Measure Specific Guidelines for Comprehensive Diabetes Care (CDC)

Transcription

1 Measure Specific Guidelines fr Cmprehensive Diabetes Care (CDC) Descriptin: Members age years f age with diabetes (Type 1 and Type 2)* that had all f the fllwing: *Members in hspice are excluded A. Eye Exam B. Kidney Disease Mnitring r Medical Attentin fr Nephrpathy C. Bld Sugar Cntrlled - HbA1c screening D. BP Cntrl A. Eye Exam: Screening r mnitring fr diabetic retinal disease. Requested Medical Recrd Dcumentatin: All Eye Care Cnsult Reprts/Crrespndence and/r dcumentatin f Retinal r dilated eye exam; Dcumentatin must include date f exam, results f exam and must shw exam perfrmed by a qualified eye care prfessinal (Ophthalmlgist/Optmetrist) Any Year Evidence f tw unilateral eye enucleatins r bilateral eye enucleatin anytime during the member s histry thrugh December 31, Evidence the member was in hspice Specific items that will meet cmpliance: A retinal r dilated eye exam, by a qualified eye care prfessinal, with r withut evidence f retinpathy in A nte r letter prepared by an phthalmlgist, ptmetrist, PCP r ther health care prfessinal indicating that an phthalmscpic exam was cmpleted by an eye care prfessinal (ptmetrist r phthalmlgist), the date when the prcedure was perfrmed and the results. 2. A chart r phtgraph indicating the date when the fundus phtgraphy was perfrmed and evidence that an eye care prfessinal (ptmetrist r phthalmlgist) reviewed the results. Alternatively, results may be read by a qualified reading center that perates under the directin f a medical directr wh is a retinal specialist. A negative retinal r dilated eye exam (n evidence f retinpathy) by a qualified eye care prfessinal in (Send all eye exams frm 2016 and we can determine if negative.) 1. Dcumentatin f a negative retinal r dilated exam by an eye care prfessinal (ptmetrist r phthalmlgist) in 2016, where results indicate retinpathy was nt present (e.g., dcumentatin f nrmal findings). a. Dcumentatin des nt have t state specifically n diabetic retinpathy t be cnsidered negative fr retinpathy; hwever, it must be clear that the patient had a dilated r retinal eye exam by an eye care prfessinal (ptmetrist r phthalmlgist) and that retinpathy was nt present. Ntatin limited t a statement that indicated diabetes withut cmplicatins des nt meet criteria. Tw unilateral eye enucleatins r bilateral eye enucleatin anytime in the member s histry thrugh December 31, Specific requirements fr dcumentatin:

2 All recrds must include the patient's name n every page, and the patient's date f birth and sex n at least ne page. Dcumentatin in the medical recrd must make it clear that the patient had a dilated r retinal exam by an eye care prfessinal (must state: ptmetrist r phthalmlgist). Dcumentatin in the medical recrd must prvide the date when the prcedure was perfrmed and the results f the exam. B. Kidney Disease Mnitring r Medical Attentin fr Nephrpathy: A nephrpathy screening r mnitring test during 2017 r evidence f nephrpathy during Requested Medical Recrd Dcumentatin: 2017 All Prblem lists, medicatin lists, health maintenance flw sheets, prgress/visit ntes 2017 All labs and urine tests: Dcumentatin must include the date f service and results f the tests 2017 All Nephrlgist, Endcrinlgist, and Cardilgist Reprts/Crrespndences All Medicatin Lists; Dcumentatin must include evidence that the prescriptin was written, was filled r the member tk the medicatin 2017 Evidence the member was in hspice Specific items that will meet cmpliance: Any f the fllwing meet criteria fr a nephrpathy screening r mnitring test r evidence f nephrpathy: A urine test fr albumin r prtein in At a minimum, dcumentatin must include a nte indicating the date when a urine test was perfrmed, and the results r finding. Any f the fllwing meet the criteria: hur urine fr albumin r prtein 2. Timed urine fr albumin r prtein 3. Spt urine (e.g., urine dipstick r test strip) fr albumin r prtein 4. Urine fr albumin/creatinine rati hur urine fr ttal prtein 6. Randm urine fr prtein/creatinine ratin Dcumentatin f a visit t a nephrlgist in 2017 Dcumentatin f a renal transplant in 2017 Dcumentatin f medical attentin fr any f the fllwing in 2017 (n restrictin n prvider type): 1. Diabetic nephrpathy 2. End Stage Renal Disease (ESRD) 3. Chrnic Renal Failure (CRF) 4. Renal Insufficiency (RI) 5. Prteinuria 6. Albuminuria 7. Renal dysfunctin 8. Acute Renal Failure (ARF) 9. Dialysis, hemdialysis r peritneal dialysis. Evidence f ACE inhibitr/arb therapy in Dcumentatin in the medical recrd must include evidence that the member received ACE Inhibitr/ARB therapy during Any f the fllwing meet criteria: Dcumentatin that a prescriptin fr an ACE inhibitr/arb was written during 2017

3 Dcumentatin that a prescriptin fr an ACE inhibitr/arb was filled during 2017 Dcumentatin that the member tk an ACE inhibitr/arb during 2017 Specific requirements fr dcumentatin: All recrds must include the patient's name n every page, and the patient's date f birth and sex n at least ne page. Dcumentatin in the medical recrd must prvide the date when the urine test was perfrmed and the results r findings f the test. A medical histry f any f the nephrpathy findings des nt meet cmpliance. (It must be current fr 2017) Dcumentatin must include evidence that the prescriptin was written, was filled r the member tk the medicatin during C. Bld Sugar Cntrlled - HbA1c screening: The mst recent HbA1c level perfrmed in Requested Medical Recrd Dcumentatin: 2017 All Prblem lists, medicatin lists, health maintenance flw sheets, prgress/visit ntes 2017 All labs tests: Dcumentatin must include the date f service and results f the tests 2017 All Nephrlgist, Endcrinlgist, and Cardilgist Reprts/Crrespndences 2017 Evidence the member was in hspice Specific items that will meet cmpliance: HbA1c Testing At a minimum, dcumentatin in the medical recrd must include a nte indicating the date when the HbA1c test was perfrmed and the result. HbA1c Pr Cntrl >9% At a minimum, dcumentatin in the medical recrd must include a nte indicating the date when the HbA1c test was perfrmed and the result. The member is cmpliant if the result fr the mst recent HbA1c level during 2017 is >9% r is missing, r was nt dne during the measurement year. HbA1c Cntrl <8% At a minimum, dcumentatin in the medical recrd must include a nte indicating the date when the HbA1c test was perfrmed and the result. The member is cmpliant if the result fr the mst recent HbA1c level during 2017 is <8%. Specific requirements fr dcumentatin: All recrds must include the patient's name n every page, and the patient's date f birth and sex n at least ne page. Ntatin f the fllwing in the medical recrd meet criteria fr HbA1c tests: A1c HbA1c HgbA1c Hemglbin A1c Glychemglbin A1c Glychemglbin Glycated hemglbin Glycsylated hemglbin

4 Ranges and threshlds d nt meet criteria fr this indicatr. A distinct numeric result is required fr cmpliance. D. BP Cntrl <140/90 mm Hg: The mst recent BP taken during Requested Medical Recrd Dcumentatin: 2017 All Prblem lists, medicatin lists, health maintenance flw sheets, prgress/visit ntes 2017 All Nephrlgist, Endcrinlgist, and Cardilgist Reprts/Crrespndences 2017 All BP readings 2017 Evidence the member was in hspice Specific items that will meet cmpliance: The mst recent BP measurement taken in 2017 is <140/90 mm Hg. Specific requirements fr dcumentatin: All recrds must include the patient's name n every page, and the patient's date f birth and sex n at least ne page. Dcumentatin in the medical recrd must prvide the date when the bld pressure measurement was perfrmed and the cmplete reading. When multiple BP measurements are recrded fr a single date, the lwest systlic and lwest diastlic BP n that date is the representative BP. The systlic and diastlic results d nt need t be frm the same reading when multiple readings are recrded fr a single date. BP readings taken n the same day that the patient receives a cmmn lw-intensity r preventive prcedure are eligible fr use. Fr example, the fllwing prcedures are cnsidered cmmn lwintensity r preventive prcedures (this list is fr reference, and is nt exhaustive): Vaccinatins Injectins (e.g., allergy, vitamin B-12, insulin, sterid, tradl, Dep-Prvera, teststerne). TB test IUD insertin Eye exam with dilating agents D nt include BP readings that meet the fllwing criteria: Taken during an acute inpatient stay r an ED visit Taken n the same day as a diagnstic test r diagnstic r therapeutic prcedure that requires a change in diet r change in medicatin n r ne day befre the day f the test r prcedure, with the exceptin f fasting bld tests. Reprted by r taken by the member. When excluding BP readings the intent is t identify diagnstic r therapeutic prcedures that require a medicatin regimen, a change in diet r a change in medicatin. Fr example, this list is fr reference, and is nt exhaustive: A clnscpy requires a change in diet (NPO n the day f prcedure) and a medicatin change (a medicatin is taken t prep the cln). Dialysis, infusins and chemtherapy are all therapeutic prcedures that require a medicatin regimen. A nebulizer treatment with albuterl is cnsidered a therapeutic prcedure that requires a medicatin regimen (the albuterl). Injectin f lidcaine prir t mle remval is cnsidered a diagnstic prcedure (if the mle is being tested) r a therapeutic prcedure (if remval f the mle is the treatment) that requires a change in medicatin (lidcaine administered fr pain cntrl during the prcedure).

5 A patient frgetting t take regular medicatins n the day f the prcedure is nt cnsidered a required change in medicatin, and therefre the BP reading is eligible.