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

Eligible Population:
Members 18 and 75 years of age as of December 31 of the measurement year. This includes Population Health Incentive Program (PHIP) and HealthChoice Performance Measure for Priority Partners.

Definition:
Percentage of members 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.

Continuous Enrollment:

• The measurement year.

Report Stratification by race and ethnicity.

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.
• Refer member to case management to help members manage chronic health conditions. (https://www.hopkinsmedicine.org/johns-hopkins-health-plans/providers-physicians/division-of-health-services#care)
  • 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: caremanagement@jhhp.org

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

Required Exclusions:

• Palliative Care
• Members in hospice or using hospice services anytime during the measurement year. 
• Members who died any time during the measurement year.
• Members 66 years of age and older as of December 31 of the measurement year (all product lines) with frailty and advanced illness.
• Medicare members 66 years of age and older by the end of the measurement period who meet either of the following:
  • Enrolled in an Institutional SNP (I-SNP).
  • Living in Long Term Care.
    
    

Measure Codes

• HbA1C Lab Test 
  • CPT: 83036, 83037
  • LOINC: 4548-4, 17855-8, 4549-2, 17856-6, 96595-4
• 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

Medication List: Diabetes Medications