Optimal Diabetes Care Specifications 2015 (01/01/2014 to 12/31/2014 Dates of Service) October 2014

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1 Summary of Changes Removal of LDL Component The LDL component has been removed for numerator calculation. Additional Ischemic Vascular Disease ICD-9 Codes Codes indicating atherosclerosis of bypass grafted vessels: to , 440.8, and See Table 2. Clarification of Eligible Providers All Advanced Practice Registered Nurses are eligible providers. This includes, but is not limited to, Certified Nurse Practitioner, Certified Nurse Specialist, and Certified Nurse Midwife. Description Methodology Rationale Composite ( optimal care) measure of the percentage of adult patients who have type 1 or type 2 diabetes with optimally managed modifiable risk factors. Population identification is accomplished via a query of a practice management system or electronic medical record (EMR) to identify the population of eligible patients (denominator). Data elements are either extracted from an EMR system or abstracted through medical record review. Full population data is required for clinics that had an EMR in place by 01/01/2013. According to the Minnesota Department of Health, diabetes is a high impact clinical condition in Minnesota. More than one in three adults and one in six youth in Minnesota have diabetes or are at high risk of developing it. Each year more than 20,000 Minnesotans are newly diagnosed with diabetes. Diabetes is the sixth leading cause of death in Minnesota and is a significant risk factor in developing cardiovascular disease and stroke, non-traumatic lower extremity amputations, blindness, and end-stage renal disease. Diabetes costs Minnesota almost $2.7 billion annually, including medical care, lost productivity and premature mortality. According to the American Diabetes Association, an estimated 25.8 million American children and adults have diabetes. Most people with diabetes have other risk factors, such as high blood pressure and cholesterol that increase the risk for heart disease and stroke. In fact, more than 65% of people with diabetes die from these complications. Measurement Period Measurement period will be a fixed 12-month period: 01/01/2014 to 12/31/2014. Page 1

2 Denominator Patients who meet each of the following criteria are included in the population: Patient was age 18 to 75 years at the start of the measurement period (date of birth was on or between 01/01/1939 to 01/01/1996). Patient was seen by an eligible provider in an eligible specialty face-to-face visit at least two times during the last two measurement periods (01/01/2013 to 12/31/2014) with visits coded with a diabetes mellitus ICD-9 diagnosis code (in any position, not only primary). Use this date of service range when querying the practice management or EMR system to allow a count of the visits. Patient was seen by an eligible provider in an eligible specialty face-to-face visit at least one time during the measurement period (01/01/2014 to 12/31/2014) for any reason. This may or may not include a face-to-face diabetes visit with a diabetes mellitus ICD-9 code. Diagnosis of Diabetes mellitus; ICD-9 diagnosis codes include: to See Table 1. Eligible specialties: Family Medicine, General Practice, Internal Medicine, Geriatric Medicine, Endocrinology Allowable Exclusions Eligible providers: Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurses (APRN) The following are allowable exclusions: Patient was a permanent nursing home resident during the measurement period. Patient was in hospice at any time during the measurement period. Patient died prior to the end of the measurement period. Patient was pregnant during measurement period (ICD-9 diagnosis codes include: to ; See Table 3). Documentation that diagnosis was coded in error. Page 2

3 Numerator The number of diabetes patients who met ALL of the following targets: The most recent HbA1c in the measurement period has a value less than 8.0. The most recent Blood Pressure in the measurement period has a systolic value of less than 140 and a diastolic value of less than 90 (both values must be less than). Patient is currently a non-tobacco user. If the patient has a co-morbidity of Ischemic Vascular Disease, the patient is on daily aspirin OR an accepted contraindication (any date). Diagnosis of Ischemic Vascular Disease; ICD-9 diagnosis codes include: to , to , 412, to 413.9, to , 414.2, 414.3, 414.8, 414.9, 429.2, to , to , 440.0, 440.1, to , to , 440.4, 440.8, 440.9, to 444.9, to See Table 2. Codes to Identify Patients who have Diabetes Mellitus Table 1: ICD-9 Diagnosis Codes for Identifying Diabetes Mellitus DMII WO CMP NT ST UNCNTR DMI WO CMP NT ST UNCNTRL DMII WO CMP UNCNTRLD DMI WO CMP UNCNTRLD DMII KETO NT ST UNCNTRLD DMI KETO NT ST UNCNTRLD DMII KETOACD UNCONTROLD DMI KETOACD UNCONTROLD DMII HPRSM NT ST UNCNTRL DMI HPRSM NT ST UNCNTRLD DMII HPROSMLR UNCONTROLD DMI HPROSMLR UNCONTROLD DMII O CM NT ST UNCNTRLD DMI O CM NT ST UNCNTRLD DMII OTH COMA UNCONTROLD Page 3

4 DMI OTH COMA UNCONTROLD DMII RENL NT ST UNCNTRLD DMI RENL NT ST UNCNTRLD DMII RENAL UNCNTRLD DMI RENAL UNCNTRLD DMII OPHTH NT ST UNCNTRL DMI OPHTH NT ST UNCNTRLD DMII OPHTH UNCNTRLD DMI OPHTH UNCNTRLD DMII NEURO NT ST UNCNTRL DMI NEURO NT ST UNCNTRLD DMII NEURO UNCNTRLD DMI NEURO UNCNTRLD DMII CIRC NT ST UNCNTRLD DMI CIRC NT ST UNCNTRLD DMII CIRC UNCNTRLD DMI CIRC UNCNTRLD DMII OTH NT ST UNCNTRLD DMI OTH NT ST UNCNTRLD DMII OTH UNCNTRLD DMI OTH UNCNTRLD DMII UNSPF NT ST UNCNTRL DMI UNSPF NT ST UNCNTRLD DMII UNSPF UNCNTRLD DMI UNSPF UNCNTRLD Page 4

5 Ischemic Vascular Disease Codes Optimal Diabetes Care Specifications Table 2: ICD-9 Diagnosis Codes for Identifying Ischemic Vascular Disease AMI ANTEROLATERAL,UNSPEC AMI ANTEROLATERAL, INITIAL AMI ANTEROLATERAL,SUBSEQ AMI ANTERIOR WALL,UNSPEC AMI ANTERIOR WALL, INITIAL AMI ANTERIOR WALL,SUBSEQ AMI INFEROLATERAL,UNSPEC AMI INFEROLATERAL, INITIAL AMI INFEROLATERAL,SUBSEQ AMI INFEROPOST, UNSPEC AMI INFEROPOST, INITIAL AMI INFEROPOST, SUBSEQ AMI INFERIOR WALL,UNSPEC AMI INFERIOR WALL, INITIAL AMI INFERIOR WALL,SUBSEQ AMI LATERAL NEC, UNSPEC AMI LATERAL NEC, INITIAL AMI LATERAL NEC, SUBSEQ TRUE POST INFARCT,UNSPEC TRUE POST INFARCT, INITIAL TRUE POST INFARCT,SUBSEQ SUBENDO INFARCT, UNSPEC SUBENDO INFARCT, INITIAL SUBENDO INFARCT, SUBSEQ AMI NEC, UNSPECIFIED Page 5

6 AMI NEC, INITIAL AMI NEC, SUBSEQUENT AMI NOS, UNSPECIFIED AMI NOS, INITIAL AMI NOS, SUBSEQUENT POST MI SYNDROME INTERMED CORONARY SYND ACUTE COR OCCLSN W/O MI AC ISCHEMIC HRT DIS NEC 412 OLD MYOCARDIAL INFARCT ANGINA DECUBITUS PRINZMETAL ANGINA ANGINA PECTORIS NEC/NOS COR ATH UNSP VSL NTV/GFT CRNRY ATHRSCL NATVE VSSL CRN ATH ATLG VN BPS GRFT CRN ATH NONATLG BLG GRFT COR ATH ARTRY BYPAS GRFT COR ATH BYPASS GRAFT NOS COR ATH NATV ART TP HRT COR ATH BPS GRAFT TP HRT CHR TOT OCCLUS COR ARTRY COR ATH DUE TO LIPID RICH PLAQUE CHR ISCHEMIC HRT DIS NEC CHR ISCHEMIC HRT DIS NOS ASCVD OCL BSLR ART WO INFRCT OCL BSLR ART W INFRCT Page 6

7 OCL CRTD ART WO INFRCT OCL CRTD ART W INFRCT OCL VRTB ART WO INFRCT OCL VRTB ART W INFRCT OCL MLT BI ART WO INFRCT OCL MLT BI ART W INFRCT OCL SPCF ART WO INFRCT OCL SPCF ART W INFRCT OCL ART NOS WO INFRCT OCL ART NOS W INFRCT CRBL THRMBS WO INFRCT CRBL THRMBS W INFRCT CRBL EMBLSM WO INFRCT CRBL EMBLSM W INFRCT CRBL ART OC NOS WO INFRC CRBL ART OCL NOS W INFRC ATHEROSCLEROSIS OF AORTA RENAL ARTERY ATHEROSCLER ATHSCL EXTRM NTV ART NOS ATH EXT NTV AT W CLAUDCT ATH EXT NTV AT W RST PN ATH EXT NTV ART ULCRTION ATH EXT NTV ART GNGRENE ATHRSC EXTRM NTV ART OTH ATHRSC OF UNSPECIFIED BYPASS GRAFT OF THE EXTRM ATHRSC OF AUTOLOGOUS VEIN BYPASS GRAFT OF THE EXTRM ATHRSC OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTRM CHR TOT OCCL ART EXTREM Page 7

8 440.8 ATHRSC OF OTHER SPECIFIED ARTERIES GENERALIZED AND NOS ATHRSC SADDLE EMBOLUS OF ABD AORTA OTHER ARTERIAL EMBOLISM AND THROMBOSIS OF ABD AORTA THORACIC AORTIC EMBOLISM UPPER EXTREMITY EMBOLISM LOWER EXTREMITY EMBOLISM ILIAC ARTERY EMBOLISM ARTERIAL EMBOLISM NEC ARTERIAL EMBOLISM NOS ATHEROEMBOLISM,UPPER EXT ATHEROEMBOLISM,LOWER EXT ATHEROEMBOLISM, KIDNEY ATHEROEMBOLISM, SITE NEC Codes Used to Identify Patients who Meet Exclusion Criteria Table 3: ICD-9 Diagnosis Codes for Identifying Pregnancy for Patients with Diabetes Mellitus ICD-9 Diagnosis Code ICD-9 Diagnosis Code Description DM of mother, complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable DM of mother, complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition DM of mother, complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication DM of mother, complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication DM of mother, complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication Page 8