Diabetic Poor Control >9% Tip Sheet

Incentives are paid to the linked primary care provider (PCP) on an annual basis, following the end of quarter four. For additional information, refer to the CBI Technical Specifications.

Members with diabetes are identified by either claim/encounter data or by pharmacy data.

• Claim/encounter data: Members who had at least two diagnoses of diabetes on different dates of service during the measurement year or the year prior to the measurement year.
• Pharmacy data: Members who were dispensed insulin or hypoglycemics/antihyperglycemics during the measurement year or the year prior to the measurement year and have at least one diagnosis of diabetes during the measurement year or the year prior to the measurement year.

Note: Medi-Cal pharmacy benefits are provided through Medi-Cal Rx. You can access their Contact Drugs List, Medi-Cal Rx portal, subscribe to Medi-Cal Rx news updates or locate a Medi-Cal Rx pharmacy on the DHCS Medi-Cal Rx homepage.

• Administrative members at the end of measurement period.
• Dual coverage members.
• Members in hospice, receiving hospice services or palliative care or who died during the measurement year.
• Members 66 years of age and older as of December 31 of the measurement year who meet both frailty and advanced illness criteria:
  • Frailty: At least two indications of frailty with different dates of service during the measurement year.
  • Advanced illness: One of the following during the measurement year or the year prior to the measurement year:
    • Encounter with an advanced illness diagnosis on at least two different dates of service.
    • Dispensed dementia medication.

Note: Laboratory claims with POS 81 are not included to identify eligible members with diagnostic codes for frailty or advanced illness.

CPT Codes: 83036, 83037 (Non Medi-Cal benefit code)

LOINC Codes: 17855-8, 17856-6, 4548-4, 4549-2, 96595-4, 97506-0

CPT Category II codes are tracking codes that, when submitted through point of service lab claims, can be used for performance measurement. Below are the defining HbA1c ranges; they may not be used as a substitute for Category I codes.

Note: Do not include CPT II codes with a modifier.

When reporting the appropriate CPT II code for the A1c result value, bill with the date of the test, not the date of the office visit when the test was reviewed.

Data for this measure is collected using claims, laboratory data, DHCS fee-for-service encounter claims and provider data submissions via the Data Submission Tool (DST) on the Provider Portal. To find gaps in data:

• Run a report from your electronic health record (EHR) system; or
• Manually compile patient data. For example, download your monthly Diabetes Care Quality Report or your Care-Based Incentives Measure Details report on the Provider Portal and compare it to your EHR/paper records.

This measure allows providers to submit HbA1c test results from the clinic EHR system or paper records to the Alliance by the DST contractual deadline. To submit, upload data files to the DST on the Provider Portal. To be accepted, data must be submitted as a CSV file. Step-by-step instructions are available in the Data Submission Tool Guide on the Provider Portal.

• HbA1c testing
  • Perform an HbA1C test every three months on patients whose therapy changed or who are not meeting glycemic goals (>9% HbA1c).
  • Set appropriate individualized A1C goals based on relevant comorbidities, demographic factors, and other considerations.
• Health education
  • Enroll members in Alliance Disease Management Programs using the Health Program Referral Form.
    • The Diabetes Prevention and Self-Management Education Program provides members with education and resources for diabetes management. Services include referrals to Alliance-approved clinical diabetes management education providers who can help members access comprehensive diabetes prevention and self-management education.
    • The Healthier Living Program (HLP) is a six-week series of self-management workshops that focus on health, wellness, and problems that are common to individuals suffering from chronic conditions. It can also help with goal setting, nutrition, exercise, medication usage, emotional support, and communication with doctors and family members. Members who participate in this program receive a $50 Target gift card.
• To increase access for your members, a point-of-care (POC) HbA1C machine is a convenient way to get up-to-date information on their diabetes management.
  • For clinical considerations, reference Point-of-Care HbA1c in Clinical Practice: Caveats and Considerations for Optimal Use – American Diabetes Association.
  • For assistance in the purchase of a POC HbA1C machine, consider the Alliance Healthcare Technology Program.

• Alliance Cultural and Linguistic Services are available to network providers.
  • Language Assistance Services – Request materials at 800-700-3874, ext. 5504.
  • Telephonic Interpreter Service – Directly access a telephonic interpreter 24 hours a day, 7 days a week.
  • Interpreter Services – Can be requested for the appointment with the member.
  • Virtual Remote Interpreter (VRI) Service – When an in-person interpreter might not be available or easy to access.
  • For information about the Cultural and Linguistic Services Program, call the Alliance Health Education Line at 800-700-3874, ext. 5580 or email us at [email protected].
• Alliance Enhanced Care Management and Community Supports.
  • Refer Alliance members through the Alliance Provider Portal, email [email protected], mail or fax, or by phone at 831-430-5512.
  • For Complex Care Management and Care Coordination, call the Care Management team at 800-700-3874 (TTY: Dial 711).
• Alliance Nurse Advice Line to talk to a nurse.
  • 844-971-8907 (TTY: Dial 711).
  • Educate all members to use the Alliance Nurse Advice Line that is available to all Alliance members 24 hours a day, 7 days a week to discuss health concerns to avoid hospital readmissions and preventable emergency visits.
  • Add to your phone-tree and route after-hours calls from Alliance members.
• Alliance Transportation Services for patients with transportation challenges.
  • For non-emergency medical transportation (NEMT) services, call 800-700-3874, ext. 5640 (TTY: Dial 711).
  • For non-medical transportation (NMT) services, call 800-700-3874, ext. 5577 (TTY: Dial 711).
• Pharmacist-Led Academic Detailing (PLAD) is an effective, multi-faceted educational program designed to support Alliance primary care clinicians and their patients. PLAD aims to improve the quality of care provided to patients with diabetes by collaborating with clinicians to implement evidence-based pharmacologic clinical guidelines in diabetes care management. The interactive sessions with clinicians are tailored to the members specific needs and interests, making it a personalized and effective experience. Sessions involve interactive discussions, case studies, and useful tools for implementing best practices in the clinical setting. For more information, please email [email protected] and include the phrase “Pharmacist-Led Academic Detailing,” or “PLAD,” in the subject line.