WCHQ Ambulatory Measure Specification
Diabetes Care Performance Measures
Measurement Period 01/01/2013-12/31/2013
Submission Period: 03/03/14 - 03/14/14
Measure Description
The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period:
1. At least two A1c blood sugar tests annually
2. Most recent A1c blood sugar level controlled to less than 8.0%
3. At least one LDL cholesterol test annually
4. Most recent LDL cholesterol controlled to less than 100 mg/dl
5. An annual nephropathy screening and/or treatment for kidney disease and/or diagnosis of kidney disease
6. Most recent Blood pressure controlled to a level of less than 140/90 mm Hg
7. All or None Process Measure (Optimal Testing) composite of two A1C’s, one LDL and one Kidney Function Monitoring Test
8. All or None Outcome Measure (Optimal Control) composite of A1C <8.0%, LDL <100 mg/dl, BP <140/90, Tobacco Non-User and Daily Aspirin or Other Anticoagulant for diabetes patients with IVD.
Disclaimer: Measures reported by WCHQ healthcare organizations represent a specific aspect of care in relation to an evidence-based standard, but are not clinical guidelines and do not establish standards of care. All providers should have an individual care plan established with their patient.
General Information/Rationale
In an effort to align with National Quality Form (NQF) endorsed diabetes measures, and referencing the 2013 American Diabetes Association (ADA) guidelines, the following goals for people with diabetes are measured by the WCHQ:
· Two A1c tests annually, at a minimum
· A1c level controlled to less than 8.0%
· LDL test annually, at a minimum
· LDL controlled to less than 100 mg/dl
· Screening and/or treatment for kidney disease annually
· Blood pressure controlled to a level of less than 140/90 mm Hg
National Quality Forum-Endorsed Measure #0575 A1c Control: https://www.qualityforum.org/QPS/0575
National Quality Forum-Endorsed Measure #0061 BP Control: https://www.qualityforum.org/QPS/0061
American Diabetes Association Clinical Practice Recommendations 2013: http://care.diabetesjournals.org/content/36/Supplement_1/S4.full
Definitions
12 Months: Measurement Period
24 Months: Measurement Period + Prior Year
Office Visit: Office visit in an outpatient, non-urgent care setting
PCP: For WCHQ measure purposes, a primary care provider is defined as any General Practice, Internal Medicine, Family Medicine, Pediatrics provider with the following degree types (MD, DO, PA, and NP), and any other practitioners identified by the healthcare system as primary care practitioners. The rationale for the additional practitioner(s) must be documented and must be applied consistently across all preventive care and chronic care measures by the organization.
· Measure Specific Specialist: As part of the denominator population for this measure visits to an Endocrinologist qualify as office visits for the denominator population.
Age Range 18-75: Patients born between 01/01/1938 and 01/01/1995.
Denominator Description
Patients whose age at the beginning of the one year measurement period is at least 18 and whose age at the end of the measurement period is less than 76 and are alive as of the last day of the Measurement Period. Expired patients for whom a specific date of expiration cannot be found are excluded from the denominator population
The rationale for the denominator population is built from the following criteria (See Figure D-1):
[Question 1] – Is this a patient with the disease or condition?
[Question 2] – Is this a patient whose care is managed within the physician group?
[Question 3] – Is this a patient currently managed in our system?
MINIMUM POPULATION SIZEFor every WCHQ Ambulatory Measure, each organization must calculate total denominator population for this measure, not a sample (see Encounter Data section). If the Denominator for any given measure is less than 50 patients, the organization does not have to report the Numerator for the measure to WCHQ. To allow for appropriate comparisons of performance across organizations, a minimum population of 50 patients ensures a maximum of a 2% incremental scale on proportional measures.
Publication on the Website: If the Denominator is less than 50, only the Physician Group Name, Population Size (N), and the following statement will display on www.wchq.org:
· The patient population is too small (N<50) for purposes of reliably predicting Physician Group performance.
Historical Trend for Low Population Sizes: The historical trend display of Physician Group performance will not include measurement periods with population sizes less than 50. For each measurement period with insufficient data, there will be no display for that period.
Site Level Reporting:
Denominator Minimum: For site level reporting there must be a minimum of 100 patients per clinic in the denominator for each measure. If the clinic denominator for any given measure is less than 100 patients the organization does not publicly report the results for the measure. The results will still be included in the organization level data.
Provider Minimum per Clinic: For site level reporting there are two options as follows:
o A minimum of 3 providers per clinic who have patients in the measure denominator. There could be a provider or providers in a given clinic who do not get counted because they have no patients in the measure denominator.
o If an organization desires, they can report site level data for a clinic with fewer than 3 providers as long as the clinic meets the 100 patient threshold. If your organization is planning to report results publicly for clinics with less than 3 providers, all clinics that meet this criteria will need to be reported.
Publication on the Website: Clinics who do not have enough providers or patients to be publicly reported for a given measure or measures will still display on the website by name but without results and with a caveat indicating that data was reported but did not meet the minimum provider or population size.
Provider and /or Clinic Attrition Recommendation:
1. If a provider or clinic has left the organization prior to the end of the measurement period and if the organization can track the provider termination date, the provider will not be included in the site level reporting results. The provider or clinic is still included in the group level results.
2. If a clinic closes or is no longer affiliated with a health care system after the end of the measurement period and prior to next year’s data being published a termination date and verbiage will be added next to that clinic’s name on the website. This will require website updating throughout the year.
Assignment of Provider to Clinic:
Organizations can use their current internal site level reporting methodology to assign a provider to a clinic. A provider must be assigned to a “home” clinic. Organizations who are not already doing internal site level reporting can work with WCHQ for assistance.
Assignment of Patient to Provider:
For purposes of WCHQ site level reporting a patient must be attributed to one provider. Organizations can use their own internal algorithm to assign a patient to a provider. Those who are not already doing this can work with WCHQ for assistance.
Encounter dataPatients eligible for inclusion in the denominator include (See Figure D-1):
[Question 1] – Is this a patient with the disease, or condition?
Those who had a minimum of two diabetes coded (including any diagnoses coded for the visit) – (Table D-1) office visits (Table D-2), with any provider (MD, DO, PA, NP) in the Physician Group with different dates of service in an ambulatory setting during the last 24 Months [Measurement Period + Prior Year], and
[Question 2] – Is this a patient whose care is managed within the physician group?
Patients who had at least two office visits (Table D-2), regardless of diagnosis code, on different dates of service, to a PCP and/or Endocrinologist in the past 24 months. If the Endocrinologist is not considered a PCP, at least one of the two office visits must be to a PCP.
[Question 3] – Is this a patient current in our system?
Those who had at least one office visit (Table D-2), regardless of diagnosis code, with a PCP and/or an Endocrinologist during the last 12 Months [Measurement Period].
Table D-1: Diagnosis Codes to Identify Patients with Diabetes Note: Will be removed and replace with value set references, including ICD-10 codes
ICD-9-CM Diagnosis Codes / Description250.xx / Diabetes mellitus
250.00 /
Diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled
250.01 /Diabetes mellitus without mention of complication, type i [juvenile type], not stated as uncontrolled
250.02 /Diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled
250.03 /Diabetes mellitus without mention of complication, type i [juvenile type], uncontrolled
250.10 /Diabetes with ketoacidosis, type ii or unspecified type, not stated as uncontrolled
250.11 /Diabetes with ketoacidosis, type i [juvenile type], not stated as uncontrolled
250.12 /Diabetes with ketoacidosis, type ii or unspecified type, uncontrolled
250.13 /Diabetes with ketoacidosis, type i [juvenile type], uncontrolled
250.20 /Diabetes with hyperosmolarity, type ii or unspecified type, not stated as uncontrolled
250.21 /Diabetes with hyperosmolarity, type i [juvenile type], not stated as uncontrolled
250.22 /Diabetes with hyperosmolarity, type ii or unspecified type, uncontrolled
250.23 /Diabetes with hyperosmolarity, type i [juvenile type], uncontrolled
250.30 /Diabetes with other coma, type ii or unspecified type, not stated as uncontrolled
250.31 /Diabetes with other coma, type i [juvenile type], not stated as uncontrolled
250.32 /Diabetes with other coma, type ii or unspecified type, uncontrolled
250.33 /Diabetes with other coma, type i [juvenile type], uncontrolled
250.40 /Diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled
250.41 /Diabetes with renal manifestations, type i [juvenile type], not stated as uncontrolled
250.42 /Diabetes with renal manifestations, type ii or unspecified type, uncontrolled
250.43 /Diabetes with renal manifestations, type i [juvenile type], uncontrolled
250.50 /Diabetes with ophthalmic manifestations, type ii or unspecified type, not stated as uncontrolled
250.51 /Diabetes with ophthalmic manifestations, type i [juvenile type], not stated as uncontrolled
250.52 /Diabetes with ophthalmic manifestations, type ii or unspecified type, uncontrolled
250.53 /Diabetes with ophthalmic manifestations, type i [juvenile type], uncontrolled
250.60 /Diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled
250.61 /Diabetes with neurological manifestations, type i [juvenile type], not stated as uncontrolled
250.62 /Diabetes with neurological manifestations, type ii or unspecified type, uncontrolled
250.63 /Diabetes with neurological manifestations, type i [juvenile type], uncontrolled
250.70 /Diabetes with peripheral circulatory disorders, type ii or unspecified type, not stated as uncontrolled
250.71 /Diabetes with peripheral circulatory disorders, type i [juvenile type], not stated as uncontrolled
250.72 /Diabetes with peripheral circulatory disorders, type ii or unspecified type, uncontrolled
250.73 /Diabetes with peripheral circulatory disorders, type i [juvenile type], uncontrolled
250.80 /Diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled
250.81 /Diabetes with other specified manifestations, type i [juvenile type], not stated as uncontrolled
250.82 /Diabetes with other specified manifestations, type ii or unspecified type, uncontrolled
250.83 /Diabetes with other specified manifestations, type i [juvenile type], uncontrolled
250.90 /Diabetes with unspecified complication, type ii or unspecified type, not stated as uncontrolled
250.91 /Diabetes with unspecified complication, type i [juvenile type], not stated as uncontrolled
250.92 /Diabetes with unspecified complication, type ii or unspecified type, uncontrolled
250.93 /Diabetes with unspecified complication, type i [juvenile type], uncontrolled
357.2 / Polyneuropathy in diabetes362.0x / Diabetic retinopathy
362.01 / Background diabetic retinopathy
362.02 / Proliferative diabetic retinopathy
362.03 / Nonproliferative diabetic retinopathy nos
362.04 /
Mild nonproliferative diabetic retinopathy
362.05 /Moderate nonproliferative diabetic retinopathy
362.06 /Severe nonproliferative diabetic retinopathy
362.07 /Diabetic macular edema
366.41 / Diabetic cataract648.0x / Complication of pregnancy, diabetes mellitus, excluding gestational diabetes
648.00 / Diabetes mellitus of mother complicating pregnancy childbirth or the puerperium unspecified as to episode of care
648.01 / Diabetes mellitus of mother with delivery
648.02 / Diabetes mellitus of mother with delivery with postpartum complication
648.03 / Antepartum diabetes mellitus
648.04 / Postpartum diabetes mellitus
Table D-2: Office Visit Encounter Codes (Outpatient) Diabetes Note: Will be removed and replace with value set references, including ICD-10 codes
CPT Codes / Description99201-99205 / Office or OPa visit E&Mb, new patient
99212-99215 / Office or OP visit E&M, established patient
99241-99245 / Office or other OP consultations
99347-99350 / Home visit for evaluation and management of an established patient
99384-99387 / Initial preventive medicine E&Mb
99394-99397 / Periodic preventive medicine E&Mb
99401-99404 / Preventive medicine counseling
99411 / Preventive medicine counseling, group
99412 / Preventive medicine counseling, group
99420 / Risk assessment, admin and interpretation
99429 / Unlisted preventive medicine service
HCPCS Code / Description
G0344
(deleted 12/31/08) / Initial preventive physical examination; face-to-face visit services limited to new beneficiary during the first six months of Medicare enrollment
G0402
(Effective 01/01/09) / Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
G0438 / Annual wellness visit; includes a personalized prevention plan of service, initial visit
G0439 / Annual wellness visit; includes a personalized prevention plan of service, subsequent visit
a outpatient
b evaluation and management
Diabetes Care Annual Review –Draft 2014
This specification is updated annually; refer to previous versions for coding and other changes
1
WCHQ Ambulatory Measure Specification
Diabetes Care Performance Measures
Measurement Period 01/01/2013-12/31/2013
Submission Period: 03/03/14 - 03/14/14
Figure D-1: Denominator Flow
Diabetes Care Annual Review –Draft 2014
This specification is updated annually; refer to previous versions for coding and other changes
1
WCHQ Ambulatory Measure Specification
Diabetes Care Performance Measures
Measurement Period 01/01/2013-12/31/2013