Quality
P
Apr 1, 2021

Hints for HEDIS® (and more)

BCBSRI is committed to making it easier for your practice to be successful in all areas of quality improvement. Together, we can achieve our shared goal of improving health outcomes by identifying and addressing open care gaps.

 

Hints for HEDIS® (and more) is a reference tool developed to explore various quality topics, including:

  • Definitions, specifications, and exclusions of the many quality measures;
  • Billing codes used to report gap closure;
  • Collection and reporting methodologies; and
  • Tips and best practices to maximize gap closure.

 

Comprehensive diabetes care

Population: Members age 18-75 with diabetes (type 1 and type 2)

Measurement period: DOS between January 1, 2021 - December 31, 2021

Lines of business: Medicare Advantage (eye exam, A1c, and nephropathy screen), and

 commercial adult (eye exam and A1c)

Exclusions: Members who do not have a diabetes diagnosis and have a diagnosis of polycystic ovarian syndrome, gestational diabetes, or steroid-induced diabetes.

Eye exam

Measure specifications:

Members age 18-75 with diabetes (type 1 and type 2) who had an eye screening for diabetic retinal disease. This includes diabetics who had one of the following:

  • A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in 2021.
  • A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in 2020.
  • Bilateral eye enucleation any time during the member’s history through December 31, 2021.
     
    Workflow and best practices:
  • Ask all diabetic members if they have had an eye exam in the last year.
    • If yes, ask where the exam was performed and request a copy for the PCP records.
    • If no, refer to an eye care professional.
  • Follow up with eye doctor practices to ensure that retinopathy screening reports are communicated back to the PCP office.

 

CPT Category II Codes to identify diabetic retinal screening with an eye care professional:

  • 2022F – Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed during the measurement year; with evidence of retinopathy.
  • 2023F – Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed during the year prior to the measurement year; without evidence of retinopathy.
  • 2024F – Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy.
  • 2025F – Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy.
  • 2026F – Eye imaging validated to match diagnosis from seven standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy.
  • 2033F – Eye imaging validated to match diagnosis from seven standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy.

 

CPT Category II Code to identify diabetic retinal screenings negative for retinopathy

  • 3072F – Low risk for retinopathy (no evidence of retinopathy in the prior year.)       

 

Hemoglobin A1c

Measure specifications:

Members age 18-75 with diabetes (type 1 and type 2) whose A1c was documented using the values below by the end of 2021.

  • Commercial Adult CDC A1c – less than or equal to 8.
  • Medicare Advantage – less than or equal to 9.

 

Workflow and best practices:

  • Check A1c for all diabetic members at a minimum annually. If elevated, counsel the member and rescreen in approximately three months.
  • Code result value using CPT Cat II codes as listed below.
  • If you use a lab feed, ensure that the gaps are closing appropriately.
  • All lab values should be documented regardless of whether the gap in care is closed, as these codes provide valuable quality information.
  •  

CPT Category II Codes to identify hemoglobin A1c levels:

  • 3044F – A1c level less than 7.0.
  • 3051F – A1c level greater than or equal to 7.0 and less than 8.0.
  • 3052F – A1c level greater than or equal to 8.0 and less than or equal to 9.0.
  • 3046F – A1c level greater than 9.0.   

 

Nephropathy screening – Medicare Advantage members only

Measure specifications:

Members age 18-75 with diabetes (type 1 and type 2) who had a nephropathy screening test or evidence of nephropathy during 2021. This includes members who had one of the following:

  • A urine test for albumin or protein including:
    • 24-hour urine for albumin or protein
    • Timed urine for albumin or protein
    • Spot urine (e.g. urine dipstick or test strip) for albumin or protein]
    • Urine for albumin/creatinine ratio
    • 24-hour urine for total protein
    • Random urine for protein/creatinine ratio

•     Evidence of treatment for nephropathy or ACE/ARB therapy

•     Evidence of stage 4 chronic kidney disease

•     Evidence of end-stage renal disease or dialysis

•     Evidence of nephrectomy or kidney transplant

•     A visit with a nephrologist (no restriction on the diagnosis or procedure code submitted)

  • At least one ACE inhibitor or ARB dispensing event

 

Workflow and best practices:

  • Check urine albumin at least annually.
  • Document if member is being treated for nephropathy or is prescribed an ACE/ARB medication.
    • Document members at stage 4 chronic kidney disease, or with ESRD or dialysis.
    • Document members seen by nephrologist.
    • Document nephrectomy or kidney transplant where appropriate.

Codes:

  • Code to identify stage 4 chronic kidney disease: ICD-10 CM Code: N18.4
  • Code to identify ESRD: ICD-10 CM Codes: N18.5, N18.6, Z99.2
  • Nephropathy screening:
    • CPT Codes: 8100 – 81005, 82042 – 82044, 84156
    • CPT Category II Codes: 3060F, 3061F, 3062F
  • Nephropathy treatment:
    • CPT Category II Codes: 3066F, 4010F
    • ICD-10 CM Codes: E08.21, E08.22, E08.29, E09.21, E09.22, E09.29, E10.21, E10.22, E10.29, E11.21, E11.22, E11.29, E13.21, E13.22, E13.29, I12.0, I12.9, I13.0, I13.10, I13.11, I13.2, I15.0, I15.1, N00.0 – N08, N14.0 – N14.4, N17.0 – N19, N25.0 – N25.9, N26.1 – N26.9, Q60.0 – Q60.6, Q61.00 – Q61.02, Q61.11, Q61.19, Q61.2 – Q61.9, R80.0 – R80.9

 

Our Quality Concierge Team (QCT) is also available to answer questions, provide updates, assist in the interpretation of monthly gap in care reports, and provide overall HEDIS support to you and your practice. Reach our QCT nurses at QualityHEDIS@bcbsri.org or (401) 459-1005.

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