Product Lines:
Advantage MD, EHP, Priority Partners and USFHP.

Measurement Period: January 1 - December 31

Description:
The percentage of persons 18–75 years of age with diabetes (types 1 and 2) whose most recent glycemic status (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) was at the following levels during the measurement year:

• Glycemic Status <8.0%.
• Glycemic Status >9.0%.

*The most recent = closest to December 31 of measurement year.

The member is only compliant if the most recent HbA1c result is < 8.0 for EHP, Priority Partners/PHIP and USFHP.

Stratifications: 
Report stratification by race and ethnicity.

Measure Reporting:
CMS Start Rating Measure for HbA1c poor control (greater than 9.0%)
Population Health Incentive Program (PHIP).
HealthChoice Performance Measure reporting for Priority Partners. 

Improvement Notation:
Glycemic status <8.0%. Increased score indicates improvement.
Glycemic status >9.0%. Decreased score indicates improvement.

Data Collection:

• Administrative.
• Hybrid.
• Supplemental.

Initial Population:

• Measure Item Count: Person.
• Age:18–75 years of age as of the last day of the measurement period.
• Benefits: Medical.
• Continuous Enrollment: The measurement period.
• Allowable Gap: No more than one gap of ≤45 days during the measurement period. No gaps on the last day of the measurement period.

Denominator:
Persons with a diagnosis of diabetes. 
• Claim/encounter data. At least two diagnoses of diabetes on different dates of service during the measurement period or the year prior to the measurement period. 
• Pharmacy data. At least one diagnosis of diabetes and at least one diabetes medication dispensing event of insulin or a hypoglycemic/antihyperglycemic medication during the measurement period or the year prior to the measurement period. 

Numerator:
Numerator 1: Glycemic status <8%.
Persons with the most recent glycemic status assessment (HbA1c or GMI) (HbA1c Lab Test Value Set; HbA1c Test Result or Finding Value Set*†; LOINC code 97506-0) during the measurement period. If there are multiple glycemic status assessments on the same date of service, use the lowest result.

• Compliant: Most recent glycemic status assessment with a result of <8.0%.
• Not compliant: Most recent glycemic status assessment is ≥8.0%; is missing a result; or if a glycemic status assessment was not done during the measurement period.

If the most recent glycemic status assessment was an HbA1c test identified based on a CPT Category II code (HbA1c Test Result or Finding Value Set), use the following to determine compliance:

• Compliant: HbA1c Level Less Than 8.0 Value Set. 
• Not compliant: HbA1c Level Greater Than or Equal To 8.0 Value Set.

Numerator 2: Glycemic status >9%. 
Persons with the most recent glycemic status assessment (HbA1c or GMI) (HbA1c Lab Test Value Set; HbA1c Test Result or Finding Value Set*†; LOINC code 97506-0) during the measurement period. If there are multiple glycemic status assessments on the same date, use the lowest result. 

• Compliant: Most recent glycemic status assessment with a result of >9.0% or is missing a result, or if a glycemic status assessment was not done during the measurement period.
• Not compliant: Most recent glycemic status assessment during the measurement period is ≤9.0%.

If the most recent glycemic status assessment was an HbA1c test identified based on a CPT Category II code (HbA1c Test Result or Finding Value Set), use the following to determine compliance:

• Compliant: CPT Category II code 3046F.
• Not compliant: HbA1c Level Less Than or Equal To 9.0 Value Set. 

Best Practice and Measure Tips

• If multiple tests were performed in the measurement year, the result from the last test is required.
• Since the last value in the year is used, have member repeat elevated test prior to the end of the year.
• Documentation in the medical record must include a note indicating the date when the HbA1c test or GMI was performed and the result.
• GMI values must include documentation of the continuous glucose monitoring (CGM) data date range used to derive the value. The terminal date in the range should be used to assign assessment date.
• GMI results collected by the member from their CGM and documented in the member’s medical record are eligible for use in reporting (provided the GMI does not meet any exclusion criteria)
• If multiple glycemic status assessments were recorded for a single date, use the lowest result.
• Always list the date of service, result and test together.
• If test result(s) are documented in the vitals section of your progress notes, please include the date of the blood draw with the result. The date of the progress notes will not count.
• Schedule labs prior to patient appointments to assist with compliance.
• Adjust therapy as indicated to improve A1c levels.
• Educate member on the A1c target and the CGM goals.
• Establish protocols and/or processes for prescribing CGM to members.
• CGM can minimize or even eliminate the necessity for fingerstick capillary glucose tests. Additionally, it offers more comprehensive data on average blood sugar levels, high and low blood sugar episodes, and fluctuations in glucose levels.
• Refer member to case management to help members manage chronic health conditions.
  • Please send us your referrals by contacting care management at:
    Phone: 800-557-6916
    Monday through Friday: 8 a.m. to 5 p.m.
    Voicemail messages received after normal business hours will be addressed the following business day.
    Email: [email protected]

Acceptable terminology:

• A1c, HbA1c, HgbA1c
• Glycohemoglobin
• Glycohemoglobin A1c
• Glycated hemoglobin
• Glycosylated hemoglobin
• Hemoglobin A1c

Not Acceptable: 

• HbA1c self-tested when not processed by a lab.
• Documentation of ranges and thresholds do not meet criteria. Example: < 9.0%.
• "Unknown" is not considered a result/finding.

Measure Exclusions

Denominator Exclusions:

• Persons receiving Palliative Care or had an encounter for Palliative Care any time during the intake period through the last day of the measurement period.
• Persons in hospice or using hospice services any time during the measurement period. 
• Persons who died any time during the measurement period.
• Persons 66 years of age or older by the last day of the measurement period, with both frailty and advanced illness.
• Medicare enrollees, 66 years of age and older by the last day of the measurement period, in an institutional SNP (I-SNP) or living long-term in an institution (LTI). 
• Diagnosis code on a laboratory claim (POS 81) for:
  • Diabetes 
  • Frailty
  • Advance illness
  • Palliative care

Numerator Exclusions:
For CPT Category II codes do not include:

• Laboratory claims (POS 81).
• CPT CAT II Modifier.

Measure Codes

• HbA1C Lab Test
  • CPT: 83036, 83037
  • LOINC: 4548-4, 17855-8, 4549-2, 17856-6, 96595-4
  • SNOMED CT US Edition: 165679005, 451061000124104
• HbA1c Level Less than 7.0
  • CPT-CAT-II: 3044F
• HbA1c Level Greater than/Equal to 7 and Less than 8
  • CPT-CAT-II: 3051F
• HbA1c Level Greater than/Equal to 8 and Less than/Equal to 9
  • CPT-CAT-II: 3052F
• HbA1C Greater than 9.0
  • CPT-CAT-II: 3046F
• Glucose management indicator
  • LOINC: 97506-0

Measure Medications

Diabetes Medications List 
Alpha-glucosidase inhibitors

• Acarbose
• Miglitol

Amylin analogs

• Pramlintide

Antidiabetic combinations

• Alogliptin-metformin 
• Alogliptin-pioglitazone
• Canagliflozin-metformin
• Dapagliflozin-metformin
• Dapagliflozin-saxagliptin
• Empagliflozin-linagliptin
• Empagliflozin-metformin
• Empagliflozin-linagliptin-metformin
• Ertugliflozin-metformin
• Ertugliflozin-sitagliptin
• Glimepiride-pioglitazone
• Glipizide-metformin
• Glyburide-metformin
• Linagliptin-metformin 
• Metformin-pioglitazone
• Metformin-rosiglitazone
• Metformin-saxagliptin
• Metformin-sitagliptin

Insulin

• Insulin aspart 
• Insulin aspart-insulin aspart protamine
• Insulin degludec 
• Insulin degludec-liraglutide
• Insulin detemir
• Insulin glargine
• Insulin glargine-lixisenatide 
• Insulin glulisine 
• Insulin isophane human
• Insulin isophane-insulin regular
• Insulin lispro
• Insulin lispro-insulin lispro protamine 
• Insulin regular human
• Insulin human inhaled

Meglitinides

• Nateglinide
• Repaglinide

Biguanides

• Metformin

Glucagon-like peptide-1 (GLP1) agonists

• Albiglutide
• Dulaglutide
• Exenatide
• Liraglutide
• Lixisenatide 
• Semaglutide
• Tirzepatide

Sodium glucose cotransporter 2 (SGLT2) inhibitor

• Canagliflozin
• Dapagliflozin
• Empagliflozin
• Ertugliflozin

Sulfonylureas

• Chlorpropamide
• Glimepiride
• Glipizide
• Glyburide
• Tolazamide
• Tolbutamide

Thiazolidinediones

• Pioglitazone
• Rosiglitazone

Dipeptidyl peptidase-4 (DDP-4) inhibitors

• Alogliptin
• Linagliptin
• Saxagliptin
• Sitagliptin