The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each of the

following:


 Hemoglobin A1c (HbA1c) testing.                 HbA1c poor control (>9.0%).

 HbA1c control (<8.0%).                                 HbA1c control (<7.0%) for a selected population*.

 Eye exam (retinal) performed.                       Medical attention for nephropathy.

 BP control (<140/90 mm Hg).


* Additional exclusion criteria are required for this indicator that will result in a different eligible population from all other indicators.

 This indicator is only reported for the commercial and Medicaid product lines.


Denominator:


Product lines:        Commercial, Medicaid, Medicare (report each product line separately).


Ages:                    18–75 years as of December 31 of the measurement year. Continuous enrollment the measurement year.


Allowable gap:      No more than one gap in enrollment of up to 45 days during the measurement year. Members from the oversample should be added to the denominator for all measure indicators. 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 (i.e., a member whose coverage lapses for 2 months [60 days]

                           is not considered continuously enrolled).


Anchor date:         December 31 of the measurement year.


Benefit:                 Medical.


Event/diagnosis:   There are two ways to identify members with diabetes: by claim/encounter data and by pharmacy data. The organization must use both methods to identify the

                              eligible population, but a member only needs to be identified by one method 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.


                             Claim/encounter data. Members who met any of the following criteria during the measurement year or the year prior to the measurement year (count services

                             that occur over both years):


 At least two outpatient visits (Outpatient Value Set), observation visits (Observation Value Set), ED visits (ED Value Set) or nonacute inpatient encounters (Nonacute Inpatient Value Set) on different dates of service, with a diagnosis of diabetes (Diabetes Value Set). Visit type need not be the same for the two visits.

At least one acute inpatient encounter (Acute Inpatient Value Set) with a diagnosis of diabetes (Diabetes Value Set).


                           Pharmacy data. Members who were dispensed insulin or hypoglycemics/ antihyperglycemics on an ambulatory basis during the measurement year or the year

                           prior to the measurement year (Table CDC-A).


Exclusions:


Note: If an organization reports this measure using the Hybrid method, and a member is found to be in hospice or using hospice services during medical record review, the member is removed from the sample and replaced by a member from the over sample. Refer to General Guideline 20: Members in Hospice.

Exclude members who meet any of the following criteria:


 65 years of age and older as of December 31 of the measurement year.  CABG. Members who had CABG (CABG Value Set) in any setting during the measurement year or the     year prior to the measurement year.

 PCI. Members who had PCI (PCI Value Set), in any setting, during the  measurement year or the year prior to the measurement year.

 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 (Outpatient Value Set) with an IVD diagnosis (IVD Value Set).

– At least one acute inpatient encounter (Acute Inpatient Value Set) with an IVD diagnosis (IVD Value Set). Thoracic aortic aneurysm. 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 (Outpatient Value Set), with a diagnosis of thoracic aortic aneurysm (Thoracic Aortic Aneurysm Value Set).

– At least one acute inpatient encounter (Acute Inpatient Value Set), with a diagnosis of thoracic aortic aneurysm (Thoracic Aortic Aneurysm Value Set). Any of the following, in any     setting, any time during the member’s history

    through December 31 of the measurement year.

– Chronic heart failure. A diagnosis of chronic heart failure (Chronic Heart Failure Value Set).

– Prior MI. A diagnosis of MI (MI Value Set).

– ESRD. ESRD (ESRD Value Set; ESRD Obsolete Value Set).

– Chronic kidney disease (stage 4). Stage 4 chronic kidney disease (CKD


Stage 4 Value Set).


– Dementia. A diagnosis of dementia (Dementia Value Set;    Frontotemporal Dementia Value Set).

– Blindness. A diagnosis of blindness (Blindness Value Set).

– Amputation (lower extremity). Lower extremity amputation (Lower Extremity Amputation Value Set).


Numerator:

HbA1c Testing

An HbA1c test (HbA1c Tests Value Set) performed during the measurement year, as identified by claim/encounter or automated laboratory data.

HbA1c Poor Control >9%

Use codes in the HbA1c Tests Value Set to identify the most recent HbA1c test during the measurement year. The member is numerator compliant if the most recent HbA1c level is >9.0% or is missing a result, or if an HbA1c test was not done during the measurement year. The member is not numerator compliant if the result for the most recent HbA1c test during the measurement year is ≤9.0%.

Organizations that use CPT Category II codes to identify numerator compliance for this indicator must search for all codes in the following value sets and use the most recent code during the measurement year to evaluate whether the member is numerator compliant.
Value Set
Numerator Compliance
HbA1c Level Less Than 7.0 Value Set

Not compliant

HbA1c Level 7.0–9.0 Value Set

Not compliant

HbA1c Level Greater Than 9.0 Value Set

Compliant

 

Note: A lower rate indicates better performance for this indicator (i.e., low rates of poor control indicate better care).

HbA1c Control <8%

Use codes in the HbA1c Tests Value Set to identify the most recent HbA1c test during the measurement year. The member is numerator compliant if the most recent HbA1c level is <8.0%. The member is not numerator compliant if the result for the most recent HbA1c test is ≥8.0% or is missing a result, or if an HbA1c test was not done during the measurement year.
Organizations that use CPT Category II codes to identify numerator compliance for this indicator must search for all codes in the following value sets and use the most recent code during the measurement year to evaluate whether the member is numerator compliant.

 

Value Set
Numerator Compliance
HbA1c Level Less Than 7.0 Value Set

Compliant

HbA1c Level 7.0–9.0 Value Set

Not compliant*

HbA1c Level Greater Than 9.0 Value Set

Not compliant

The CPT Category II code (3045F) in this value set indicates most recent HbA1c (HbA1c) level 7.0%–9.0% and is 

not specific enough to denote numerator compliance for this indicator. For members with this code, the organization 

must  use other sources (laboratory data, hybrid reporting method) to identify the actual value and determine if the 

HbA1c result was <8%. Because providers assign the Category II code after reviewing test results, the date of 

service for the Category II code may not match the date of service for the HbA1c test found in other sources; if dates 

differ, use the date of service when the test was performed. The date of service for the Category II code and the test 

result must follow the requirements outlined in General Guideline 36 (i.e., the dates of service for the code and the 

test result must be no more than seven days apart).


HbA1c Control <7% for a Selected Population 

Use codes in the HbA1c Tests Value Set to identify the most recent HbA1c test during the measurement year. The member is numerator compliant if the most recent HbA1c level is <7.0%. The member is not numerator compliant if the result for the most recent HbA1c test is ≥7.0% or is missing a result, or if an HbA1c test was not performed during the measurement year.

Organizations that use CPT Category II codes to identify numerator compliance for this indicator must search for all codes in the following value sets and use the most recent code during the measurement year to evaluate whether the member is numerator compliant.
Value Set
Numerator Compliance
HbA1c Level Less Than 7.0 Value Set

Compliant

HbA1c Level 7.0–9.0 Value Set

Not compliant

HbA1c Level Greater Than 9.0 Value Set

Not compliant

 

Note: This indicator uses the eligible population with additional eligible population criteria (e.g., removing members with required exclusions).

Eye Exam

Screening or monitoring for diabetic retinal disease as identified by administrative data. This includes diabetics who had one of the following:
  • A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year.
  • A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year.Any of the following meet criteria:
Any code in the Diabetic Retinal Screening Value Set billed by an eye care professional (optometrist or ophthalmologist) during the measurement year.
  • Any code in the Diabetic Retinal Screening Value Set billed by an eye care professional (optometrist or ophthalmologist) during the year prior to the measurement year, with a negative result (negative for retinopathy).
  • Any code in the Diabetic Retinal Screening Value Set billed by an eye care professional (optometrist or ophthalmologist) during the year prior to the measurement year, with a diagnosis of diabetes without complications (Diabetes Mellitus Without Complications Value Set). All codes must be on the same claim.Any code in the Diabetic Retinal Screening With Eye Care Professional Value Set billed by any provider type during the measurement year.
  • Any code in the Diabetic Retinal Screening With Eye Care Professional Value Set billed by any provider type during the year prior to the measurement year, with a negative result (negative for retinopathy).Any code in the Diabetic Retinal Screening Negative Value Set billed by any provider type during the measurement year.