2017 CMS Web Interface

Transcription

1 CMS Web Interface Diabetes Mellitus (DM) Cmpsite (All r Nthing Scring) DM-2 (NQF 0059): Diabetes: Hemglbin A1c (HbA1c) Pr Cntrl (>9%) DM-7 (NQF 0055): Diabetes: Eye Exam Measure Steward: NCQA Web Interface V10 Page 1 f 26 11/15/2016

2 Cntents INTRODUCTION 4 WEB INTERFACE SAMPLING INFORMATION 5 BENEFICIARY SAMPLING 5 NARRATIVE MEASURE SPECIFICATION 6 DM-2: DIABETES: HEMOGLOBIN A1C (HBA1C) POOR CONTROL (>9%) 6 DESCRIPTION: 6 IMPROVEMENT NOTATION: 6 INITIAL POPULATION: 6 DENOMINATOR: 6 DENOMINATOR EXCLUSIONS: 6 DENOMINATOR EXCEPTIONS: 6 NUMERATOR: 6 NUMERATOR EXCLUSIONS: 6 DEFINITIONS: 6 GUIDANCE: 6 NARRATIVE MEASURE SPECIFICATION 7 DM-7: DIABETES: EYE EXAM 7 DESCRIPTION: 7 IMPROVEMENT NOTATION: 7 INITIAL POPULATION: 7 DENOMINATOR: 7 DENOMINATOR EXCLUSIONS: 7 DENOMINATOR EXCEPTIONS: 7 NUMERATOR: 7 NUMERATOR EXCLUSIONS: 7 DEFINITIONS: 7 GUIDANCE: 7 SUBMISSION GUIDANCE 8 PATIENT CONFIRMATION 8 SUBMISSION GUIDANCE 9 COMPOSITE CONFIRMATION 9 SUBMISSION GUIDANCE 10 NUMERATOR REPORTING 10 Web Interface V10 Page 2 f 26 11/15/2016

3 DM-2: Diabetes: Hemglbin A1c (HbA1c) Pr Cntrl (>9%) 10 SUBMISSION GUIDANCE 11 NUMERATOR REPORTING 11 DM-7: Diabetes: Eye Exam 11 DOCUMENTATION REQUIREMENTS 12 APPENDIX I: PERFORMANCE CALCULATION FLOW 13 APPENDIX II: DOWNLOADABLE RESOURCE MAPPING TABLE 23 APPENDIX III: MEASURE RATIONALE AND CLINICAL RECOMMENDATION STATEMENTS 24 RATIONALE: 24 CLINICAL RECOMMENDATION STATEMENTS: 24 APPENDIX IV: USE NOTICES, COPYRIGHTS, AND DISCLAIMERS 26 COPYRIGHT 26 Web Interface V10 Page 3 f 26 11/15/2016

4 INTRODUCTION There are a ttal f 15 individual measures (including ne cmpsite cnsisting f tw measures) included in the CMS Web Interface targeting high-cst chrnic cnditins, preventive care, and patient safety The measures dcuments are represented individually and cntain measure specific infrmatin The crrespnding cding dcuments are psted separately in an Excel frmat The Measure Dcuments are being prvided t allw grup practices and Accuntable Care Organizatins (ACOs) an pprtunity t better understand each f the 15 individual measures included in the CMS Web Interface data submissin methd Each Measure Dcument cntains infrmatin necessary t submit data thrugh the CMS Web Interface Narrative specificatins, supprting submissin dcumentatin, and calculatin flws are prvided within each dcument Please review all f the measure dcumentatin in its entirety t ensure cmplete understanding f these measures Web Interface V10 Page 4 f 26 11/15/2016

5 WEB INTERFACE SAMPLING INFORMATION BENEFICIARY SAMPLING Fr mre infrmatin n the sampling prcess and methdlgy please refer t the Web Interface Sampling Dcument, available at CMSgv Web Interface V10 Page 5 f 26 11/15/2016

6 NARRATIVE MEASURE SPECIFICATION DM-2: Diabetes: Hemglbin A1c (HbA1c) Pr Cntrl (>9%) DESCRIPTION: Percentage f patients years f age with diabetes wh had hemglbin A1c > 90% during the measurement perid IMPROVEMENT NOTATION: Lwer scre indicates better quality INITIAL POPULATION: Patients years f age with diabetes with a visit during the measurement perid DENOMINATOR: Equals Initial Ppulatin DENOMINATOR EXCLUSIONS: Nne DENOMINATOR EXCEPTIONS: Nne NUMERATOR: Patients whse mst recent HbA1c level (perfrmed during the measurement perid) is > 90% DEFINITIONS: Nne NUMERATOR EXCLUSIONS: Nt Applicable GUIDANCE: Patient is numeratr cmpliant if mst recent HbA1c level is > 9%, the mst recent HbA1c result is missing, r if there are n HbA1c tests perfrmed and results dcumented during the measurement perid If the HbA1c test result is in the medical recrd, the test can be used t determine numeratr cmpliance Only patients with a diagnsis f Type 1 r Type 2 diabetes shuld be included in the denminatr f this measure; patients with a diagnsis f secndary diabetes due t anther cnditin shuld nt be included Web Interface V10 Page 6 f 26 11/15/2016

7 NARRATIVE MEASURE SPECIFICATION DM-7: Diabetes: Eye Exam DESCRIPTION: Percentage f patients years f age with diabetes wh had a retinal r dilated eye exam by an eye care prfessinal during the measurement perid r a negative retinal r dilated eye exam (n evidence f retinpathy) in the 12 mnths prir t the measurement perid IMPROVEMENT NOTATION: Higher scre indicates better quality INITIAL POPULATION: Patients years f age with diabetes with a visit during the measurement perid DENOMINATOR: Equals Initial Ppulatin DENOMINATOR EXCLUSIONS: Nne DENOMINATOR EXCEPTIONS: Nne NUMERATOR: Patients with an eye screening fr diabetic retinal disease This includes diabetics wh had ne f the fllwing: A retinal r dilated eye exam by an eye care prfessinal in the measurement perid r a negative retinal r dilated eye exam (n evidence f retinpathy) by an eye care prfessinal in the year prir t the measurement perid DEFINITIONS: Nne NUMERATOR EXCLUSIONS: Nt Applicable GUIDANCE: Only patients with a diagnsis f Type 1 r Type 2 diabetes shuld be included in the denminatr f this measure; patients with a diagnsis f secndary diabetes due t anther cnditin shuld nt be included The eye exam must be perfrmed by an phthalmlgist r ptmetrist Web Interface V10 Page 7 f 26 11/15/2016

8 SUBMISSION GUIDANCE PATIENT CONFIRMATION Establishing patient eligibility fr reprting requires the fllwing: Guidance Determine if the patient s medical recrd can be fund OR OR If yu can lcate the medical recrd select Yes If yu cannt lcate the medical recrd select N - Medical Recrd Nt Fund Determine if the patient is qualified fr the sample If the patient is deceased, in hspice, mved ut f the cuntry r was enrlled in HMO select Nt Qualified fr Sample, select the applicable reasn frm the prvided drp-dwn menu, and enter the date the patient became ineligible Patient Cnfirmatin If N Medical Recrd Nt Fund r Nt Qualified fr Sample is selected, the patient is cmpleted but nt cnfirmed The patient will be skipped and anther patient must be reprted in their place, if available The Web Interface will autmatically skip any patient fr whm N Medical Recrd Nt Fund r Nt Qualified fr Sample is selected in all ther measures int which they have sampled If Nt Qualified fr Sample is selected and the date is unknwn, yu may enter the last date f the measurement perid (ie, 12/31/) The Measurement Perid is defined as January 1 December 31, NOTE: - In Hspice: Select this ptin if the patient is nt qualified fr sample due t being in hspice care at any time during the measurement perid (this includes nn-hspice patients receiving palliative gals r cmfrt care) - Mved ut f Cuntry: Select this ptin if the patient is nt qualified fr sample because they mved ut f the cuntry any time during the measurement perid - Deceased: Select this ptin if the patient died during the measurement perid - HMO Enrllment: Select this ptin if the patient was enrlled in an HMO at any time during the measurement perid (ie, Medicare Advantage, nn-medicare HMOs, etc) Web Interface V10 Page 8 f 26 11/15/2016

9 COMPOSITE CONFIRMATION SUBMISSION GUIDANCE Determine if the patient has a dcumented histry OR active diagnsis f diabetes during the measurement perid r year prir t the measurement perid OR OR If the patient has a dcumented histry f DM in the medical recrd select Yes If yu are unable t cnfirm the diagnsis f DM fr the patient select Nt Cnfirmed - Diagnsis If there is an ther CMS apprved reasn fr patient disqualificatin frm the measure select N - Other CMS Apprved Reasn Denminatr cdes can be fund in the Web Interface DM Cmpsite Cding Dcument The Dwnladable Resurce Mapping Table can be lcated in Appendix II f this dcument Guidance Denminatr CMS Apprved Reasn may nly be selected when apprved by CMS T request a CMS Apprved Reasn, yu wuld need t prvide the patient rank, measure and reasn fr request in a Quality Payment Prgram Service Desk inquiry A CMS decisin will be prvided in the reslutin f the inquiry The patient will be skipped and anther patient must be reprted in their place, if available By selecting "N - Other CMS Apprved Reasn", the patient is nly remved frm the measure fr which the reasn was requested, nt all Web Interface measures NOTE: - Active Diagnsis is defined as a diagnsis that is either n the patient s prblem list, a diagnsis cde listed n the encunter, r is dcumented in a prgress nte indicating that the patient is being treated r managed fr the disease r cnditin during the measurement perid Web Interface V10 Page 9 f 26 11/15/2016

10 NUMERATOR REPORTING SUBMISSION GUIDANCE DM-2: Diabetes: Hemglbin A1c (HbA1c) Pr Cntrl (>9%) Determine if the patient had ne r mre HbA1c tests perfrmed during the measurement perid OR If the patient did nt have ne r mre HbA1c tests dcumented select N If the patient had ne r mre HbA1c tests dcumented select Yes AND If yes, recrd the mst recent date the bld was drawn fr the HbA1c in MM/DD/YYYY frmat If yes, recrd the mst recent HbA1c value OR if test was perfrmed but result is nt dcumented, recrd "0" (zer) value Numeratr cdes can be fund in the Web Interface DM Cmpsite Cding Dcument The Dwnladable Resurce Mapping Table can be lcated in Appendix II f this dcument Guidance Numeratr If N is selected, d nt prvide Date Drawn and HbA1c Value NOTE: - Synnyms fr HbA1c testing may include Glychemglbin A1c, HbA1c, Hemglbin A1c, HgbA1c, A1c - Use the fllwing pririty ranking: Lab reprt draw date Lab reprt date Flw sheet dcumentatin Practitiner ntes Other dcumentatin - Patient Reprted Requirement: Date and mst recent value (distinct value required) - Ranges and threshlds d nt meet criteria fr this indicatr A distinct numeric result is required fr numeratr cmpliance - At a minimum, dcumentatin in the medical recrd must include a nte indicating the date n which the HbA1c test was perfrmed and the result - Dcumentatin f mst recent HbA1c result may be cmpleted during a telehealth encunter Web Interface V10 Page 10 f 26 11/15/2016

11 NUMERATOR REPORTING DM-7: Diabetes: Eye Exam SUBMISSION GUIDANCE Determine if patient was screened fr diabetic retinal disease identified by ne f the fllwing: A retinal r dilated eye exam by an eye care prfessinal during the measurement perid OR a negative retinal exam (n evidence f retinpathy) by an eye care prfessinal in the year prir t the measurement perid OR If the patient was nt screened fr diabetic retinal disease select N If the patient was screened fr diabetic retinal disease select Yes Numeratr cdes can be fund in the Web Interface DM Cmpsite Cding Dcument The Dwnladable Resurce Mapping Table can be lcated in Appendix II f this dcument Guidance Numeratr NOTE: - Patient Reprted Requirement: Date (year) and result/finding - If an endcrinlgist r PCP perfrms the apprpriate imaging in their ffice and the results are reviewed by an eye care prfessinal (ptmetrist r phthalmlgist) during the measurement perid r the year prir t the measurement perid (if negative fr retinpathy) then it is eligible fr use in reprting - If the eye exam is nt perfrmed r reviewed by an phthalmlgist r ptmetrist, results may be read by a qualified reading center that perates under the directin f a medical directr wh is a retinal specialist - Dcumentatin f diabetic retinal disease screening may be cmpleted during a telehealth encunter Web Interface V10 Page 11 f 26 11/15/2016

12 DOCUMENTATION REQUIREMENTS When submitting data thrugh the CMS Web Interface, the expectatin is that medical recrd dcumentatin is available that supprts the actin reprted in the Web Interface ie, medical recrd dcumentatin is necessary t supprt the infrmatin that has been submitted Web Interface V10 Page 12 f 26 11/15/2016

13 Appendix I: Perfrmance Calculatin Flw Web Interface V10 Page 13 f 26 11/15/2016

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18 Patient Cnfirmatin Flw Fr, cnfirmatin f the Medical Recrd Fund, r indicating the patient is Nt Qualified fr Sample with a reasn f In Hspice, Mved ut f Cuntry, Deceased, r HMO Enrllment, will nly need t be dne nce per patient Refer t the Measure Reprting Dcument fr further instructins 1 Start Patient Cnfirmatin Flw 2 Check t determine if Medical Recrd can be fund a If n, Medical Recrd nt fund, mark apprpriately fr cmpletin and stp abstractin This remves the patient frm the beneficiary sample fr all measures The patient will be skipped and replaced Stp prcessing b If yes, Medical Recrd fund, cntinue prcessing 3 Check t determine if Patient Qualified fr the sample a If n, the patient des nt qualify fr the sample, select the reasn why and enter the date (if date is unknwn, enter 12/31/) the patient became ineligible fr sample Fr example; In Hspice, Mved ut f Cuntry, Deceased, HMO Enrllment Mark apprpriately fr cmpletin and stp abstractin This remves the patient frm the beneficiary sample fr all measures The patient will be skipped and replaced Stp prcessing b If yes, the patient des qualify fr the sample; cntinue t the Measure Cnfirmatin Flw fr Diabetes Web Interface V10 Page 18 f 26 11/15/2016

19 Measure Cnfirmatin Flw fr Diabetes Fr, measure specific reasns a patient is Nt Cnfirmed r excluded fr Denminatr Exclusin r Other CMS Apprved Reasn will need t be dne fr each measure where the patient appears Refer t the Measure Reprting Dcument fr further instructins 1 Start Measure Cnfirmatin Flw fr Diabetes Cmplete fr cnsecutively ranked patients aged 18 t 75 years at the beginning f the measurement perid Further infrmatin regarding patient selectin fr specific disease and patient care measures can be fund in the Web Interface Sampling Methdlgy Dcument Fr patients wh have the incrrect date f birth listed, a change f the patient date f birth by the abstractr may result in the patient n lnger qualifying fr the DM cmpsite If this is the case, the system will autmatically remve the patient frm the cmpsite requirements 2 Check t determine if the patient has a dcumented histry r active diagnsis f diabetes during the measurement perid r year prir t the measurement perid a If n, the patient des nt have a dcumented histry f diabetes during the measurement perid r year prir t the measurement perid, mark apprpriately fr cmpletin and stp abstractin Patient is remved frm the perfrmance calculatins fr this cmpsite The patient will be skipped and replaced Stp prcessing b If yes, the patient des have a dcumented histry f diabetes during the measurement perid r year prir t the measurement perid, cntinue prcessing 3 Check t determine if the patient qualifies fr the cmpsite (Other CMS Apprved Reasn) a If n, the patient des nt qualify fr the cmpsite select: N Other CMS Apprved Reasn fr patient disqualificatin Mark apprpriately fr cmpletin and stp abstractin Patient is remved frm the perfrmance calculatins fr this cmpsite The patient will be skipped and replaced Other CMS Apprved Reasn may nly be selected if yu have received an apprval frm CMS in the reslutin f a requested Quality Payment Prgram Service Desk Inquiry at QPP Service Desk Stp prcessing b If yes, the patient des qualify fr the cmpsite, cntinue t DM-2 measure flw Web Interface V10 Page 19 f 26 11/15/2016

20 Measure Flw fr DM-2 The measure diagrams were develped by CMS as a supplemental resurce t be used in cnjunctin with the measure specificatins They shuld nt be used as a substitutin fr the measure specificatins Fr Dwnladable Resurce Mapping Table, g t Appendix II and use the Variable Names lcated in the appendix alng with the applicable tabs within the DM Cding Dcument 1 Start prcessing DM-2 (NQF 0059) Flw fr the patients that qualified fr the sample in the Patient Cnfirmatin Flw and the Measure Cnfirmatin Flw fr Diabetes Nte: Include remainder f patients listed in the Web Interface that were cnsecutively cnfirmed and cmpleted fr this measure in the denminatr Fr the sample calculatin in the flw these patients wuld fall int the d categry (eligible denminatr, ie 210 patients) 2 Check t determine if the patient had ne r mre HbA1c tests perfrmed during the measurement perid a If n, patient did nt have ne r mre HbA1c tests perfrmed during the measurement perid, perfrmance is met and the patient will be included in the numeratr Fr the sample calculatin in the flw these patients wuld fall int the a¹ categry (numeratr, ie 40 patients) Stp prcessing b If yes, the patient had ne r mre HbA1c tests perfrmed during the measurement perid, recrd the mst recent date the bld was drawn fr the HbA1c in MM/DD/YYYY frmat and the mst recent HbA1c value OR if test was perfrmed but result is nt dcumented, recrd 0 (zer) value Cntinue prcessing 3 Check t determine if the patient s mst recent HbA1c value was greater than nine percent r equal t zer percent a If n, patient s mst recent HbA1c value was nt greater than nine percent r equal t zer percent, perfrmance is nt met and the patient shuld nt be included in the numeratr Stp prcessing b If yes, patient s mst recent HbA1c value was greater than nine percent r equal t zer percent, perfrmance is met and the patient will be included in the numeratr Fr the sample calculatin in the flw these patients wuld fall int the a² categry (numeratr, ie 40 patients) Stp prcessing Sample Calculatin Perfrmance Rate Equals Perfrmance Met is categry a¹ plus a² in the measure flw (80 patients) Denminatr is categry d in measure flw (210 patients) 80 (Perfrmance Met) divided by 210 (Denminatr) equals a perfrmance rate f 3810 percent Calculatin May Change Pending Perfrmance Met Fr this Measure, a Lwer Rate Indicates Better Perfrmance/Cntrl Web Interface V10 Page 20 f 26 11/15/2016

21 Measure Flw fr DM-7 The measure diagrams were develped by CMS as a supplemental resurce t be used in cnjunctin with the measure specificatins They shuld nt be used as a substitutin fr the measure specificatins Fr Dwnladable Resurce Mapping Table, g t Appendix II and use the Variable Names lcated in the appendix alng with the applicable tabs within the DM Cding Dcument 1 Start prcessing DM-7 (NQF 0055) Flw fr the patients that qualified fr the sample in the Patient Cnfirmatin Flw and the Measure Cnfirmatin Flw fr Diabetes Nte: Include remainder f patients listed in the Web Interface that were cnsecutively cnfirmed and cmpleted fr this measure in the denminatr Fr the sample calculatin in the flw these patients wuld fall int the d categry (eligible denminatr, ie 210 patients) 2 Check t determine if the patient was screened fr diabetic retinal disease during the measurement perid OR a negative retinal exam was dcumented in the year prir t the measurement perid a If n, the patient was nt screened fr diabetic retinal disease during the measurement perid OR a negative retinal exam was nt dcumented in the year prir t the measurement perid, perfrmance is nt met and the patient shuld nt be included in the numeratr Stp prcessing b If yes, the patient was screened fr diabetic retinal disease during the measurement perid OR a negative retinal exam was dcumented in the year prir t the measurement perid, perfrmance is met and the patient shuld be included in the numeratr Fr the sample calculatin in the flw these patients wuld fall int the a categry (numeratr, ie 180 patients) Stp prcessing Sample Calculatin Perfrmance Rate Equals Perfrmance Met is categry a in the measure flw (180 patients) Denminatr is categry d in measure flw (210 patients) 180 (Perfrmance Met) divided by 210 (Denminatr) equals a perfrmance rate f 8571 percent Calculatin May Change Pending Perfrmance Met Web Interface V10 Page 21 f 26 11/15/2016

22 Measure Flw Diabetes Cmpsite The measure diagrams were develped by CMS as a supplemental resurce t be used in cnjunctin with the measure specificatins They shuld nt be used as a substitutin fr the measure specificatins Fr Dwnladable Resurce Mapping Table, g t Appendix II and use the Variable Names lcated in the appendix alng with the applicable tabs within the DM Cding Dcument 1 Start prcessing Diabetes Cmpsite Measure Flw fr the patients that qualified fr sample in the Patient Cnfirmatin Flw and the Measure Cnfirmatin Flw fr Diabetes Nte: Include remainder f patients listed in the Web Interface that were cnsecutively cnfirmed and cmpleted fr the cmpnents within this denminatr fr the cmpsite measure Fr the sample calculatin in the flw these patients wuld fall int the d categry (eligible denminatr, ie 210 patients) 2 Check t determine if the patient had ne r mre HbA1c tests during the measurement perid (DM-2) a If n, the patient did nt have ne r mre HbA1c tests during the measurement perid, the patient fails the cmpsite measure Stp prcessing cmpsite measure b If yes, the patient did have ne r mre HbA1c tests during the measurement perid, recrd the mst recent date the bld was drawn fr the HbA1c in MM/DD/YYYY frmat and the mst recent HbA1c value OR if test was perfrmed but result is nt dcumented, recrd 0 (zer) value Cntinue prcessing 3 Check t determine if the patient s mst recent HbA1c value was greater than nine percent r equal t zer percent a If n, the patient s mst recent HbA1c value was nt greater than nine percent r equal t zer percent, the patient passes 1 f the 2 cmpnents f the Diabetes cmpsite measure Cntinue prcessing fr DM-7 b If yes, the patient s mst recent HbA1c value was greater than nine percent r equal t zer percent, the patient fails 1 f the 2 cmpnents f the Diabetes cmpsite measure Stp prcessing cmpsite measure 4 Check t determine if the patient was screened fr diabetic retinal disease during the measurement perid OR a negative retinal exam was dcumented in the year prir t the measurement perid (DM-7) a If n, the patient was nt screened fr diabetic retinal disease during the measurement perid OR a negative retinal exam was nt dcumented in the year prir t the measurement perid, the patient fails 1 f 2 cmpnents f the Diabetes cmpsite measure Stp prcessing cmpsite measure b If yes, the patient was screened fr diabetic retinal disease during the measurement perid OR a negative retinal exam was dcumented in the year prir t the measurement perid, the patient passes 1 f 2 cmpnents f the Diabetes cmpsite measure Cntinue prcessing 5 Determine if the patient passed DM-2 and DM-7 cmpnents f the cmpsite measure If the patient passed bth cmpnents, the patient meets the cmpsite measure Fr the sample calculatin in the flw these patients wuld fall int the a categry (numeratr, ie 190 patients) Sample Calculatin Perfrmance Rate Equals Perfrmance Met is categry a in the measure flw (190 patients) Denminatr is categry d in measure flw (210 patients) 190 (Perfrmance Met) divided by 210 (Denminatr) equals a perfrmance rate f 9048 percent Calculatin May Change Pending Perfrmance Met Web Interface V10 Page 22 f 26 11/15/2016

23 Appendix II: Dwnladable Resurce Mapping Table Each data element within this measure s denminatr r numeratr is defined as a pre-determined set f clinical cdes These cdes can be fund in the Web Interface DM Cding Dcument *DM Cmpsite ( All r Nthing Scring) Measure Cmpnent/Excel Tab Data Element Variable Name Cding System(s) Denminatr/Denminatr Cdes Diabetes Diagnsis DM_DX_CODE I9 I10 SNM Numeratr/Numeratr Cdes Hemglbin A1c (DM-2) A1C_CODE Eye Exam EYE_EXAM_CODE (DM-7) NEGATIVE_FINDING_CODE *Fr EHR mapping, the cding within the DM Cmpsite is cnsidered t be all inclusive LN WITH mst recent A1c date and value SNM SNM Web Interface V10 Page 23 f 26 11/15/2016

24 Appendix III: Measure Ratinale and Clinical Recmmendatin Statements RATIONALE: DM-2: Diabetes: Hemglbin A1c (HbA1c) Pr Cntrl (>9%) As the seventh leading cause f death in the US, diabetes kills apprximately 75,000 peple a year (CDC FastStats 2015) Diabetes is a grup f diseases marked by high bld glucse levels, resulting frm the bdy's inability t prduce r use insulin (CDC Statistics 2014, ADA Basics 2013) Peple with diabetes are at increased risk f serius health cmplicatins including visin lss, heart disease, strke, kidney failure, amputatin f tes, feet r legs, and premature death (CDC Fact Sheet 2014) In 2012, diabetes cst the US an estimated $245 billin: $176 billin in direct medical csts and $69 billin in reduced prductivity This is a 41 percent increase frm the estimated $174 billin spent n diabetes in 2007 (ADA Ecnmic 2013) Reducing A1c bld level results by 1 percentage pint (eg, frm 80 percent t 70 percent) helps reduce the risk f micrvascular cmplicatins (eye, kidney and nerve diseases) by as much as 40 percent (CDC Estimates 2011) DM-7: Diabetes: Eye Exam As the seventh leading cause f death in the US, diabetes kills apprximately 75,000 peple a year (CDC FastStats 2015) Diabetes is a grup f diseases marked by high bld glucse levels, resulting frm the bdy's inability t prduce r use insulin (CDC Statistics 2014, ADA Basics 2013) Peple with diabetes are at increased risk f serius health cmplicatins including visin lss, heart disease, strke, kidney failure, amputatin f tes, feet r legs, and premature death (CDC Fact Sheet 2014) In 2012, diabetes cst the US an estimated $245 billin: $176 billin in direct medical csts and $69 billin in reduced prductivity This is a 41 percent increase frm the estimated $174 billin spent n diabetes in 2007 (ADA Ecnmic 2013) In , f adults with diabetes aged 40 years r lder, 42 millin (285%) peple had diabetic retinpathy, damage t the small bld vessels in the retina that may result in lss f visin (CDC Statistics, 2014) CLINICAL RECOMMENDATION STATEMENTS: DM-2: Diabetes: Hemglbin A1c (HbA1c) Pr Cntrl (>9%) American Diabetes Assciatin (2015): - Lwering A1C t apprximately 7% r less has been shwn t reduce micrvascular cmplicatins f diabetes, and, if implemented sn after the diagnsis f diabetes, it is assciated with lng-term reductin in macrvascular disease Therefre, a reasnable A1C gal fr many nnpregnant adults is 7% (Level f evidence: B) - Prviders might reasnably suggest mre stringent A1C gals (such as 65%) fr selected individual patients if this can be achieved withut significant hypglycemia r ther adverse effects f treatment Apprpriate patients might include thse with shrt duratin f diabetes, type 2 diabetes treated with lifestyle r metfrmin nly, lng life expectancy, r n significant cardivascular disease (CVD) (Level f evidence: C) - Less stringent A1C gals (such as 8%) may be apprpriate fr patients with a histry f severe hypglycemia, limited life expectancy, advanced micrvascular r macrvascular cmplicatins, extensive cmrbid cnditins, r lng-standing diabetes in whm the general gal is difficult t attain despite diabetes self-management educatin, apprpriate glucse mnitring, and effective dses f multiple glucse-lwering agents including insulin (Level f evidence: B) DM-7: Diabetes: Eye Exam American Diabetes Assciatin (ADA) (2015): Web Interface V10 Page 24 f 26 11/15/2016

25 - Adults with type 1 diabetes shuld have an initial dilated and cmprehensive eye examinatin by an phthalmlgist r ptmetrist within 5 years after the nset f diabetes (Level f evidence: B) - Patients with type 2 diabetes shuld have an initial dilated and cmprehensive eye examinatin by an phthalmlgist r ptmetrist shrtly after the diagnsis f diabetes (Level f evidence: B) Web Interface V10 Page 25 f 26 11/15/2016

26 Appendix IV: Use Ntices, Cpyrights, and Disclaimers COPYRIGHT NCQA Ntice f Use These perfrmance measures were develped and are wned by the Natinal Cmmittee fr Quality Assurance ("NCQA") These perfrmance measures are nt clinical guidelines and d nt establish a standard f medical care NCQA makes n representatins, warranties, r endrsement abut the quality f any rganizatin r physician that uses r reprts perfrmance measures and NCQA has n liability t anyne wh relies n such measures NCQA hlds a cpyright in this measure and can rescind r alter this measure at any time Users f the measure shall nt have the right t alter, enhance, r therwise mdify the measure and shall nt disassemble, recmpile, r reverse engineer the surce cde r bject cde relating t the measure Anyne desiring t use r reprduce the measure withut mdificatin fr a nncmmercial purpse may d s withut btaining any apprval frm NCQA All cmmercial uses must be apprved by NCQA and are subject t a license at the discretin f NCQA Use by health care prviders in cnnectin with their wn practices is nt cmmercial use A "cmmercial use" refers t any sale, license, r distributin f a measure fr cmmercial gain, r incrpratin f a measure int any prduct r service that is sld, licensed, r distributed fr cmmercial gain, even if there is n actual charge fr inclusin f the measure Natinal Cmmittee fr Quality Assurance, all rights reserved Perfrmance measures develped by NCQA fr CMS may lk different frm the measures slely created and wned by NCQA CPT cntained in the Measures specificatins is cpyright American Medical Assciatin Web Interface V10 Page 26 f 26 11/15/2016