Diabetes is a complex chronic illness requiring ongoing patient monitoring. NCQA includes diabetes in its HEDIS® measures on which providers are rating annually. Since diabetes HbA1c testing is a key measure to assess for future medical conditions related to complications of undiagnosed diabetes, the National Commission for Quality Assurance (NCQA) requires health plans to review claims for diabetes in patient health records.  The findings contribute to health plan stars ratings for Commercial and Medicare plans and the Quality Rating System (QRS) measurement for Marketplace plans. A systematic sample of patient records is pulled annually as part of the HEDIS® medical record review to assess for documentation.

 

Which HEDIS measures are Diabetes Measures?

The diabetes measures focus on members 18-75 years of age with diabetes (type 1 and type 2) who had each of the following assessments:

 

  • Hemoglobin A1c (HbA1c) testing
  • HbA1c poor control (>9.0%)
  • HbA1c control (<8.0%)
  • Dilated Retinal exam
  • Medical attention for nephropathy

 

The American College of Physicians’ guidelines for people with type 2 diabetes recommend the desired A1c blood sugar control levels remain between 7 to 8 percent.1

In order to meet the HEDIS measure “HbA1c control <8”, you must document the date the test was performed and the corresponding result. For this reason, report one of the four Category II codes and use the date of service as the date of the test, not the date of the reporting of the Category II code.

To report most recent hemoglobin A1c level hemoglobin A1c level greater than or equal to 8.0% and less than 9.0%, use 3052F. To report most recent A1c level ≤9.0%, use codes 3044F, 3051F, 3052F.2

  1. Most recent hemoglobin A1c level less than 7.0% use 3044F
  2. Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0% use 3051F
  3. Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0% use 3052F
  4. Most recent hemoglobin A1c level greater than 9.0% use 3046F 


NOTE: Multiple dates of service may be associated with a single lab test (e.g., a collection date, a reported date and a claim date). For a laboratory test CPT II code to count toward HEDIS, the Category II date of service and the test result date must be no more than seven days apart.

Continued management and diverse pathways to care are essential in controlling blood glucose and reducing the risk of complications. While it is extremely beneficial for the patient to have continuous management, it also benefits our providers. As HEDIS rates increase, there is potential for the provider to earn maximum or additional revenue through Pay for Quality, Value Based Services, and other pay-for-performance models.3

 

Sources include:

  • Diabetes Prevalence: 2015 state diagnosed diabetes prevalence, cdc.gov/diabetes/data; 2012 state undiagnosed diabetes prevalence, Dall et al., ”The Economic Burden of Elevated Blood Glucose Levels in 2012”, Diabetes Care, December 2014, vol. 37.
  • Diabetes Incidence: 2015 state diabetes incidence rates, cdc.gov/diabetes/data
  • Cost: American Diabetes Association, “Economic Costs of Diabetes in the U.S. in 2017”, Diabetes Care, May 2018.
  • Research expenditures: 2017 NIDDK funding, projectreporter.nih.gov; 2017 CDC diabetes funding, www.cdc.gov/fundingprofiles

 

  1 https://www.medicalnewstoday.com/articles/321123#An-A1C-of-7-to-8-percent-is-recommended

  2 https://www.ama-assn.org/system/files/2020-01/cpt-cat2-codes-alpha-listing-clinical-topics.pdf

  3https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/value-based-programs.html 

 

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May 2020 Anthem Provider News - Georgia