Discussion: Applying Measurement Tools One example of a measurement tool is the Healthcare Effectiveness Data and Information Set (HEDIS) comprehensive care measures.

Diabetes Care Measure DefinitionThe CDC measure evaluates 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) • Eye exam (retinal) performed • BP control (<140/90 mm Hg) • Medical Attention for Nephropathy (Medicare) We are committed to working with you to improve the quality of care and health outcomes for your patients, our members. The Healthcare Effectiveness Data and Information Set (HEDIS ®) tool is used to measure many aspects of performance. This tip sheet details some of the key features of the HEDIS® measures for Diabetes Care. In HEDIS 2021 there are two diabetes measures Comprehensive Diabetes Care (CDC) and Kidney Evaluation for Diabetic Patients (KED). HEDIS ® 2021 (MY 2020) Lines of Business Commercial, Medicaid, Medicare HEDIS 2021 Updates• Added Kidney Health Evaluation for Patients with Diabetes (KED) • Retired the “Medical Attention for Nephropathy” indicator for the commercial and Medicaid product lines.

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• Added telephone visits, e-visits and virtual check-ins to the Administrative Specification as appropriate settings for BP readings.

• Clarified that eye exam results read by a system that provides an artificial intelligence (AI) interpretation meet criteria.

• Removed the requirements for remote monitoring devices to allow BPs taken by any digital device.

• Removed the exclusion of BP readings reported or taken by the member.

Required Documentation • Claim/encounter data • Pharmacy data • Medical Record documentation may also count toward documentation.

Exclusions • Members who use hospice services or elect to use a hospice benefit, regardless of when the services began in the measurement year.

• End Stage Renal Disease or Kidney Transplant.

• Female patients with a diagnosis of pregnancy during the measurement year.

• Patients 66-80 yrs. and older with both advanced illness criteria and frailty diagnosis. • Patients 81 yrs. and older with a frailty diagnosis. Hemoglobin A1c (HbA1c) The most recent HgbA1c value < 9%. Medical record must include a note with date when HbA1c test was done with a distinct numeric result.

Retinal Eye Exam Screening or monitoring 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.

• A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year.

• Bilateral eye enucleation any time during the member’s history through December 31 of the measurement year.

BP Control (<140/90 mm Hg) Most recent BP reading for members 18-75 taken during an outpatient visit, non-acute encounter or remote monitoring event during the measurement year.

Medical Attention for Nephropathy (Medicare) • This measure evaluates nephropathy screening, monitoring, or evidence of nephropathy during the measurement year for Medicare members 18-75 years of age.

• Key Change for MY 2020: Medical Attention for Nephropathy is retired from the CDC measure for Commercial and Medicaid lines of business. Kidney Health Evaluation for Patients with Diabetes (KED) KED is the percentage of members 18-85 years of age with diabetes (type 1 and type 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a urine albumin-creatinine ration (uACR).

Best Practices:

Improving HEDIS Scores • Check the EMR for open care gaps.

• Work with your PHW Provider Relations Representative to understand your CDC metrics and how to address care gaps.

• Make sure digital eye exam, remote imaging and fundus photography are read by an eye care professional (optometrist or ophthalmologist) so the results count.

• Schedule virtual or telephone visits for members who are nervous about coming in to the office. Patients may now report BP readings remotely with a digital device.

• Order HbA1C and Nephropathy labs for diabetic members prior to their appointments and record the value. OutpatientCPT: 99201-99205, 99211-99215, 99241-99245 HCPCS: G0402, G0438, G0439, G0463, T1015 Non-Acute Inpatient CPT: 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337 Remote BP Monitoring CPT: 93784, 93788, 93790, 99091 Diastolic 80-89 CPT-CAT-II: 3079F Diastolic Greater than/ Equal to 90 CPT-CAT-II: 3080F Diastolic Less than 80 CPT-CAT-II: 3078F Systolic Greater than/ Equal to 140 CPT-CAT-II: 3077F Stystolic Less than 140 CPT-CAT-II: 3074F, 3075F Diabetic Retinal Screening with an Eye Care Professional CPT-CAT-II: 2022F, 2024F, 2026F Unilateral Eye Enucleation with a Bilateral Modifier CPT: 65091, 65093, 65101, 65103, 65105, 65110, 65112, 65114 CPT Modifier: 50 HbA1c CPT: 83036, 83037 CPT-CAT-II: 3044F, 3045F, 3046F Urine Protein Tests CPT: 81000-81003, 81005, 82042-82044, 84156 CPT-CAT-II: 3060F, 3061F, 3062F Nephropathy Treatment CPT-CAT-II: 3066F, 4010F Common Codes* Description Codes *codes subject to change

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