BCBSRI is committed to making it easier for your practice to be successful in all areas of quality improvement. Together, we can achieve our shared goal of improving health outcomes by identifying and addressing open care gaps.

Hints for HEDIS (and more) is a reference tool developed to explore various quality topics, including:

• Definitions, specifications, and exclusions of the many quality measures
• Billing codes used to report gap closure
• Collection and reporting methodologies
• Tips and best practices to maximize gap closure

Our Quality Concierge Team (QCT) is also available to answer questions, provide updates, assist in the interpretation of monthly gaps in care reports, and provide overall HEDIS support to you and your practice. Reach our QCT nurses at QualityHEDIS@bcbsri.org or (401) 459-1005.

Care gaps may be closed via claims submission with the use of appropriate Current Procedural Terminology (CPT®) Category II codes. Coding for quality also makes it easier for you to track preventive care services and test results that our members received while under your care.

The codes included below also address care opportunities set forth by the National Committee for Quality Assurance (NCQA) through the Healthcare Effectiveness Information Set (HEDIS) performance measures*.

Comprehensive diabetes care (CDC)

Comprehensive diabetes care is composed of four different components:

• Hemoglobin A1c (HbA1c) testing
• Eye exam (retinal) performed
• Medical attention for nephropathy
• BP control (<140/90 mm Hg)

Eligible population: Adult members ages 18-75 with diabetes (type 1 and type 2)

Lines of business: Medicare Advantage and commercial plans

Exclusions:

• Members living long-term in an institution any time during the measurement year
• Members enrolled in hospice
• Members with a dispensed dementia medication
• Members meeting frailty and advanced illness criteria

Hemoglobin A1c control codes

• 3044F – A1c level less than 7.0
• 3051F – A1c level 7.0 - 8.0
• 3052F – A1c level 8.0 - 9.0
• 3042F – A1c level greater than 9.0

Retinal eye exam codes

• 2022F – Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed during the measurement year; with evidence of retinopathy

• 2023F – Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed during the year prior to the measurement year; without evidence of retinopathy
• 2024F – Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy
• 2025F – Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy
• 2026F – Eye imaging validated to match diagnosis from seven standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy
• 2033F – Eye imaging validated to match diagnosis from seven standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy
• 3072F – Diabetic retinal screenings negative for retinopathy (no evidence of retinopathy in the prior year)

Nephropathy screening codes

• 3060F – Screening test for nephropathy; positive microalbuminuria test reviewed and documented
• 3061F – Screening test for nephropathy; negative microalbuminuria test reviewed and documented
• 3062F – Positive microalbuminuria test result reviewed and documented
• 3066F – Treatment for nephropathy
• 4010F – Patient prescribed or currently taking ACE/ARB

Controlling high blood pressure codes

• 3074F – Most recent systolic blood pressure less than 130
• 3075F – Most recent systolic blood pressure between 130-139
• 3077F – Most recent systolic blood pressure greater than/equal to 140
• 3078F – Most recent diastolic blood pressure less than 80
• 3079F – Most recent diastolic blood pressure between 80-89
• 3080F – Most recent diastolic blood pressure greater than/equal to 90

*HEDIS indicators are intended to standardize performance measurement and do not necessarily represent the ideal standard of care. If you have any questions, please contact your quality concierge representative at (401) 459-1005 or QualityHEDIS@bcbsri.org.