measure names: diabetes hba1c test owner: …measure names: diabetes hba1c test owner: ncqa (cdc)...
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Measure Names: Diabetes HbA1c Test Owner: NCQA (CDC)
Diabetes Lipid Test Diabetes Microalbumin Test for Nephropathy Diabetes Eye Exam
Measure Code: HBA, LDL, MIC, EYE Lab Data: Y
Rule Description: 1) The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who had a hemoglobin A1c (HbA1c) test. 2) The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who had an LDL-C screen. 3) The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who had medical attention for nephropathy. 4) The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who had an eye exam (retinal) performed.
Applicable Provider Specialties: Mixed Specialties Clinic, Family Medicine, Internal Medicine, Geriatric Medicine, Endocrinology, Nephrology (except for nephropathy measure), Cardiovascular (for Diabetes Lipid measure only)
General Requirement Summary and Supporting Information
1. Continuous enrollment: 1 year 2. Anchor date: 31st December of the measurement year 3. Gaps in enrollment: One 45-day gap allowed in each year of continuous enrollment 4. Medical coverage: Yes 5. Drug coverage: No 6. Attribution time frame: 1 year 7. Exclusions apply: Yes 8. Age range: 18-75 years
Summary of changes for 2011
1. Deleted 022* from Table CDC-C2: CPT and Revenue codes for Acute inpatient or emergency room visit type
2. Deleted 077* from Table CDC-C1: CPT and Revenue codes for Outpatient and Nonacute inpatient visit type
3. Deleted CPT code 67038 from Table CDC-I: CPT and HCPCS codes to identify eye exams
4. Added LOINC codes 56553-1, 57369-1, 58448-2, 58992-9, 59159-4 to Table CDC- J: Codes to identify Nephropathy Screening Tests
5. Added CPT code 36147 to Table CDC-K: CPT, HCPCS and Revenue codes to identify evidence of nephropathy
6. Added LOINC code 59261-8 to Table CDC-D: Codes to identify HbA1c tests
7. Updated links to HEDIS 2011 NDC lists
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Denominator: Denominator criteria are identical across all diabetes measures. In order to keep the qualifying denominators consistent across all measures, the exclusions are applied universally (i.e., not dependent on the numerator being negative). Denominator Description: All patients aged 18-75 at the end of the measurement year with a diagnosis of type 1 or type 2 diabetes.
Inclusion Criteria: Patients who meet the age requirement in the measurement year and meet at least one of the three event conditions that identify diabetes in either the measurement year or the year prior to the measurement year.
Eligibility Criteria:
Condition # Evnt Detailed Criteria Timeframe Description
Age is 18-75 Age in Years = 18-75 As of the end of the measurement year
AND
Has medical coverage Coverage Indicator Medical = Y During the measurement year
Claim Criteria
Condition Description # Evnt Detailed Criteria Timeframe
At least one ambulatory prescription for insulin or an oral hypoglycemic/ antihyperglycemic drug
1 Table CDC-A: Prescriptions to Identify Members With Diabetes HEDIS 2011NDC drug list is available at http://www.ncqa.org/tabid/1274/Default.aspx
OR Any Diagnosis code for Diabetes mellitus Table CDC-B: Codes to identify Diabetes And Any CPT procedure code for Outpatient or Nonacute inpatient visit type Table CDC-C1: CPT and Revenue codes for Outpatient and Nonacute inpatient visit type
Or
At least two face-to-face encounters with different dates of service in an ambulatory setting or nonacute inpatient setting with a diagnosis of diabetes
2 (dx and
place code must be on same claim as proc or rev code) (need 2
visits with diff dates of
service) Any Revenue Code UB for Outpatient or Nonacute inpatient visit type Table CDC-C1: CPT and Revenue codes for Outpatient and Nonacute inpatient visit type
During the measurement year or the year prior to measurement year
12/5/2012 Page 2
And Place of Service Code Medstat for Outpatient or Nonacute inpatient Table - Place of service code : Outpatient or Nonacute inpatient
OR Any Diagnosis code for Diabetes mellitus Table CDC-B: Codes to identify Diabetes and Any CPT Procedure Code for Acute inpatient or emergency room visit type Table CDC-C2: CPT and Revenue codes for Acute inpatient or emergency room visit type
Or Any Revenue Code UB for Acute inpatient or emergency room visit type Table CDC-C2: CPT and Revenue codes for Acute inpatient or emergency room visit type and
At least one face-to-face encounter in an inpatient or emergency room setting with a diagnosis of diabetes
1 (dx must be
on same claim as
proc or rev code/place code comb
Place of Service Code Medstat for Acute inpatient or emergency room Table- Place of service code: Acute
)
inpatient or emergency room
During the measurement year or the year prior to measurement year
Exclusion Criteria: Patients diagnosed with polycystic ovaries, gestational diabetes, or steroid-induced diabetes anytime on or before the end of the measurement year, and there are no face-to face encounters for diabetes in either the measurement year or the year prior to the measurement year (*look-back is limited to measurement year and year prior to measurement year as this was judged adequate for case finding)
Condition # Evnt Detailed Criteria Timeframe Description
(History of polycystic ovaries
1 Diagnosis Code for polycystic ovaries Table CDC-N: Codes to identify exclusions
Anytime prior to or during the measurement year*
AND No face-to-face encounters in any setting with a diagnosis of diabetes
1 No diagnosis for code for Diabetes mellitus, Table CDC-B: Codes to identify Diabetes
During the measurement year or the year prior to measurement year
12/5/2012 Page 3
OR
History of gestational diabetes or steroid-induced diabetes)
1 Any Diagnosis Code for gestational diabetes or steroid-induced diabetes Table CDC-N: Codes to identify exclusions
Anytime prior to or during the measurement year*
AND No face-to-face encounters in any setting with a diagnosis of diabetes
1 No diagnosis for code for Diabetes mellitus, Table CDC-B: Codes to identify Diabetes
During the measurement year or the year prior to measurement year
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HbA1c Test Numerator
Numerator Description: For each patient who meets the denominator criteria, those who received an HbA1c test during the measurement year
Inclusion Criteria: Patients who had one or more hemoglobin A1c (HbA1C) tests during the measurement year
Condition # Detailed Criteria Timeframe Description Evnt
CPT Procedure Code for HbA1c tests Table CDC-D: Codes to identify HbA1c tests
Or
At least one HbA1c test performed
1
LOINC for HbA1c Table CDC-D: Codes to identify HbA1c tests
During the measurement year
Lipid Test Numerator
Numerator Description: For each patient who meets the denominator criteria, those who received an LDL-C test during the measurement year
Inclusion Criteria: Patients who had one or more lipid (LDL-C) tests during the measurement year
Condition # Detailed Criteria Timeframe Description Evnt
CPT Procedure Code for LDL-C tests Table CMC-D: Codes to identify LDL-C Screening
Or
At least one LDL-C test performed
1
LOINC for LDL-C tests Table CMC-D: Codes to identify LDL-C Screening
During the measurement year
Microalbumin Test Numerator
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Numerator Description: For each patient who meets the denominator criteria, those who had screening for nephropathy or evidence of nephropathy during the measurement year
Inclusion Criteria: Patients who received a urine microalbumin test or had evidence of nephropathy, as demonstrated by medical attention for nephropathy or a visit to a nephrologist, during the measurement year
Condition Description
# Evnt Detailed Criteria Timeframe
CPT Procedure Code for urine microalbumin test Table CDC- J: Codes to identify Nephropathy Screening Tests
Or
At least one urine microalbumin test performed
1
LOINC for urine microalbumin Table CDC- J: Codes to identify Nephropathy Screening Tests
During the measurement year
OR
Evidence of visit to a nephrologist
1 Provider Type Code Claim Medstat 290= Nephrology 413= Pediatrics, other specialty
During the measurement year
OR
Any Diagnosis Code for evidence of nephropathy Table CDC-K: ICD Codes to identify evidence of nephropathy
Or
CPT Procedure Codes for evidence of nephropathy Table CDC-K: CPT, HCPCS and Revenue codes to identify evidence of nephropathy
Or
HCPCS Procedure Codes for evidence of nephropathy Table CDC-K: CPT,HCPCS and Revenue codes to identify evidence of nephropathy
Or
Evidence of diagnosis of or treatment for nephropathy
1
ICD 9 Procedure Codes for treatment of nephropathy Table CDC-K: ICD Codes to identify evidence of nephropathy
During the measurement year
Or
Revenue Code UB Table CDC-K: CPT,HCPCS and Revenue
During the measurement year
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codes to identify evidence of nephropathy
Or
Bill Type Code UB = 72*
Or
Place of Service Code Medstat 65= End-Stage Renal Disease Facility)
OR
(CPT Procedure Code for ACE inhibitor/ARB therapy prescribed= 4009F
Or
ACE inhibitor/ARB therapy
1
Table CDC-L: ACE Inhibitors/ARBs HEDIS 2011 NDC drug list is available at http://www.ncqa.org/tabid/1274/Default.aspx
During the measurement year
Eye Exam Numerator
Numerator Description: For each patient who meets the denominator criteria, those who received a retinal or dilated eye exam by an optometrist or ophthalmologist during the measurement year
Inclusion Criteria: Patients who had at least one retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) during the measurement year
Condition Description # Evnt Detailed Criteria Timeframe
Provider Type Code Claim Medstat = 330, 415, 830, 945 and (CPT Procedure Codes for eye exams Table CDC-I: CPT and HCPCS codes to identify eye exams
Or Provider Type Code Claim Medstat = 330, 415, 830, 945 and HCPCS Procedure Codes for eye exams Table CDC-I: CPT and HCPCS codes to identify eye exams
During the measurement year
Or
At least one retinal or dilated eye exam by an eye care professional as dx or
proc code
Provider Type Code Claim Medstat = 330, 415, 830, 945
During the measurement year
1 (prov type must be on same claim
)
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and Diagnosis Code V720 = Examinations of eyes and vision Table CDC-I : ICD codes to identify eye exams
Or CPT Category II codes for eye exams Table CDC-I: CPT and HCPCS codes to identify eye exams
Or ICD9 Procedure Codes for eye exams) Table CDC-I : ICD codes to identify eye exams
Appendix
Table CDC-A: Prescriptions to Identify Members with Diabetes
Description Prescription Alpha-glucosidase inhibitors acarbose miglitol Amylin analogs pramlinitide Antidiabetic combinations glimepiride-pioglitazone
glimepiride-rosiglitazone glipizide-metformin
glyburide-me metformin- metformin-
metformin-rosiglitazone tformin pioglitazone repaglinide
metformin-sitagliptin
Insulin insulin aspart insulin aspart-insulin aspart protamine insulin detemir insulin glargine insulin glulisine insulin inhalation insulin isophane beef-pork insulin isophane human insulin isophane pork insulin isophane-insulin regular
insulin lispro insulin lispro-insulin lispro protamine insulin regular beef-pork insulin regular human insulin regular pork insulin zinc beef-pork insulin zinc extended human insulin zinc human insulin zinc pork
Meglitinides repaglinide nateglinide Miscellaneous antidiabetic agents
exenatide sitagliptin saxagliptin
Sulfonylureas acetohexamide chlorpropamide
glimepiride glipizide
glyburide tolazamide
tolbutamide
Thiazolidinediones pioglitazone rosiglitazone
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Table CDC-B: Codes to identify Diabetes ICD Diagnosis Description code 250 Diabetes mellitus 250.00 Diabetes mellitus without mention of complication, type II or unspecified, not stated
as uncontrolled 250.01 Diabetes mellitus without mention of complication, type I juvenile, not stated as
uncontrolled 250.02 Diabetes mellitus without mention of complication, type II or unspecified,
uncontrolled 250.03 Diabetes mellitus without mention of complication, type I, juvenile uncontrolled 250.1 Diabetes with ketoacidosis, type II or unspecified, not stated as uncontrolled 250.11 Diabetes with ketoacidosis, type I juvenile, not stated as uncontrolled 250.12 Diabetes with ketoacidosis, type II or unspecified, uncontrolled 250.13 Diabetes with ketoacidosis, type I, juvenile uncontrolled 250.2 Diabetes with hyperosmolarity, type II or unspecified, not stated as uncontrolled 250.21 Diabetes with hyperosmolarity, type I juvenile, not stated as uncontrolled 250.22 Diabetes with hyperosmolarity, type II or unspecified, uncontrolled 250.23 Diabetes with hyperosmolarity, type I, juvenile uncontrolled 250.3 Diabetes with other coma, type II or unspecified, not stated as uncontrolled 250.31 Diabetes with other coma, type I juvenile, not stated as uncontrolled 250.32 Diabetes with other coma,type II or unspecified, uncontrolled 250.33 Diabetes with other coma, type I, juvenile uncontrolled 250.4 Diabetes with renal manifestations, type II or unspecified, not stated as uncontrolled 250.41 Diabetes with renal manifestations, type I juvenile, not stated as uncontrolled 250.42 Diabetes with renal manifestations, type II or unspecified, uncontrolled 250.43 Diabetes with renal manifestations, type I, juvenile uncontrolled 250.5 Diabetes with ophthalmic manifestations, type II or unspecified, not stated as
uncontrolled 250.51 Diabetes with ophthalmic manifestations, type I juvenile, not stated as uncontrolled 250.52 Diabetes with ophthalmic manifestations, type II or unspecified, uncontrolled 250.53 Diabetes with ophthalmic manifestations, type I, juvenile uncontrolled 250.6 Diabetes with neurological manifestations, type II or unspecified, not stated as
uncontrolled 250.61 Diabetes with neurological manifestations, type I juvenile, not stated as uncontrolled 250.62 Diabetes with neurological manifestations, type II or unspecified, uncontrolled 250.63 Diabetes with neurological manifestations, type I, juvenile uncontrolled 250.7 Diabetes with peripheral circulatory disorders, type II or unspecified, not stated as
uncontrolled
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250.71 Diabetes with peripheral circulatory disorders, type I juvenile, not stated as uncontrolled
250.72 Diabetes with peripheral circulatory disorders, type II or unspecified, uncontrolled 250.73 Diabetes with peripheral circulatory disorders, type I, juvenile uncontrolled 250.8 Diabetes with other specified manifestations, type II or unspecified, not stated as
uncontrolled 250.81 Diabetes with other specified manifestations, type I juvenile, not stated as
uncontrolled 250.82 Diabetes with other specified manifestations, type II or unspecified, uncontrolled 250.83 Diabetes with other specified manifestations, type I, juvenile uncontrolled 250.9 Diabetes with unspecified complication, type II or unspecified, not stated as
uncontrolled 250.91 Diabetes with unspecified complication, type I juvenile, not stated as uncontrolled 250.92 Diabetes with unspecified complication, type II or unspecified, uncontrolled 250.93 Diabetes with unspecified complication, type I, juvenile uncontrolled 357.2 Polyneuropathy in diabetes 362.0 Diabetic retinopathy 362.01 Background Diabetic retinopathy 362.02 Proliferative Diabetic retinopathy 362.03 Nonproliferative Diabetic retinopathy 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 cataract 648.0 Diabetes mellitus complicating pregnancy, childbirth, peurperium
Table CDC-C1: CPT and Revenue codes for Outpatient and Nonacute inpatient visit type
CPT Procedure code Description: Outpatient Visit 92002 New patient, Ophthalmological services, intermediate 92004 New patient, Ophthalmological services, comprehensive 92012 Established patient, Ophthalmological services, intermediate 92014 Established patient, Ophthalmological services, comprehensive 99201 New patient, office or other outpatient service 99202 New patient, office or other outpatient service 99203 New patient, office or other outpatient service
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99204 New patient, office or other outpatient service 99205 New patient, office or other outpatient service 99211 Established patient, office or other outpatient service 99212 Established patient, office or other outpatient service 99213 Established patient, office or other outpatient service 99214 Established patient, office or other outpatient service 99215 Established patient, office or other outpatient service 99217 Hospital observation services, observation care discharge services 99218 Hospital observation services, intial observation care, New or established patient 99219 Hospital observation services, intial observation care, New or established patient 99220 Hospital observation services, intial observation care, New or established patient 99241 Office or other outpatient consultations, New or established patient 99242 Office or other outpatient consultations, New or established patient 99243 Office or other outpatient consultations, New or established patient 99244 Office or other outpatient consultations, New or established patient 99245 Office or other outpatient consultations, New or established patient 99341 Home services, New patient 99342 Home services, New patient 99343 Home services, New patient 99344 Home services, New patient 99345 Home services, New patient 99347 Home services, Established patient 99348 Home services, Established patient 99349 Home services, Established patient 99350 Home services, Established patient 99384 Preventive medicine services, 12-17 years, new patient 99385 Preventive medicine services, 12-17 years, new patient 99386 Preventive medicine services, 12-17 years, new patient 99387 Preventive medicine services, 12-17 years, new patient 99394 Preventive medicine services, 12-17 years, established patient 99395 Preventive medicine services, 12-17 years, established patient 99396 Preventive medicine services, 12-17 years, established patient 99397 Preventive medicine services, 12-17 years, established patient 99401 Preventive medicine, individual counseling, new or established, 15 min 99402 Preventive medicine, individual counseling, new or established, 30 min 99403 Preventive medicine, individual counseling, new or established, 45 min 99404 Preventive medicine, individual counseling, new or established, 60 min 99411 Preventive medicine, group counseling, 30 min
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99412 Preventive medicine, group counseling, 60 min 99420 Other preventive medicine services, adminstration and interpretion 99429 Other preventive medicine services, unlisted 99455 Work related or medical disability evaluation services 99456 Work related or medical disability evaluation services Revenue code UB Description: Outpatient Visit 0510 CLINIC 0511 CHRONIC PAIN CL 0512 DENTAL CLINIC 0513 PSYCH CLINIC 0514 OB-GYN CLINIC 0515 PEDS CLINIC 0516 URGENT CLINIC 0517 FAMILY CLINIC 0519 OTHER CLINIC 0520 FREESTAND CLINIC 0521 RURAL/CLINIC 0522 RURAL/HOME 0523 FR/STD FAMILY CLINIC 0526 FR/STD URGENT CLINIC 0527 FR/STD URGENT CLINIC 0528 FR/STD URGENT CLINIC 0529 OTHER FR/STD CLINIC 0570 AIDE/HOME HEALTH 0571 AIDE/HOME HEALTH/VISIT 0572 AIDE/HOME HEALTH/HOUR 0579 AIDE/HOME HEALTH/OTHER 0580 VISIT/HOME HLTH 0581 VISIT/HOME HLTH/VISIT 0582 VISIT/HOME HLTH/HOUR 0583 VISIT/HOME HLTH/ASSES 0589 VISIT/HOME HLTH/OTHER 0590 UNIT/HOME HEALTH 0599 UNIT/HOME HEALTH/OTHER 0820 HEMO/OP OR HOME 0821 HEMO/ COMPOSITE 0822 HEMO/HOME/SUPPL 0823 HEMO/HOME/EQUIP
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0824 HEMO/HOME/100% 0825 HEMO/HOME/SUPSERV 0829 HEMO/HOME/OTHER 0830 PERITONEAL/OP OR HOME 0831 PERITONEAL/ COMPOSITE 0832 PERITONEAL/HOME/SUPP 0833 PERITONEAL/HOME/EQUIP 0834 PERITONEAL/HOME/100% 0835 PERITONEAL/HOME/SUPSERV 0839 PERITONEAL/HOME/OTHER 0840 CAPD/OP OR HOME 0841 CAPD/ COMPOSITE 0842 CAPD/HOME/SUPP 0843 CAPD/HOME/EQUIP 0844 CAPD/HOME/100% 0845 CAPD/HOME/SUPSERV 0849 CAPD/HOME/OTHER 0850 CCPD/OP OR HOME 0851 CCPD/COMPOSITE 0852 CCPD/HOME/SUPPL 0853 CCPD/HOME/EQUIP 0854 CCPD/HOME/100% 0855 CCPD/HOME/SUPSERV 0859 CCPD/HOME/OTHER 0880 DIALY/MISC 0881 DIALY/ULTRAFILT 0882 HOME DIALYSIS AID VISIT 0889 DIALY/MISC/OTHER 0982 PRO FEE/OUTPT 0983 PRO FEE/CLINIC
CPT Procedure code Description: Nonacute inpatient visit 99304 Initial Nursing facility care, New or established patient 99305 Initial Nursing facility care, New or established patient 99306 Initial Nursing facility care, New or established patient 99307 Subsequent nursing facility care 99308 Subsequent nursing facility care
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99309 Subsequent nursing facility care 99310 Subsequent nursing facility care 99315 Nursing facility discharge services 99316 Nursing facility discharge services 99318 Other Nursing facility services 99324 Domiciliary, rest home or custodial care services, New patient 99325 Domiciliary, rest home or custodial care services, New patient 99326 Domiciliary, rest home or custodial care services, New patient 99327 Domiciliary, rest home or custodial care services, New patient 99328 Domiciliary, rest home or custodial care services, New patient 99334 Domiciliary, rest home or custodial care services, established patient 99335 Domiciliary, rest home or custodial care services, established patient 99336 Domiciliary, rest home or custodial care services, established patient 99337 Domiciliary, rest home or custodial care services, established patient Revenue code UB Description: Nonacute inpatient visit 0118 REHAB/PVT 0128 REHAB/2BED 0138 REHAB/3&4 BED 0148 REHAB/PVT/DLX 0158 REHAB/WARD 0190 SUBACUTE 0191 SUBACUTE/LEVEL I 0192 SUBACUTE/LEVEL II 0193 SUBACUTE/ LEVEL III 0194 SUBACUTE/ IV 0199 SUBACUTE/OTHER 0524 FR/STD FAMILY CLINIC 0525 FR/STD FAMILY CLINIC 0550 SKILLED NURSING 0551 SKILLED NUR/VISIT 0552 SKILLED NUR/HOUR 0559 SKILLED NURS/OTHER 0660 RESPITE CARE 0661 RESPITE NURSE 0662 RESPITE /AID/HMEMKE/COMP 0663 RESPITE/DAILY 0669 RESPITE/CARE
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Table - Place of service code : Outpatient or Nonacute inpatient Medstat Place
Medstat Place of Service of Service Code
4 Homeless Shelter 5 Indian Hlth Svc Free-stand Fac 6 Indian Hlth Svc Prov-based Fac 7 Tribal 638 Free-standing Fac 8 Tribal 638 Provider-based Fac 9 Prison-Correctional Facility
11 Office 12 Patient Home 15 Mobile Unit 20 Urgent Care Facility 22 Outpatient Hospital 24 Ambulatory Surgical Center 26 Military Treatment Facility 49 Independent Clinic 50 Federally Qualified Health Ctr 52 Psych Facility Partial Hosp 53 Community Mental Health Center 57 Non-resident Subst Abuse Facil 61 Comprehensive Inpt Rehab Fac 62 Comprehensive Outpt Rehab Fac 65 End-Stage Renal Disease Facil 71 Public Health Clinic 72 Rural Health Clinic 95 Outpatient, NOS
99 ~
Table CDC-C2: CPT and Revenue codes for Acute inpatient or emergency room visit type
CPT Procedure code Description: Acute inpatient 99221 Initial hospital services, new or established patient 99222 Initial hospital services, new or established patient
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99223 Initial hospital services, new or established patient 99231 Subsequent hospital care 99232 Subsequent hospital care 99233 Subsequent hospital care 99238 Hospital discharge services 99239 Hospital discharge services 99251 Inpatient consultations, new or established patient 99252 Inpatient consultations, new or established patient 99253 Inpatient consultations, new or established patient 99254 Inpatient consultations, new or established patient 99255 Inpatient consultations, new or established patient 99291 Critical care, evaluation and management Revenue code UB Description: Acute inpatient 0100 ALL INCL R&B/ANC 0101 ALL INCL R&B 0110 ROOM-BOARD/PVT 0111 MED-SUR-GY/PVT 0112 OB/PVT 0113 PEDS/PVT 0114 PSYCH/PVT 0119 OTHER/PVT 0120 ROOM-BOARD/SEMI 0121 MED-SUR-GY/2BED 0122 OB/2BED 0123 PEDS/2BED 0124 PSYCH/2BED 0129 OTHER/2BED 0130 ROOM-BOARD/3&4BED 0131 MED-SUR-GY/3&4BED 0132 OB/3&4BED 0133 PEDS/3&4BED 0134 PSYCH/3&4BED 0139 OTHER/3&4BED 0140 ROOM-BOARD/PVT/DLX 0141 MED-SUR-GY/PVT/DLX 0142 OB/PVT/DLX 0143 PEDS/PVT/DLX 0144 PSYCH/PVT/DLX
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0149 OTHER/PVT/DLX 0150 ROOM-BOARD/WARD 0151 MED-SUR-GY/WARD 0152 OB/WARD 0153 PEDS/WARD 0154 PSYCH/WARD 0159 OTHER/WARD 0160 R&B 0164 R&B/STERILE 0167 R&B/SELF 0169 R&B/OTHER 0200 ICU 0201 ICU/SURGICAL 0202 ICU/MEDICAL 0203 ICU/PEDS 0204 ICU/PSTAY 0206 ICU/INTERMEDIATE 0207 ICU/BURN CARE 0208 ICU/TRAUMA 0209 ICU/OTHER 0210 CORONARY CARE 0211 CCU/MYO INFARC 0212 CCU/PULMONARY 0213 CCU/TRANSPLANT 0214 CCU/INTERMEDIATE 0219 CCU/OTHER 0720 DELIVROOM/LABOR 0721 LABOR 0722 DELIVERY ROOM 0723 CIRCUMCISION 0724 BIRTHING CENTER 0729 OTHER/DELIV-LABOR 0800 RENAL DIALYSIS 0801 DIALY/INPT 0802 DIALY/INPT/PER 0803 DIALY/INPT/CAPD 0804 DIALY/INPT/CCPD 0809 DIALY/INPT/OTHER
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0987 PRO FEE/HOS VIS
CPT Procedure code Description: Emergency Department 99281 Emergency services, new or established patient 99282 Emergency services, new or established patient 99283 Emergency services, new or established patient 99284 Emergency services, new or established patient 99285 Emergency services, new or established patient Revenue code UB Description: Emergency Department 0450 EMERG ROOM 0451 ER/EMTALA 0452 ER/BEYOND EMTALA 0456 URGENT CARE 0459 OTHER EMER ROOM 0981 PRO FEE/ER
Table - Place of service code: Acute inpatient or emergency room visit type Medstat Place
Medstat Place of Service of Service Code
21 Inpatient Hospital 23 Emergency Room - Hospital 25 Birthing Center 51 Inpatient Psychiatric Facility 55 Residential Subst Abuse Facil
Table CDC-N: Codes to identify exclusions ICD DIAGNOSIS Description 249 Secondary diabetes mellitus 256.4 Polycystic ovaries 251.8 Other specified disorders of pancreatic internal secretion 648.8 Gestational diabetes 962.0 Poisoning by hormones and synthetic substitutes, adrenal cortical steroids
Table CDC-D: Codes to identify HbA1c tests
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CPT code Description 83036 Glycosylated Hemoglobin A1C 83037 Glycosylated Hemoglobin A1C, for home use CPT Category II Description 3044F HbA1c less than 7.0% 3045F HbA1c 7.0%- 9% 3046F HbA1c greater than 9.0% LOINC Description 4548-4 HbA1c tests 4549-2 HbA1c tests 17856-6 HbA1c tests 59261-8 HbA1c tests
Table CMC-D: Codes to identify LDL-C Screening CPT code Description 80061 Lipid panel 83700 Lipoprotein, blood 83701 Lipoprotein, blood 83704 Lipoprotein, blood 83721 Lipoprotein, LDL cholesterol CPT Category II Description 3048F Most recent LDL-C, less than 100mg/dl 3049F Most recent LDL-C, 100-139mg/dl 3050F Most recent LDL-C, greater than or equal to 130mg/dl LOINC Description 2089-1 LDL-C tests 12773-8 LDL-C tests 13457-7 LDL-C tests 18261-8 LDL-C tests 18262-6 LDL-C tests 22748-8 LDL-C tests 39469-2 LDL-C tests 49132-4 LDL-C tests 55440-2 LDL-C tests
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Table CDC- J: Codes to identify Nephropathy Screening Tests CPT code Description 82042 Albumin, urine, quantitative 82043 Urine, microalbumin, quantitative 82044 Urine, microalbumin, semiquantitative 84156 Protein, total, urine CPT Category II Description 3060F Positive microalbuminuria test result documented 3061F Negative microalbuminuria test result documented LOINC Description 1753-3 Nephropathy screening test 1754-1 Nephropathy screening test 1755-8 Nephropathy screening test 1757-4 Nephropathy screening test 2887-8 Nephropathy screening test 2888-6 Nephropathy screening test 2889-4 Nephropathy screening test 2890-2 Nephropathy screening test 9318-7 Nephropathy screening test 11218-5 Nephropathy screening test 12842-1 Nephropathy screening test 13801-6 Nephropathy screening test 14585-4 Nephropathy screening test 18373-1 Nephropathy screening test 20621-9 Nephropathy screening test 21059-1 Nephropathy screening test 21482-5 Nephropathy screening test 26801-1 Nephropathy screening test 27298-9 Nephropathy screening test 30000-4 Nephropathy screening test 30001-2 Nephropathy screening test 30003-8 Nephropathy screening test 32209-9 Nephropathy screening test 32294-1 Nephropathy screening test 32551-4 Nephropathy screening test 34366-5 Nephropathy screening test 34535-5 Nephropathy screening test
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35663-4 Nephropathy screening test 40486-3 Nephropathy screening test 40662-9 Nephropathy screening test 40663-7 Nephropathy screening test 43605-5 Nephropathy screening test 43606-3 Nephropathy screening test 43607-1 Nephropathy screening test 44292-1 Nephropathy screening test 14956-7 Nephropathy screening test 14957-5 Nephropathy screening test 14958-3 Nephropathy screening test 14959-1 Nephropathy screening test 13705-9 Nephropathy screening test 47558-2 Nephropathy screening test 49023-5 Nephropathy screening test 50561-0 Nephropathy screening test 50949-7 Nephropathy screening test 53121-0 Nephropathy screening test 53525-2 Nephropathy screening test 53530-2 Nephropathy screening test 53531-0 Nephropathy screening test 53532-8 Nephropathy screening test 56553-1 Nephropathy screening test 57369-1 Nephropathy screening test 58448-2 Nephropathy screening test 58992-9 Nephropathy screening test 59159-4 Nephropathy screening test
CDC-K: ICD Codes to identify evidence of nephropathy ICD-9 CM diagnosis
Description: Evidence of treatment for nephropathy
250.4 Diabetes with renal manifestation 403 Hypertensive chronic kidney disease 404 Hypertensive heart and chronic kidney disease 405.01 Secondary hypertension, malignant, renovascular 405.11 Secondary hypertension, benign, renovascular 405.91 Secondary hypertension, unspecified, renovascular
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580 Acute glomerulonephritis with lesion of proliferative glomerulonephritis 581 Nephrotic syndrome 582 Chronic glomerulonephritis 583 Nephritis and nephropathy, not specified as acute or chronic with lesion of
proliferative glomerulonephritis 584 Acute kidney failure 585 Chronic kidney disease 586 Renal failure, unspecified 587 Renal sclerosis, unspecified 588 Disorders resulting from impaired renal function 753.0 Renal agenesis and dysgenesis 753.1 Cystic kidney disease 791.0 Proteinuria V42.0 Organ or tissue replaced by transplant, kidney V45.1 Renal dialysis status V56 Encounter for dialysis and dialysis catheter care ICD-9-CM Procedure
Description: Evidence of treatment for nephropathy
38.95 Venous catheterization for renal dialysis 39.27 Arteriovenostomy for renal dialysis 39.42 Revision of arteriovenous shunt for renal dialysis 39.43 Removal of arteriovenous shunt for renal dialysis 39.53 Repair of arteriovenous fistula 39.93 Insertion of vessal to vessal cannula 39.94 Replacement of vessal to vessal cannula 39.95 Hemodialysis 54.98 Peritoneal dialysis 55.4 Partial nephrectomy 55.5 Complete nephrectomy 55.6 Transplant of kidney
Table CDC-K: CPT, HCPCS and Revenue codes to identify evidence of nephropathy CPT code Description: Evidence of treatment for nephropathy 36145 introduction of needle or catheter, arteriovenous shunt for dialysis, 36147 introduction of needle or catheter, arteriovenous shunt for dialysis 36800 Insertion of cannula for hemodialysis, vein to vein 36810 Insertion of cannula for hemodialysis, arteriovenous
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36815 Insertion of cannula for hemodialysis, arteriovenous 36818 Arteriovenous anastomosis, open upper arm cephalic vein transposition 36819 Arteriovenous anastomosis, upper arm basilic vein transposition 36820 Arteriovenous anastomosis, forearm vein transposition 36821 Arteriovenous anastomosis, direct any site 36831 Arteriovenous fistula, without revision autogenous or nonautogenous dialysis graft,
thrombectomy 36832 Arteriovenous fistula, revision autogenous or nonautogenous dialysis graft, without
thrombectomy 36833 Arteriovenous fistula, autogenous or nonautogenous dialysis graft, thrombectomy 50300 Donor nephrectomy, from cadaver 50320 Donor nephrectomy, from living donor 50340 Recipient nephrectomy 50360 Renal allotransplantation, implantation of graft without recipient nephrectomy 50365 Renal allotransplantation, implantation of graft with recipient nephrectomy 50370 Removal of transplanted renal allograft 50380 Renal autotransplantation, reimplantation of kidney 90920 ESRD services, 12-19 years, 90921 ESRD services, 20 years and older, 90924 ESRD services, 12-19 years 90925 ESRD services, 20 years and older 90935 Hemodialysis procedure with physician evaluation 90937 Hemodialysis procedure with physician evaluation 90940 Hemodialysis access flow study to determine blood flow in grafts and arteriovenous
fistulae 90945 Dialysis procedure other than hemodialysis requiring physician evaluation 90947 Dialysis procedure other than hemodialysis requiring physician evaluation 90957 ESRD related services, 12-19 years 90958 ESRD related services, 12-19 years, 2-3 physician visits per month 90959 ESRD related services, 12-19 years, 1physician visit per month 90960 ESRD services, 20 years and older, 4 or more physician visits per month 90961 ESRD services, 20 years and older, 4 or more physician visits per month 90962 ESRD services, 20 years and older, 4 or more physician visits per month 90965 ESRD services, 12-19 years 90966 ESRD services, 20 years and older 90969 ESRD related services, 12-19 years 90970 ESRD services, 20 years and older 90989 Dialysis training,
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90993 Dialysis training, 90997 Hemoperfusion 90999 Unlisted dialysis procedure, inpatient or outpatient 99512 Home visit for hemodialysis 3066F Documentation of treatment for nephropathy HCPCS Description: Evidence of treatment for nephropathy G0257 Emergency dialysis treatment for ESRD G0314 ESRD related services, 12-19 years, 4 or more physician visits G0315 ESRD related services, 12-19 years, 2 or 3 physician visits G0316 ESRD related services, 12-19 years, 1 physician visits G0317 ESRD related services, 20 years and over, 4 or more physician visits G0318 ESRD related services, 20 years and over, 2-3 more physician visits G0319 ESRD related services, 20 years and over, 1 more physician visits G0322 ESRD related services, 12-19 years, dialysis, per month G0323 ESRD related services, 20 years, dialysis, per month G0326 ESRD related services, 12-19 years, dialysis, per day G0327 ESRD related services, 20 years, dialysis, per day G0392 Transluminal balloon angioplasty, hemodialysis access, arterial G0393 Transluminal balloon angioplasty, hemodialysis access, venous S9339 Home therapy, peritoneal dialysis UB Revenue Description: Evidence of treatment for nephropathy 0367 OR/KIDNEY TRANS 0800 RENAL DIALYSIS 0801 DIALY/INPT 0802 DIALY/INPT/PER 0803 DIALY/INPT/CAPD 0804 DIALY/INPT/CCPD 0809 DIALY/INPT/OTHER 0820 HEMO/OP OR HOME 0821 HEMO/COMPOSITE 0822 HEMO/HOME/SUPPL 0823 HEMO/HOME/EQUIP 0824 HEMO/HOME/100% 0825 HEMO/HOME/SUPSERV 0829 HEMO/HOME/OTHER 0830 PERITONEAL/OP OR HOME 0831 PERTNL/COMPOSITE 0832 PERTNL/HOME/SUPPL
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0833 PERTNL/HOME/EQUIP 0834 PERTNL/HOME/100% 0835 PERTNL/HOME/SUPSERV 0839 PERTNL/HOME/OTHER 0840 CAPD/OP OR HOME 0841 CAPD/ COMPOSITE 0842 CAPD/HOME/SUPPL 0843 CAPD/HOME/EQUIP 0844 CAPD/HOME/100% 0845 CAPD/HOME/SUPSERV 0849 CAPD/HOME/OTHER 0850 CCPD/OP OR HOME 0851 CCPD/COMPOSITE 0852 CCPD/HOME/SUPPL 0853 CCPD/HOME/EQUIP 0854 CCPD/HOME/100% 0855 CCPD/HOME/SUPSERV 0859 CCPD/HOME/OTHER 0880 DIALY/MISC 0881 DIALY/ULTRAFILT 0882 HOME DIALYSIS AID VISIT 0889 DIALY/MISC/OTHER
Table CDC-K: Codes to identify Urine Macroalbumin (not used since lab results are not generally available) CPT Codes Description 81000 Urinalysis, by dip stick or tablet 81001 Urinalysis, automated with microscopy 81002 Urinalysis, non automated, without microscopy 81003 Urinalysis, automated without microscopy 81005 Urinalysis, qualitative or semiquantitative, except immunoassays CPT Category II Description 3062F Positive macroalbuminuria test result documented and reviewed LOINC Description 5804-0 Urine Macroalbumin tests 20454-5 Urine Macroalbumin tests 50561-0 Urine Macroalbumin tests 53525-2 Urine Macroalbumin tests
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Table CDC-L: ACE Inhibitors/ARBs
Description Prescription Angiotensin converting enzyme inhibitors
lisinopril moexipril
perindopril quinapril
ramipril trandolapril
benazepril captopril
enalapril fosinopril
Angiotensin II inhibitors
candesartan eprosartan
irbesartan losartan
olmesartan valsartan telmisartan
Antihypertensive combinations
enazepril amlodipine-olmesartan amlodipine-valsartan amlodipine-hydrochlorothiazide-
valsartan aliskiren-valsartan benazepril-hydrochlorothiazide
candesartan-hydrochlorothiazide captopril-hydrochlorothiazide enalapril-hydrochlorothiazide eprosartan-hydrochlorothiazide fosinopril-hydrochlorothiazide hydrochlorothiazide-irbesartan hydrochlorothiazide-lisinopril
hydrochlorothiazide-losartan hydrochlorothiazide-moexipril hydrochlorothiazide-olmesartan hydrochlorothiazide-quinapril hydrochlorothiazide-telmisartan hydrochlorothiazide-valsartan trandolapril-verapamil
amlodipine-b
Table CDC-I: CPT and HCPCS codes to identify eye exams CPT Code Description 67028 Intravitreal injection of a pharmacologic agent 67030 Discission of vitreous strands 67031 Severing of vitreous strands 67036 Vitrectomy 67039 Vitrectomy 67040 Vitrectomy 67041 Vitrectomy 67042 Vitrectomy 67043 Vitrectomy 67101 Repair of retinal detachment 67105 Repair of retinal detachment 67107 Repair of retinal detachment 67108 Repair of retinal detachment 67110 Repair of retinal detachment 67112 Repair of retinal detachment 67113 Repair of retinal detachment 67121 Removal of implanted material, intraocular
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67141 Prophylaxis of retinal detachment 67145 Prophylaxis of retinal detachment 67208 Destruction of localized lesion of retina 67210 Destruction of localized lesion of retina 67218 Destruction of localized lesion of retina 67220 Destruction of localized lesion of choroid 67221 Destruction of localized lesion of choroid 67227 Destruction of progressive retinopathy 67228 Treatment of progressive retinopathy 92002 Ophthalmological services, New patient 92004 Ophthalmological services, New patient 92012 Ophthalmological services, established patient 92014 Ophthalmological services, established patient 92018 Special Ophthalmological services 92019 Special Ophthalmological services 92225 Ophthalmoscopy 92226 Ophthalmoscopy 92230 Ophthalmoscopy 92235 Ophthalmoscopy 92240 Ophthalmoscopy 92250 Ophthalmoscopy 92260 Ophthalmoscopy 99203 New patient, office or other outpatient service 99204 New patient, office or other outpatient service 99205 New patient, office or other outpatient service 99213 Established patient, office or other outpatient service 99214 Established patient, office or other outpatient service 99215 Established patient, office or other outpatient service 99242 Office or other outpatient consultations, New or established patient 99243 Office or other outpatient consultations, New or established patient 99244 Office or other outpatient consultations, New or established patient 99245 Office or other outpatient consultations, New or established patient CPT Category II Description 2022F Dilated retinal eye exam 2024F 7 standard field stereoscopic photos, documented and reviewed 2026F Eye imaging 3072F Low risk for retinopathy HCPCS Description
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S0620 Routine ophthalmological exam, new patient S0621 Routine ophthalmological exam, established patient S0625 Retinal telescreening by digital imaging of fundus S3000 Diabetic indicator, retinal eye exam, dilated, bilateral
Table CDC-I : ICD codes to identify eye exams ICD-9-CM diagnosis Description V72.0 Examinations of eyes and vision ICD-9-CM Procedure Description 14.1 Diagnostic procedures on retina, choroid, vitreous, and posterior chamber 14.2 Destruction of lesion of retina and choroid 14.3 Repair of retinal tear 14.4 Repair of retinal detachment with scleral buckling and implant 14.5 Other repair of retinal detachment 14.9 Other operations on retina, choroid, and posterior chamber 95.02 Comprehensive eye exam 95.04 Comprehensive eye exam under anesthesia 95.11 Fundus photography 95.12 Fluorescein angiography or angioscopy of eye 95.16 P32 and other tracer studies of eye