes to identify eye exams For exams performed in the year prior to the measurement year, a result must be available
Table CDC-G: Codes to Identify Eye Exams
CPT
67028, 67030, 67031, 67036, 67038-67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92225, 92226, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245
CPT Category II
2022F, 2024F, 2026F, 3072F
HCPCS
S0620, S0621, S0625, S3000
ICD-9-CM Diagnosis
V720
ICD-9-CM Procedure
141-145, 149, 9502-9504, 9511, 9512, 9516
determine that a dilated exam was performed The organization does not need to limit CPT Category II codes or HCPCS S0625 to an optometrist or an ophthalmologist These codes indicate an eye exam was performed by an eye care professional CPT Category II code 3072F can only be used if the claim/encounter was during the measurement year because it indicates the member had no evidence of retinopathy in the prior year Additionally, because the code definition itself indicates results were negative, an automated result is not required
_____________ Current Procedural Terminology
2008 American Medical Association All rights reserved
Eye exams provided by eye care professionals are a proxy for dilated eye examinations because there is no administrative way to
HEDIS 2009 Volume 2 Technical Update
October 1, 2008
Comprehensive Diabetes Care LDL-C screening An LDL-C test performed during the measurement year, as identified by claim/ encounter or automated laboratory data Use any code listed in table CDC-H Organizations may use a calculated LDL for LDL-C screening and control indicators
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Table CDC-H: Codes to Identify LDL-C Screening
CPT
80061, 83700, 83701, 83704, 83721
CPT Category II
3048F, 3049F, 3050F
LOINC
2089-1, 12773-8, 13457-7, 18261-8, 18262-6, 22748-8, 24331-1, 39469-2, 49132-4
LDL-C control 100 mg/dL
Use automated laboratory data to identify the most recent LDL-C test during the measurement year The member is numerator compliant if the most recent automated LDL-C level is 100 mg/dL If the automated result for the most recent LDL-C test during the measurement year is 100 mg/dL or is missing, or if an LDL-C test was not done during the measurement year, the member is not numerator compliant An organization that uses CPT Category II codes
to identify numerator compliance for this indicator must search for all codes in Table CDC-I and use the most recent code during the measurement year to evaluate whether the member is numerator compliant Use Table CDC-I to determine compliance 3048F indicates the member is numerator compliant; 3049F, 3050F indicate the member is not numerator compliant
Table CDC-I: Codes to Identify LDL-C Levels
Description
Numerator compliant LDL-C 100 mg/dL Not numerator compliant LDL-C 100 mg/dL
CPT Category II
3048F 3049F, 3050F
Medical attention for nephropathy
A nephropathy screening test or evidence of nephropathy, as documented through administrative data Note: A process flow diagram is included at the end of this specification to help implement this specification A nephropathy screening test during the measurement year Table CDC-J
Nephropathy screening test
Table CDC-J: Codes to Identify Nephropathy Screening Tests
Description
Nephropathy screening test
CPT
82042, 82043, 82044, 84156
CPT Category II
3060F, 3061F
LOINC
1753-3, 1754-1, 1755-8, 1757-4, 2887-8, 2888-6, 2889-4, 2890-2, 9318-7, 11218-5, 12842-1, 13801-6, 14956-7, 149575, 14958-3, 14959-1, 13705-9, 14585-4, 18373-1,
20621-9, 21059-1, 21482-5, 26801-1, 27298-9, 30000-4, 30001-2, 30003-8, 32209-9, 32294-1, 32551-4, 34366-5, 34535-5, 35663-4, 40486-3, 40662-9, 40663-7, 43605-5, 43606-3, 43607-1, 44292-1
_____________ Current Procedural Terminology 2008 American Medical Association All rights reserved
October 1, 2008
HEDIS 2009 Volume 2 Technical Update
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Comprehensive Diabetes Care Evidence of nephropathy Any of the following meet criteria for evidence of nephropathy A claim/encounter with a code to indicate evidence of treatment for nephropathy Table CDC-K during the measurement year A nephrologist visit during the measurement year, as identified by the organizations specialty provider codes no restriction on the Diagnosis or Procedural code submitted A positive urine macroalbumin test in the measurement year, as documented by claim/encounter or automated laboratory data Refer to Table CDC-K for codes to identify urine macroalbumin tests Trace urine macroalbumin test results are not considered numerator compliant Evidence of ACE inhibitor/ARB therapy during the measurement year Members who had a claim indicating therapy Table CDC-K or received an ambulatory prescription or were
dispensed an ambulatory prescription for ACE inhibitors or ARBs during the measurement year are compliant Table CDC-L lists the ACE inhibitors/ARBs included in this measure
HEDIS 2009 Volume 2 Technical Update
October 1, 2008
Comprehensive Diabetes Care
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Table CDC-K: Codes to Identify Evidence of Nephropathy
Description
Urine macroalbumin test
CPT
81000-81003, 81005
CPT Category II
3062F
HCPCS
ICD-9-CM Diagnosis
ICD-9-CM Procedure
UB Revenue
UB Type of Bill
POS
LOINC
5804-0, 20454-5, 24356-8, 24357-6
Evidence of treatment for nephropathy
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
3066F
G0257, G0314G0319, G0322, G0323, G0326, G0327, G0392, G0393, S9339
2504, 403, 404, 40501, 40511, 40591, 580-588, 7530, 7531, 7910, V420, V451, V56
3895, 3927, 3942, 3943, 3953, 39933995, 5498, 554-556
0367, 080x, 082x-085x, 088x
72x
65
ACE inhibitor/ ARB therapy
4009F
A CPT Category II code indicates a positive result for urine macroalbumin; the organization must use automated laboratory data to confirm a
positive result for tests identified by CPT or LOINC codes
Table CDC-L: ACE Inhibitors/ARBs
Description
Angiotensin converting enzyme inhibitors Angiotensin II inhibitors Antihypertensive combinations
benazepril captopril candesartan eprosartan
enalapril fosinopril irbesartan losartan
amlodipine-benazepril benazepril-hydrochlorothiazide candesartan-hydrochlorothiazide captopril-hydrochlorothiazide enalapril-hydrochlorothiazide eprosartan-hydrochlorothiazide
Prescription perindopril quinapril olmesartan valsartan
lisinopril moexipril telmisartan fosinopril-hydrochlorothiazide hydrochlorothiazide-irbesartan hydrochlorothiazide-lisinopril hydrochlorothiazide-losartan hydrochlorothiazide-moexipril hydrochlorothiazide-olmesartan
ramipril trandolaprilt
hydrochlorothiazide-quinapril hydrochlorothiazide-telmisartan hydrochlorothiazide-valsartan trandolapril-verapamil
Note: NCQA will provide a comprehensive list of medications and NDC codes on its Web site wwwncqaorg by November 14, 2008
_____________ Current Procedural Terminology 2008 American Medical Association All rights reserved
October 1, 2008
HEDIS 2009 Volume 2 Technical
Update
10
Comprehensive Diabetes Care Blood pressure control 130/80 mm Hg Use automated data to identify the most recent BP reading during the measurement year The member is numerator compliant if the BP is 130/80 mm Hg The member is not compliant if the BP is 130/80 mm Hg or if there is no automated BP reading during the measurement year If there are multiple BPs on the same date of service, use the lowest systolic and lowest diastolic BP on that date as the representative BP An organization that uses CPT Category II codes to identify numerator compliance for this indicator must search for all codes in Table CDC-M and use the most recent codes during the measurement year to evaluate whether the member is numerator compliant for both systolic and diastolic levels
Table CDC-M: Codes to Identify Systolic and Diastolic BP Levels 130/80
Description
Numerator compliant BP 130/80 mm Hg Not numerator compliant BP 130/80 mm Hg 3074F 3075F, 3077F
CPT Category II Systolic Diastolic
3078F 3079F, 3080F
Blood pressure control 140/90 mm Hg
Use automated data to identify the most recent BP reading during the measurement year Refer to Table CDC-N and use the most recent code to evaluate
whether the member is numerator compliant The member is numerator compliant if the BP is 140/90 mm Hg The member is not compliant if the BP is 140/90 mm Hg or if there is no automated BP reading during the measurement year If there are multiple BPs on the same date of service, use the lowest systolic and lowest diastolic BP on that date as the representative BP An organization that uses CPT Category II codes to identify numerator compliance for this indicator must search for all codes in Table CDC-N and use the most recent codes during the measurement year to evaluate whether the member is numerator compliant for both systolic and diastolic levels
Table CDC-N: Codes to Identify Systolic and Diastolic BP Levels 140/90
Description
Numerator compliant BP 140/90 mm Hg Not numerator compliant BP 140/90 mm Hg 3077F
CPT Category II Systolic Diastolic
3074F, 3075F, 3076F 3078F, 3079F 3080F
_____________ Current Procedural Terminology 2008 American Medical Association All rights reserved
HEDIS 2009 Volume 2 Technical Update
October 1, 2008
Comprehensive Diabetes Care
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Hybrid Specification
Denominator A systematic sample of 548 drawn from the eligible population for each product
line A sample size of 548 is based on the goal of achieving a sample of at least 411 for the HbA1c 7 denominator after required exclusions Members who meet the required exclusion criteria for the HbA1c 7 indicator should not be substituted with members from the oversample These members will only be excluded when reporting the denominator for the HbA1c 7 indicator In other words, organizations should report the FSS for the HbA1c 7 indicator as 548 minus the required exclusions Required exclusions for the HbA1c control 7 indicator Administrative Medical record For the HbA1c control 7 indicator, exclude members who meet any of the following criteria
Refer to the Administrative Specification to identify required exclusions from administrative data For the HbA1c control 7 indicator, exclude members who meet any of the following criteria 6575 years of age as of December 31 of the measurement year CABG or PTCA Dated documentation of CABG or PTCA in the measurement year or the year prior to the measurement year IVD Documentation of an IVD diagnosis Look as far back as possible in the members history through December 31 of the measurement year Appropriate diagnoses include: IVD
Ischemic heart disease Angina Coronary atherosclerosis Coronary artery occlusion Cardiovascular disease Occlusion or stenosis of precerebral arteries including basilar, carotid and vertebral arteries Atherosclerosis of renal artery Atherosclerosis of native arteries of the extremities Chronic total occlusion of artery of the extremities Arterial embolism and thrombosis Atheroembolism CHF Documentation of CHF diagnosis Look as far back as possible in the members history through December 31 of the measurement year Prior MI Documentation of prior MI Look as far back as possible in the members history through December 31 of the measurement year CRF/ESRD Documentation of CRF or ESRD Look as far back as possible in the members history through December 31 of the measurement year Dementia Documentation of dementia Look as far back as possible in the members history through December 31 of the measurement year
October 1, 2008
HEDIS 2009 Volume 2 Technical Update
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Comprehensive Diabetes Care Blindness Documentation of blindness in one or both eyes Look as far back as possible in the members history through December 31 of the measurement year Amputation lower extremity
Documentation of lower extremity amputation Look as far back as possible in the members history through December 31 of the measurement year Numerators HbA1c testing Administrative Medical record An HbA1c test performed during the measurement year as identified by administrative data or medical record review Refer to the Administrative Specification to identify positive numerator hits from administrative data At a minimum, documentation in the medical record must include a note indicating the date on which the HbA1c test was performed and the result The organization may count notation of the following in the medical record A1c HbA1c HbA1c poor control 9 Hemoglobin A1c Glycohemoglobin A1c HgbA1c
The most recent HbA1c level performed during the measurement year is 90 or is missing or was not done during the measurement year, as documented through automated laboratory data or medical record review Note: For this indicator, a lower rate indicates better performance ie, low rates of poor control indicate better care
Administrative Medical record HbA1c control 8 Administrative Medical record HbA1c control 7
Refer to the Administrative Specification to identify positive numerator
hits from administrative data At a minimum, documentation in the medical record must include a note indicating the date on which the HbA1c test was performed and the result The most recent HbA1c level performed during the measurement year is 80 as identified by automated laboratory data or medical record review Refer to the Administrative Specification to identify positive numerator hits from administrative data At a minimum, documentation in medical record must include a note indicating the date on which the HbA1c test was performed and the result The most recent HbA1c level performed during the measurement year is 70 as identified by automated laboratory data or medical record review Note: This indicator uses the eligible population with additional eligible population criteria ie, removing members with comorbid conditions
Administrative Medical record
Refer to the Administrative Specification to identify positive numerator hits from administrative data At a minimum, documentation in medical record must include a note indicating the date on which the HbA1c test was performed and the result
HEDIS 2009 Volume 2 Technical Update
October 1, 2008
Comprehensive Diabetes Care Eye
exam An eye screening for diabetic retinal disease as identified by administrative data or medical record review This includes diabetics who had one of the following A retinal or dilated eye exam by an eye care professional optometrist or ophthalmologist in the measurement year, or A negative retinal exam no evidence of retinopathy by an eye care professional in the year prior to the measurement year Administrative Medical record Refer to the Administrative Specification to identify positive numerator hits from administrative data At a minimum, documentation in the medical record must include one of the following A note or letter prepared by an ophthalmologist, optometrist, PCP or other health care professional indicating that an ophthalmoscopic exam was completed by an eye care professional, the date on which the procedure was performed and the results, or
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A chart or photograph of retinal abnormalities indicating the date on which the fundus photography was performed and evidence that an eye care professional reviewed the results Alternatively, results may be read by a qualified reading center that operates under the direction of a medical director who is a retinal
specialist LDL-C screening Administrative Medical record An LDL-C test performed during the measurement year as identified by claim/ encounter or automated laboratory data or medical record review Refer to the Administrative Specification to identify positive numerator hits from administrative data 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 The organization may use a calculated LDL for LDL-C screening and control indicators The most recent LDL-C level performed during the measurement year is 100 mg/dL, as documented through automated laboratory data or medical record review Refer to the Administrative Specification to identify positive numerator hits from administrative data Documentation in medical record must include, at a minimum, a note indicating the date on which the LDL-C test was performed and the result The organization may calculate LDL-C levels 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 lipoprotein a is measured, use the following calculation LDL-C total
cholesterol HDL triglycerides/5 03 [lipoprotein a] These formulae are used when all levels are expressed in mg/dL and cannot be used if triglycerides 400 mg/dL
LDL-C control 100 mg/dL Administrative Medical record
October 1, 2008
HEDIS 2009 Volume 2 Technical Update
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Comprehensive Diabetes Care Medical attention for nephropathy A nephropathy screening test during the measurement year or evidence of nephropathy during the measurement year as documented through either administrative data or medical record review Note: A process flow diagram is included at the end of this specification to help implement this specification Administrative Medical record Refer to the Administrative Specification to identify positive numerator hits from administrative data Nephropathy screening test At a minimum, documentation must include a note indicating the date on which a urine microalbumin test was performed, and the result Any of the following meet criteria for a urine microalbumin test 24-hour urine for microalbumin Timed urine for microalbumin Spot urine for microalbumin Urine for microalbumin/creatinine ratio 24-hour urine for total protein Random urine for protein/creatinine
ratio Evidence of nephropathy Any of the following meet criteria for evidence of nephropathy Documentation of a visit to a nephrologist Documentation of medical attention for any of the following no restriction on provider type Diabetic nephropathy ESRD CRF Chronic kidney disease CKD Renal insufficiency Proteinuria Albuminuria Renal dysfunction Acute renal failure ARF Dialysis, hemodialysis or peritoneal dialysis A positive urine macroalbumin test At a minimum, documentation in medical record must include a note indicating the date on which the test was performed, and a positive result Any of the following meet criteria for a positive urine macroalbumin test Positive urinalysis random, spot or timed for protein Positive urine random, spot or timed for protein Positive urine dipstick for protein Positive tablet reagent for urine protein Positive result for albuminuria Positive result for macroalbuminuria Positive result for proteinuria Positive result for gross proteinuria
HEDIS 2009 Volume 2 Technical Update
October 1, 2008
Comprehensive Diabetes Care Note: Trace urine macroalbumin test results are not considered numerator compliant Evidence of ACE
inhibitor/ARB therapy Documentation in medical record must include, at minimum, a note indicating that the member received an ambulatory prescription for ACE inhibitors/ARBs within the measurement year Blood pressure control 130/80 mm Hg Blood pressure control 140/90 mm Hg Administrative Medical record Identifying the medical record The most recent BP level taken during the measurement year is 130/80 mm Hg, as documented through administrative data or medical record review The most recent BP level taken during the measurement year is 140/90 mm Hg, as documented through administrative data or medical record review Refer to the Administrative Specification to identify positive numerator hits from administrative data To determine if BP is adequately controlled, the organization must identify the representative BP following the steps below The organization should use the medical record from which it abstracts data for the other CDC indicators If the organization does not abstract for other indicators, it should use the medical record of the provider that manages the members diabetes If that medical record does not contain a BP, the organization may use the medical record of another PCP
or specialist from which the member receives care Identify the most recent BP reading notated during the measurement year Do not include BP readings that meet the following criteria BPs taken during an acute inpatient stay or an ED visit
15
Step 1
BPs taken during an outpatient visit which was for the sole purpose of having a diagnostic test or surgical procedure performed eg, sigmoidoscopy, removal of a mole BPs obtained the same day as a major diagnostic or surgical procedure eg, stress test, administration of IV contrast for a radiology procedure, endoscopy BP readings taken by the member Step 2 Identify the lowest systolic and lowest diastolic BP reading from the most recent BP 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
Exclusions optional
Members with a diagnosis of polycystic ovaries Table CDC-O who did not have any face-to-face encounters with a diagnosis of diabetes CDC-B, in any setting, during the measurement year or the year prior to the measurement year
Diagnosis can occur at any time in the members history, but must have occurred by December 31 of the measurement year Members with gestational or steroid-induced diabetes CDC-O who did not have any face-to-face encounters with a diagnosis of diabetes CDC-B, in any setting, during the measurement year or the year prior to the measurement year Diagnosis can occur during the measurement year or the year prior to the measurement year, but must have occurred by December 31 of the measurement year
October 1, 2008
HEDIS 2009 Volume 2 Technical Update
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Comprehensive Diabetes Care
Table CDC-O: Codes to Identify Exclusions
Description
Polycystic ovaries Steroid induced Gestational diabetes
ICD-9-CM Diagnosis
2564 2518, 9620 6488
Note
The organization may select data collection method Administrative vs Hybrid at the indicator level, but the method for screening and control rates must be consistent, as must the methodology for BP control indicators Blindness is not an exclusion for a diabetic eye exam because it is difficult to distinguish between individuals who are legally blind but require a retinal exam and those who are completely blind and therefore do not require an
exam
HEDIS 2009 Volume 2 Technical Update
October 1, 2008
Comprehensive Diabetes Care
17
Monitoring for Diabetic Nephropathy
Step 1 Is there documentation of ESRD, chronic or acute renal failure, renal insufficiency, diabetic nephropathy or dialysis? YES STOP Member is compliant
NO Go to Step 2
Step 2
Review for a urinalysis test that indicates a protein test was run or a dipstick was performed for gross protein macroalbuminuria in 2008
Is the test positive for 2008? NO
YES
STOP Member is compliant
Go to Step 3
Was the test done in 2008? Review for a microalbumin lab test NO
YES
STOP Member is compliant
Step 3
Go to Step 4
Step 4
Review for evidence of ACE inhibitor/ARB therapy NO STOP Member is noncompliant
Is there evidence of therapy in 2008?
YES
STOP Member is compliant
October 1, 2008
HEDIS 2009 Volume 2 Technical Update
18
Comprehensive Diabetes Care
Data Elements for Reporting
Organizations that submit HEDIS data to NCQA must provide the following data elements
Table CDC-1/2/3: Data Elements for Comprehensive Diabetes Care
Administrative
Measurement year Data collection methodology Administrative or Hybrid Eligible population Number of numerator
events by administrative data in eligible population before exclusions Current years administrative rate before exclusions Minimum required sample size MRSS or other sample size Oversampling rate Final sample size FSS Number of numerator events by administrative data in FSS Administrative rate on FSS Number of original sample records excluded because of valid data errors Number of administrative data records excluded Number of medical records excluded Number of employee/dependent medical records excluded Records added from the oversample list Denominator Numerator events by administrative data Numerator events by medical records Reported rate Lower 95 confidence interval Upper 95 confidence interval Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates
Hybrid
Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates
Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates Each of the 10 rates
HEDIS 2009 Volume 2 Technical Update
October 1, 2008
Source:aidsnutrition.org
