According to the Centers for Disease Control and Prevention, approximately 38 million Americans have diabetes. Because symptoms can develop slowly, one in five of them don’t know they have it. You play an important role in supporting our members through regular screenings, tests and office visits.

We track Healthcare Effectiveness Data and Information Set (HEDIS^®) measures from the National Committee for Quality Assurance related to diabetes care, including:

• Glycemic Status Assessment for Patients with Diabetes, which captures the percentage of our members ages 18 to 75 with diabetes (type 1 and type 2) whose most recent glycemic status (hemoglobin A1C) or glucose management indicator was at the following levels during the measurement year:

  • Less than or equal to 9.0%

  • Greater than 9.0%

• Eye Exam for Patients with Diabetes, which tracks members ages 18 to 75 with diabetes (type 1 and type 2) who have a retinal eye exam by an eye care professional to screen or monitor for diabetic retinal disease.

• Kidney Health Evaluation for Patients with Diabetes, which tracks members ages 18 to 85 with diabetes (type 1 and type 2) who received a kidney health evaluation during the measurement year. An evaluation includes a blood test for kidney function (estimated glomerular filtration rate) and a urine test for kidney damage (urine albumin-creatinine ratio).

Tips to close gaps in care

• Identify care gaps and schedule lab tests before office visits to review results and adjust treatment plans if needed.

• Document the exact date hemoglobin A1c assessments were performed and the results. If documenting glucose management indicator value, include the exact date range. Use Current Procedural Terminology (CPT^®) II codes to identify the most recent HbA1C test during the measurement year. Repeat abnormal lab tests later in the year to document improvement.

• Ensure all components of the urine test for kidney damage are complete, such as one urine albumin-creatinine ratio or both a quantitative urine albumin test and a urine creatinine test with service dates four days or less apart.

• Monitor and document blood pressure status at each visit and adjust medications as needed for control.

• Document medication adherence and make necessary adjustments to medications.

• Encourage members with diabetes to have annual retinal or dilated eye exams by an eye care professional.

• For our members on statin therapy, discuss the proper dose, frequency and importance of staying on the medication. Suggest 90-day prescriptions where applicable.

• Communicate with members and other treating providers to ensure all tests are completed and results are documented in the medical record.

Resources

• These measures contribute to ratings for Centers for Medicare & Medicaid Services’ Five-Star Quality Rating System. Refer to our Stars Guidebook for more details. You can access it in the Availity^® Essentials HealthSpring Medicare Advantage payer space in the Resources section or email your HealthSpring representative to request a copy.

• We have information to support discussions about diabetes with our members.

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their evidence of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.