Arizona Health Care Cost Containment System
Arizona Long Term Care System (ALTCS) Performance Measure

PERFORMANCE MEASURES FOR DIABETES MANAGEMENT
Measurement Period: October 1, 2003, through September 30, 2004
Prepared by the Division of Health Care Management
November 2005

Anthony D. Rodgers
Director, AHCCCS

For questions or comments about this report, contact:
Rochelle Tigner
Quality Improvement Manager, Clinical Quality Management
Division of Health Care Management, AHCCCS
(602) 417-4683
rttigner@ahcccs.state.az.

Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS) Performance Measure:
MANAGEMENT OF DIABETES
For the Measurement Period October 1, 2003, through September 30, 2004

INTRODUCTION
Background ................................................................................................................
Purpose .......................................................................................................................

1
2

DIABETES COMPLICATIONS AND PREVENTIVE PRACTICES
What is Diabetes? .......................................................................................................
Prevention of Diabetes Complications .......................................................................

2
3

STUDY METHODS
Population ..................................................................................................................
Sample Frame ............................................................................................................
Measurement Period ..................................................................................................
Data Sources ..............................................................................................................
Data Collection ..........................................................................................................
Data Quality and Reliability ......................................................................................
Deviation from Previous Methodology .....................................................................
Study Indicators .........................................................................................................
Performance Measure Goals ......................................................................................
National Benchmarks .................................................................................................

3
3
4
4
4
4
4
5
5
5

RESULTS AND ANALYSIS
Included Cases ...........................................................................................................
Hb A1c Testing ..........................................................................................................
Lipid Screening ..........................................................................................................
Eye Examinations ......................................................................................................
Results by Geographic Area ......................................................................................

5
5
6
6
6

DISCUSSION
Overall Results ...........................................................................................................
Contractor Performance .............................................................................................
Quality Improvement Efforts …….............................................................................
Conclusion .................................................................................................................

6
7
7
8

REFERENCES

8

TABLES AND FIGURES
APPENDIX: METHODOLOGY AND TECHNICAL SPECIFICATIONS

10
i

Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS) Performance Measures:
MANAGEMENT OF DIABETES
For the Measurement Period October 1, 2003, through September 30, 2004

INTRODUCTION
adults with diabetes has risen by about 60
percent.5 The prevalence of diabetes in
Arizona also has increased during that
time.6 Contributing to this increase is the
large number of “baby boomers” who are
aging and living longer than previous
generations. A sedentary lifestyle and a
dramatic rise of obesity in the U.S.
population also are increasing the
incidence of diabetes.7

Background
Diabetes is the sixth leading cause of death
among Americans, resulting in at least
70,000 deaths each year. It is a
contributing factor in another 140,000 or
more deaths annually. 1,2
The federal Centers for Disease Control
and Prevention (CDC) estimates that more
than 18 million Americans age 20 years
and older, or 6.3 percent of all people in
this age group, have diabetes.2
An
estimated 244,000 Arizona adults had a
diagnosis of diabetes in 2002, the most
recent year for which state and national
data are available.3

Nearly 20 percent of all
people 60 and older have
diabetes.

In the United States, Hispanics, blacks,
American Indians and Alaska natives are
two to three times more likely to have
diabetes than non-Hispanic whites. The
prevalence of diabetes also is higher
among older Americans: nearly 20 percent
of all people 60 and older have diabetes.2

Centers for Disease Control and Prevention

At least 3.5 million hospitalizations each
year are associated with diabetes.8 Direct
and indirect costs related to diabetes
(including the costs of permanent disability
and premature death) were estimated to be
$132 billion in the U.S. in 2002.9

The prevalance of diabetes among adults
enrolled in the Arizona Long Term Care
System (ALTCS) is greater than 13
percent, or twice the rate in the general
population. National data show higher
rates of diabetes among people with low
socioeconomic status and those covered by
Medicaid, compared with all people.4

Diabetes is the leading cause of end-stage
kidney disease and new cases of blindness
among adults. It also is responsible for
more than 60 percent of nontraumatic
lower-limb
amputations.
Other
complications include heart disease, stroke,
and nervous system disorders.2

Since 1991, the number of American
1

Purpose
The purpose of this study is to monitor,
overall and by contracted health plan
(Contractor), the percentage of ALTCS
members with diabetes who receive certain
clinical services to detect and prevent or
reduce
complications.
This
report
summarizes current results of the ALTCS
Contractor Performance Measures for
diabetes care, and makes recommendations
for improvement.

Direct and indirect costs
related to diabetes were
estimated to be $132 billion in
the U.S. in 2002.
Study conducted by the Lewin Group. Inc.
for the American Diabetes Association

DIABETES COMPLICATIONS AND PREVENTIVE PRACTICES
diagnosed in about 4 percent of women
during pregnancy, and may be manifested
later as type 2 diabetes.

What is Diabetes?
Diabetes mellitus is a group of chronic
diseases characterized by high levels of
blood glucose, which occur when the body
does not properly produce or use insulin.
Insulin is a hormone that is needed to
convert carbohydrates into glucose, a
simple sugar that is a primary source of
energy. Both genetics and lifestyle, such as
obesity and lack of exercise, are associated
with the disease.2,10

With diabetes, sustained high blood sugars
result in microvascular complications; that
is, damage to the very fine blood vessels of
the eyes, peripheral nerves and kidneys.
Diabetic retinopathy (damage to the retina
of the eye) causes 12,000 to 24,000 new
cases of blindness each year. Up to 70
percent of people with diabetes have mild
to severe forms of nervous system damage,
including impaired sensation or pain in the
feet or hands, slowed digestion of food,
carpal tunnel syndrome and other nerve
problems.2 Diabetes is the leading cause of
end stage renal (kidney) disease.

There are three major types of diabetes: 2,10
• Type 1 diabetes, which accounts for 5
to 10 percent of all diagnosed cases,
usually begins in childhood and occurs
when the cells that produce insulin are
destroyed.
• Type 2 diabetes, which accounts for 90
to 95 percent of diagnosed cases, occurs as
the body develops insulin resistance or the
pancreas loses the ability to produce
insulin. Type 2 is associated with both
genetic and behavioral factors, including
age, obesity, physical inactivity, family
history and race or ethnicity. Normally
seen in adults, type 2 diabetes is on the rise
in children and young adults.
• Gestational
diabetes,
which
is

Macrovascular complications include
coronary and peripheral artery disease,
which may lead to heart attack or stroke.
As with many diseases, other conditions
(known as comorbid conditions) may be
present with diabetes. For example, the
increased prevalence of lipid abnormalities
found with type 2 diabetes contributes to
higher rates of cardiovascular disease
among diabetics.11

2

Lipid Management –– Managing lipid
levels has been shown to reduce
macrovascular disease – or complications
affecting the heart, brain and legs – in
people with type 2 diabetes, especially
those who have a history of cardiovascular
problems.11,12 Control of cholesterol and
lipids
can
reduce
cardiovascular
complications by 20 to 50 percent.2

Prevention of Diabetes Complications
Despite its deadly effects, diabetes can be
controlled. Many complications of the
disease can be prevented or reduced with
early detection, improved care and better
education of patients in self-management
techniques.5,11
Glucose
Control
––
Control
of
hyperglycemia (increased blood sugar) is
critical to reducing both the incidence and
progression of complications associated
with diabetes. Physicians utilize a
glycosylated hemoglobin, or Hb A1c, test
to monitor patients’ blood glucose levels.
This test indicates a person’s average
glucose level over a two- to three-month
period by measuring the amount of glucose
that has bonded with hemoglobin in the
body’s red blood cells.

A fasting lipid profile is performed to
measure total cholesterol (TC), highdensity
lipoproteins
(HDL)
and
triglycerides. These results are used to
calculate
and
manage
low-density
lipoprotein (LDL) levels.
Eye Care — It is estimated that regular eye
exams and timely treatment, including
laser
therapy,
could
reduce
the
development of severe vision loss by up to
60 percent.2 People with type 1 and type 2
diabetes should have a comprehensive
dilated
eye
examination
by
an
ophthalmologist or optometrist, in order to
detect and treat retinopathy and prevent
vision loss.

Studies in the United States and abroad
have shown that improved glycemic
control benefits people with either type 1
or type 2 diabetes. In general, for every
percentage point decrease in Hb A1c levels,
the risk of developing microvascular
complications is reduced by 35 to 40
percent. 2,12,13

STUDY METHODS

AHCCCS used Health Plan Employer Data
and Information Set (HEDIS) 2004
specifications
from
the
National
Committee for Quality Assurance (NCQA)
as a guideline for measurement of diabetes
care services. HEDIS methodology
includes six indicators of comprehensive
diabetes care. AHCCCS has identified
three of these indicators for performance
measurement: Hb A1c testing, lipid
screening, and eye exams.

Population
The population included in this
measurement consisted of elderly or
physically disabled (E/PD) members
enrolled in ALTCS.
Sample Frame
The sample frame consisted of E/PD
members who:
• were ages 18 through 75 years as of
September 30, 2004,
3

•

subsystem. When encounters for specific
services within the measurement period
(or, in some cases the previous year) were
not found in encounter data, AHCCCS
provided demographic data for those
sample members to the appropriate
Contractors using a standardized electronic
data collection tool. Contractors collected
data for additional services provided to
their members, including some services
that were paid for by Medicare. This
information was entered into the electronic
tool according to detailed instructions from
AHCCCS.

were continuously enrolled with one
ALTCS Contractor, with no more than one
gap in enrollment, not exceeding 31 days,
as of September 30, 2004, and
• had a diagnosis of type 1 or type 2
diabetes in the measurement period or the
year prior to the measurement period.
Members were identified as having type 1
or type 2 diabetes by either pharmacy or
encounter data (records of claims paid by
Contractors for covered services). For
example, a member was identified as
having diabetes if he or she had one faceto-face encounter with a diagnosis of
diabetes in an acute inpatient or emergency
room setting during the measurement
period or the previous year.

Data Quality and Reliability
AHCCCS conducts validation studies to
evaluate the completeness, accuracy and
timeliness of encounter data. Based on the
most recent data validation study by
AHCCCS, less than 6 percent of all
encounters in PMMIS are inaccurate when
compared with corresponding medical
records.

Measurement Period
The services measured were provided from
October 1, 2003, through September 30,
2004.
Data Sources
AHCCCS uses a statewide, automated
managed care data system known as the
Prepaid Medical Management Information
System (PMMIS). AHCCCS enrollment
and encounter data contained in PMMIS
were used to select sample members for
this study and collect some data. Medical
and case management records collected by
Contractors were used to supplement
encounter data.

In order to document data collected outside
of the AHCCCS encounter system for this
study, Contractors were required to submit
hard copies of the appropriate sections of
medical or case management records with
their electronic data tools.
Deviation from Previous Methodology
This study differs from previous measures
of diabetes preventive care services
conducted by AHCCCS. In the two
previous measurements, results were based
on administrative data only and consisted
of a combination of AHCCCS encounter
data and analytic data obtained from the
Centers for Medicare and Medicaid
Services (CMS). The previous results were
obtained and analyzed by Health Services
Advisory Group (HSAG), an independent
Quality
Improvement
Organization,
through a collaborative agreement.

Data Collection
As many as 80 percent of ALTCS elderly
and physically disabled members also are
covered by Medicare. Medicare is the
primary payer for these “dually enrolled”
members, and AHCCCS does not receive
encounters for services paid for by another
program or insurer.
AHCCCS initially collected data on
diabetes services from its encounter
4

AHCCCS undertook this collaborative
project with HSAG to collect data on
diabetes care services for members who
were dually enrolled in Medicaid and
Medicare. HSAG was able to obtain data
from CMS on services provided to some
members under Medicare. However, data
on services provided to dually enrolled
members through Medicare managed care
plans was not available from CMS. In
order to collect more complete data for the
diabetes Performance Measures, AHCCCS
began using the current hybrid data
collection process, beginning with this
measurement.

Performance Measure Goals
AHCCCS has established Contractor
Performance Standards for these measures.
If ALTCS Contractors have achieved the
AHCCCS
Minimum
Performance
Standard (MPS) for any indicator, they
should strive to meet the AHCCCS Goal.
Measure

MPS

Goal

Hb A1c testing

51 %

55%

Lipid screening

47%

51%

Eye exams

31%

35%

These Performance standards are designed
to provide milestones for Contractors to
meet in achieving the AHCCCS longrange goals for these indicators, known as
Benchmarks. The AHCCCS-established
Benchmarks are: Hb A1c testing, 85
percent; lipid screening, 81 percent; and
eye exams, 64 percent.

Study Indicators
Hb A1c testing — This indicator measured
the percent of members who had one or
more Hb A1c tests during the measurement
period.
Lipid (LDL-C) screening — This indicator
measured the percent of members who had
one or more lipid screenings during the
measurement period or the preceding year.

National Benchmarks
NCQA has reported national averages for
Medicaid HEDIS measures for diabetes
care. The 2003 mean (average) for annual
Hb A1c testing among Medicaid plans was
74.8 percent. The mean for LDL-C
screening was 75.9 percent. The mean for
eye exams was 45.0 percent.

Eye examinations — This indicator
measured the percent of members who had
a retinal exam by an optometrist or
ophthalmologist during the measurement
period or the preceding year

RESULTS AND ANALYSIS
Included Cases
This measurement included 1,154 ALTCS
E/PD members with diabetes.

Rates by Contractor ranged from 60.9
percent to 88.4 percent. All seven
Contractors
exceeded
the
current
AHCCCS goal for this measure and two
exceeded the AHCCCS long-range
benchmark (Figure 1). Five Contractors
achieved rates above the national Medicaid
HEDIS average for 2003.

Hb A1c Testing
The overall rate of members who received
an Hb A1c test during the measurement
period was 76.7 percent (Table 1).
5

Results by Geographic Area
The overall rate of eye exams was
significantly higher in rural counties,
compared with urban counties (p<.001).
There was no significant difference in rates
of Hb A1c testing and lipid screening
between rural and urban areas (p= .345 and
.266, respectively).

Lipid (LDL-C) Screening
The overall rate of members who had an
LDL-C screening, or fasting lipid profile,
during the measurement period or the
preceding year was 69.2 percent (Table 2).
Rates by Contractor ranged from 63.5
percent to 81.4 percent. All Contractors
exceeded the current AHCCCS goal for
this measure and one achieved the
AHCCCS long-range benchmark (Figure
2). This same Contractor also exceeded the
national Medicaid HEDIS average for
2003.

Diabetes Care Rates,
Rural vs. Urban Counties
100

Eye Examinations
The overall rate of members who had a
dilated
eye
examination
in
the
measurement period or the preceding year
was 50.1 percent (Table 3).

80

60

40

Rates by Contractor ranged from 31.1
percent to 73.5 percent. All Contractors
achieved the Minimum Performance
Standard for this measure, six exceeded the
current goal, and two surpassed the longrange benchmark (Figure 3). Six
Contractors achieved rates above the
national Medicaid HEDIS average for
2003.

20

0
Hb A1c

Lipid
Rural

Eye
Urban

DISCUSSION

measurement
period,
according
to
methodology used for previous studies. As
expected, rates generated by administrative
data only, including some data for
Medicare services obtained from CMS,
were substantially lower than the rates
generated by a combination of AHCCCS
encounter and medical record or case
management data.

Overall Results
As previously noted, AHCCCS has
collected administrative data for this
measure through a collaboration with
HSAG over the past two years. In addition
to the hybrid data collection conducted by
AHCCCS and its Contractors for this
study, HSAG also collected and analyzed
diabetes care data for the current
6

Contractor performance also were raised
accordingly.

The following graph shows the difference
in rates generated from hybrid data,
compared with administrative data only.

Quality Improvement Efforts
In order to assist ALTCS Contractors with
quality improvement, AHCCCS has been
providing health plans with educational
opportunities, outreach resources, and
information on successful strategies for
increasing the use of preventive-care
practices. Successful member-focused
strategies include:14-18
•
Automated reminders by telephone,
advising patients that they are due for tests.
•
Nurse follow-up by phone, especially
as part of a case management or disease
management program.
•
Social support groups and group visits
with providers.
•
Use of diabetes educators, dietitians,
pharmacists
and/or
mental
health
professionals as part of the care team.
•
Culturally relevant patient materials or
interventions, such as food preparation
classes that incorporate traditional foods,
in diabetes education.

Diabetes Care Rates,
Hybrid vs. Administrative Data
100

80

60

40

20

0
Hb A1c

Hybrid

Lipid

Eye

Administrative

Several AHCCCS Contractors have
utilized these kinds of strategies, often as
part of disease management programs for
members with diabetes. In addition to
member education and follow up,
Contractors have developed and distributed
practice
guidelines
and
provided
practitioner education on current standards
of care for diabetes.

Contractor Performance
All Contractors are meeting the current
AHCCCS
Minimum
Performance
Standards for diabetes care and most have
exceeded current goals. Compared with the
most recent HEDIS data for Medicaid
health plans, most ALTCS Contractors
exceeded national averages for Hb A1c
testing and eye exams. It also should be
noted that some AHCCCS Contractors are
achieving rates of diabetes preventive care
services that are comparable with HEDIS
commercial health plan averages.

At least one Contractor has focused
diabetes education efforts on caregivers of
members in home and community-based
settings, such as assisted living facilities
(ALFs). Attendant care givers and ALF
staff are expected to ensure that members
have regular appointments with their
primary care physicians (PCPs) to have
routine tests performed. The Health Plan’s
case managers also maintain close
communication with PCPs.

The current standards for ALTCS
Contractors were implemented in 2004.
For the contract year ending September 30,
2006, AHCCCS increased the Minimum
Performance Standard for each measure,
based on the HEDIS national averages for
Medicaid Health Plans. AHCCCS goals for
7

http://www.cdc.gov/nchs/hus.htm.
September 20, 2005.

Conclusion
Diabetes can be devastating and costly.
However, clinical services that help
monitor and control glucose and lipid
levels, or detect retinal damage early, can
help reduce the burden of disease. With a
substantial portion of their members
diagnosed with diabetes, AHCCCS
Contractors are focusing significant efforts
on managing care of these members.

Accessed

5

Centers for Disease Control and Prevention.
Diabetes: disabling, deadly, and on the rise.
Centers for Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion. Available
at:
http://www.cdc.gov/nccdphp/aag/pdf/aag_ddt2
004.pdf. Accessed September 15, 2004.
6

Centers for Disease Control and Prevention.
Percentage of adults with diagnosed diabetes.
Centers for Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion. Available
at: http://www.cdc.gov/nccdphp/aag_ddt2004_
access.htm. Accessed September 15, 2004.

AHCCCS will continue working with
ALTCS Contractors, especially those with
the lowest rates, to assist them in reaching
goals for these Performance Measures in
the future.

7

National
Diabetes
Information
Clearinghouse. Diabetes overview. National
Institute of Diabetes and Digestive and Kidney
Diseases.
Available
at:
http://diabetes.niddk.nih.gov/dm/pubs/overvie
w/index.htm#who. Accessed August 30, 2005.

REFERENCES
1

Centers for Disease Control and Prevention.
Indicators for choric disease surveillance.
MMWR. 2004; 53(RR-11):91. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtm
l/rr5311a1.htm. Accessed September 14, 2004.

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Centers for Disease Control and Prevention.
Indicators for choric disease surveillance.
MMWR. 2004; 53(RR-11):100. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtm
l/rr5311a1.htm. Accessed September 14, 2004.

2

Centers for Disease Control and Prevention.
National diabetes fact sheet: United states,
2003. Atlanta, GA. U.S. Department of Health
and Human Services, Centers for Disease
Control and Prevention. 2004. Available at:
http://www.cdc.gov/diabetes/pubs/factsheet.ht
m. Accessed September 15, 2004.

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American Diabetes Association. Economic
costs of diabetes in the US in 2002. Diabetes
Care.
2003;26:917-932.
Available
at:
http://www.care.diabetesjournals.org/cgi/conte
nt/full/26/3/917. Accessed March 19, 2003.

3

Centers for Disease Control and Prevention.
Diabetes surveillance system: State-specific
estimates of diagnosed diabetes among adults.
Centers for Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion. Available
at:
http://www.cdc.gov/diabetes/statistics/prev/stat
e/table15.htm. Accessed September 15, 2004.

10

Beers MH, Berkow R, eds. The Merck
Manual of Diagnosis and Therapy. 17th ed.
Whitehouse Station, NJ: Merck Research
Laboratories; 1999.
11

American Diabetes Association. Standards
of medical care for patients with diabetes
mellitus. Diabetes Care. 2003 (Suppl. 1);
26:S33-S50.

4

National Center for Health Statistics. Health,
United States, 2004. Table 8: Age-adjusted
percentages (with standard errors) of selected
diseases and conditions among persons 18
years of age and over, by selected
characteristics: United states, 2003. Centers for
Disease Control and Prevention. Hyattsville,
Maryland:
2004.
Available
at:

12

Centers for Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion. Chronic
disease prevention: preventing diabetes and its
complications.
Available
at:
http://www.cdc.gov/nccdphp/pe_factsheets/pe
_ddt.htm. Accessed March 28, 2003.

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13

Osterweil N. Tight glucose control may
provide long-term benefits in diabetics.
Medscape Medical News, 2004. Available at:
http://www.medscape.com/viewarticle/480466.
Accessed June 16, 2004.
14

Karter AJ, Ferrara A, Darbibiab JA,
Ackerson LM, Selby JV. Self-monitoring of
blood glucose: language and financial barriers
in a managed care population with diabetes.
Diabetes
Care.
2000;
23(4):477-483.
Available at:

http://care.diabetesjournals.org/cgi/content/abs
tract/23/4. Accessed April 4, 2003.
15

Piette JD, Weinberger M, Kraemer FB,
McPhee SJ. Impact of automated calls with
nurse follow-up on diabetes treatment
outcomes in a department of veterans affairs
health care system. Diabetes Care. 2001;
24(2):202-208.
Available
at:
http://care.diabetesjournals.org/cgi/content/abs
tract/full/24/2 Accessed April 4, 2003.
16

Brown SA, Garcia AA, Kouzekanani K,
Hanis CA. Culturally competent diabetes selfmanagement
education
for
Mexican
Americans. Diabetes Care. 2002; 25(2):259268. Available at:
http://care.diabetesjournals.org/cgi/content/full
/25/2 Accessed April 4, 2003.
17

Gilliland SS, Azen SP, Perez GE, Carter JS.
Strong in body and spirit: Lifestyle
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diabetes in New Mexico. Diabetes Care. 2002;
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18

Sadur CN, Moline N, Costa M, et al.
Diabetes management in a health maintenance
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9

TABLE 1
Arizona Health Care Cost Containment System (AHCCCS)
ALTCS PERFORMANCE MEASURES FOR DIABETES MANAGEMENT:
ANNUAL Hb A1c BLOOD TESTS
Measurement Period: October 1, 2003, through September 30, 2004

Included Cases

Total Receiving
HbA1c Test

Percent Receiving
HbA1c Test

Cochise Health Systems

86

76

88.4%

Pinal/Gila County LTC

102

89

87.3%

Maricopa LTC

252

207

82.1%

Mercy Care LTC

229

176

76.9%

Pima Health System LTC

212

160

75.5%

Yavapai County LTC

89

65

73.0%

Evercare Select

184

112

60.9%

TOTAL

1154

885

76.7%

Contractor

10

Figure 1
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS)
ALTCS PERFORMANCE MEASURES FOR DIABETES MANAGEMENT
ANNUAL HB A1C TESTING
Measurement Period: October 1, 2003, through September 30, 2004

100%

Percent of Members Receiving Services

90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Cochise Health
Systems

Evercare Select

Maricopa LTC

Mercy Care LTC

Pima Health
System LTC

Current AHCCCS Goal
Long-range Goal (Benchmark)

11

Pinal/Gila County
LTC

Yavapai County
LTC

TABLE 2
Arizona Health Care Cost Containment System (AHCCCS)
ALTCS PERFORMANCE MEASURES FOR DIABETES MANAGEMENT:
BIENNIAL LIPID SCREENING
Measurement Period: October 1, 2003, through September 30, 2004

Included Cases

Total Receiving
Lipid Screening

Percent Receiving
Lipid Screening

Pinal/Gila County LTC

102

83

81.4%

Pima Health System LTC

212

157

74.1%

Mercy Care LTC

229

161

70.3%

Cochise Health Systems

86

60

69.8%

Yavapai County LTC

89

61

68.5%

Evercare Select

184

117

63.6%

Maricopa LTC

252

160

63.5%

TOTAL

1154

799

69.2%

Contractor

12

Figure 2
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS)
ALTCS PERFORMANCE MEASURES FOR DIABETES MANAGEMENT
BIENNIAL LIPID SCREENING
Measurement Period: October 1, 2003, through September 30, 2004

100%

Percent of Members Receiving Services

90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Cochise Health
Systems

Evercare Select

Maricopa LTC

Mercy Care LTC

Pima Health
System LTC

Current AHCCCS Goal
Long-range Goal (Benchmark)

13

Pinal/Gila County
LTC

Yavapai County
LTC

TABLE 3
Arizona Health Care Cost Containment System (AHCCCS)
ALTCS PERFORMANCE MEASURES FOR DIABETES MANAGEMENT:
BIENNIAL RETINAL EXAMS
Measurement Period: October 1, 2003, through September 30, 2004

Included Cases

Total Receiving
Retinal Exam

Percent Receiving
Retinal Exam

Pinal/Gila County LTC

102

75

73.5%

Yavapai County LTC

89

63

70.8%

Mercy Care LTC

229

122

53.3%

Evercare Select

184

93

50.5%

Cochise Health Systems

86

42

48.8%

Maricopa LTC

252

117

46.4%

Pima Health System LTC

212

66

31.1%

TOTAL

1154

578

50.1%

Contractor

14

Figure 3
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS)
ALTCS PERFORMANCE MEASURES FOR DIABETES MANAGEMENT
BIENNIAL RETINAL EXAM
Measurement Period: October 1, 2003, through September 30, 2004

100%
90%

Percent of Members Receiving Services

80%
70%
60%
50%
40%
30%
20%
10%
0%

Cochise Health
Systems

Evercare Select

Maricopa LTC

Mercy Care LTC

Pima Health
System LTC

Current AHCCCS Goal
Long-range Goal (Benchmark)

15

Pinal/Gila County
LTC

Yavapai County
LTC

APPENDIX
Methodology and Technical Specifications:
Diabetes Management Performance Measures
For the Measurement Period Ending September 30, 2004
Population
The population included all elderly and physically disabled (E/PD) members in the Arizona
Long Term Care System (ALTCS) who are enrolled with the following Contractors: Cochise
LTC (110003 and 550003), Evercare Select (110049 and 550047), Maricopa County LTC
(110023 and 550021), Mercy Care LTC (110306 and 550306), Pima Health System LTC
(110015 and 550013), Pinal/Gila LTC (110065 and 550063), and Yavapai LTC (110025 and
550025).
Inclusion Criteria
Members ages 18 through 75 years as of September 30, 2004, were included based on the
following enrollment criteria:
• Enrolled as of September 30, 2004
• Members in the population
• Continuously enrolled with one ALTCS Contractor with no more than one gap in
enrollment, not exceeding 31 days
Members were identified as having a diagnosis of type 1 or type 2 diabetes by either of
the following methods: *
•

Pharmacy - National Drug Codes (NDC)
OR

•

Claims/encounter data - Two face-to-face encounters with different dates of service in an
ambulatory setting or non-acute inpatient setting, or one face-to-face encounter in an acute
inpatient emergency room setting during the measurement period or the year prior with a
diagnosis of diabetes

* Refer to Technical Specifications for more information
Exclusion Criteria
Members were excluded from the study based on the following criteria:
• Younger than 18 years of age
• Older than 75 years of age
• Members not in the population
• Tribal members
• Members with prior period coverage
• Members not enrolled on the last day of the study period
• Members with a gap in enrollment greater than 31 days
• Members in the fee-for-service program

i

•

Members with the following diagnoses:
Description
Steroid Induced Diabetes
Polycystic Ovaries
Gestational Diabetes

ICD-9-CM Codes
251.8, 962.0

256.4
648.8

Sample Frame
The sample frame consisted of a representative random sample by Contractor.
Sample Selection
Sample selection was calculated for each Contractor to provide a 95-percent confidence level
and 5-percent confidence interval.
Sample Frame Stratification
The sample frame was stratified by ALTCS Contractor and by rural vs. urban area.
Data Sources
AHCCCS enrollment and encounter data were used to select sample members for this study
and collect some data. Medical records, case management notes and laboratory data collected
by Contractors were used to supplement encounter data.
Data Collection
AHCCCS initially collected data on diabetes services from its encounter subsystem. When
encounters for specific services within the measurement period (or in the previous year for
lipid screening and eye exams) were not found in encounter data, AHCCCS provided
demographic data for those sample members to the appropriate Contractors using a
standardized electronic data collection tool. Contractors collected data for additional services
provided to their members, including some services that were paid for by Medicare. This
information was entered into the electronic tool according to detailed instructions from
AHCCCS.
Data Quality and Reliability
AHCCCS conducts validation studies to evaluate the completeness, accuracy and timeliness
of encounter data. Based on the most recent data validation study by AHCCCS, less than 6
percent of all encounters in PMMIS are inaccurate when compared with corresponding
medical records.
In order to document data collected outside of the AHCCCS encounter system for this study,
Contractors were required to submit hard copies of the appropriate sections of medical, case
management or laboratory records with their electronic data tools.
Denominators
The total number of members who were identified as diabetics

ii

Numerators
1. The number of members in the denominator who had an annual Hb A1c blood test
2. The number of members in the denominator who had a biennial fasting lipid profile
3. The number of members in the denominator who had a biennial retinal exam
Analysis
• The numerator was divided into the denominator for each corresponding indicator to
determine the indicator rate.
• Data was analyzed as a statewide aggregate for all members in the denominator and by
individual Contractor.
• Standard deviations and patterns of abnormal distribution of data were utilized to identify
any outliers.
• All other stratifications as deemed appropriate (e.g., age or gender) were analyzed.
• Individual Contractor rates were compared to AHCCCS Minimum Performance Standards
and Goals, and to NCQA national averages.
Deviations from HEDIS
This study is based on HEDIS specifications for the indicators measured. The HEDIS measure
of Comprehensive Diabetes Care includes additional indicators, which were not part of the
AHCCCS study:
• Hb A1c poorly controlled (greater than 9.5 percent)
• LDL-C controlled (LDL less than 130 mg/dL)
• Kidney disease (nephropathy) monitored
This study used a combination of AHCCCS encounter and medical record data. AHCCCS
also allowed Contractors to collect data from case management systems, as a proxy for
medical record review. This is a deviation from HEDIS hybrid methodology, which only
specifies medical record review in addition to administrative data.
Deviation from Previous Methodology
This study differs from previous measures of diabetes preventive care services conducted by
AHCCCS. In the two previous measurements, results were based on administrative data only
and consisted of a combination of AHCCCS encounter data and analytical data obtained from
the Centers for Medicare and Medicaid Services (CMS). The previous results were obtained
and analyzed by Health Services Advisory Group (HSAG), an independent Quality
Improvement Organization, through a collaborative agreement. However, data on services
provided to dually enrolled members through Medicare managed care plans was not available
from CMS. In order to collect more complete data for the Diabetes Performance Measures,
AHCCCS began using the current hybrid data collection process, beginning with this
measurement.
HEDIS specifications allow health plans to count toward the numerator a negative retinal
examination (no evidence of retinopathy) performed by an optometrist or ophthalmologist in
the year priod to the measurement year if the member meets both the following criteria:
• the member was not prescribed or dispensed insulin during the measurement year, and

iii

•

the member’s most recent Hb A1c level (performed during the measurement year) was
less than 8.0 percent.
AHCCCS did not exercise this option. It counted toward the numerator only documented
instances in which a member had a retinal exam within the measurement period or the
preceeding year.
Definitions
Statistically Significant:
A finding is described as statistically significant when it can be demonstrated that the
probability of obtaining such a difference by chance only is relatively low. It is customary to
describe a finding as statistically significant when the obtained result is among those that,
theoretically, would occur no more than 5 out of 100 times (p<= .05) or occur no more than 1
out of 100 times (p<=. 01) when the only factors operating are the chance variations that
occur whenever random samples are drawn. It is important to note that a finding may be
statistically significant but may not be clinically or financially significant.
• Statistically significant values were calculated using the Pearson chi-square test. The
parameter used was Degree of Freedom: 1
• Statistically significant levels were set at p<= .05.
Relative Change:
The Relative Percent Change from the previous measurement period was calculated using the
following formula:
Current Rate (%) – Previous Rate (%)
Previous Rate (%)

iv

TECHNICAL SPECIFICATIONS
Diagnosis
May be identified by pharmacy data, claims or encounters
Pharmacy Data:
List of National Drug Codes (NDC) available at:
http://www.ncqa.org/Programs/HEDIS/hedis2003NDClists.htm
OR
Claims/Encounter Data:
Two face-to-face encounters with different dates of service in an ambulatory setting or
non-acute inpatient setting, or one face-to-face encounter in an acute inpatient
emergency room setting during the measurement year or year prior with a diagnosis of
diabetes. A diagnosis of diabetes will be determined by utilizing the following codes:
Description
Diabetes
diagnosis
Outpatient/nonacute inpatient

Acute
inpatient/ED

ICD-9-CM Codes
250, 357.2, 362.0,
366.41, 648.0

UB-92 Revenue Codes

CPT Codes

49X-53X, 55X-59X,
65X, 66X, 76X, 82X85X, 88X, 92X, 94X,
96X, 972-979, 982-986,
988

92002-92014, 9920199205, 99211-99215,
99217-99220, 9924199245, 99271-99275,
99288, 99301-99303,
99311-99313, 9932199323, 99331-99333,
99341-99355, 9938499387, 99394-99397,
99401-99404, 99411,
99412, 99420-99429,
99499
99221-99223, 9923199233, 99238-99239,
99251-99255, 9926199263, 99281-99288,
99291-99292, 9935699357

10X-16X, 20X-22X,
45X, 72X, 80X, 981,
987

Criteria for Hb A1c
• One (or more) Hb A1c test(s) conducted during the measurement year, denoted by CPT
code 83036

v

Criteria for Eye Exam
• A retinal exam performed during the measurement year or year prior to the measurement
year
Codes to Identify Eye Exams:
CPT Codes
67101, 67105, 67107-67108, 67110, 67112, 67141,
67145, 67208, 67210, 67218, 67227,67228, 92002,
92004, 92012, 92014, 92018 ,92019, 92225, 92226,
92230, 92235, 92240, 92250, 92260, 92287,99204,
99205, 99214, 99215, 99242-99245

ICD-9-CM Codes
14.1-14.5, 14.9, 95.02-95.04, 95.11,
95.12, 95.16

Criteria for LDL-C Screening
• An LDL-C test done during the measurement year or year prior to the measurement year
denoted by CPT Codes: 80061, 83715, 83716, or 83721
Exclusions
Description
Steroid Induced Diabetes
Polycystic Ovaries
Gestational Diabetes

ICD-9-CM Codes
251.8 - 962.0
256.4
648.8

vi

Enrollment File

Variable Name
Health Plan ID
Health Plan Name
Last Name
First Name
Middle Initial
AHCCCS ID
SSN
Date of Birth
Date of Death
Sex
Marital Status
Ethnicity
Street 1
Street 2
City
State
Zip Code
Rate Code
Current Placement
Residential Code
Current Location
Enrollment Date
Disenrollment Date
Facility ID
Placement Begin Date
Placement End Date
Eligibility Type
Fiscal County
Residence County
Medicare Part A
Part A Begin Date
Part A End Date
Medicare Part B
Part B Begin Date
Part B End Date

Format
Number
Text
Text
Text
Text
Text
Number
Date
Date
Text
Text
Text
Text
Text
Text
Text
Number
Text
Text
Text
Text
Date
Date
Number
Date
Date
Text
Number
Number
Text
Date
Date
Text
Date
Date

Length
6
25
20
10
1
9
9
8
8
1
1
2
25
25
20
2
9
4
1
1
3
8
8
6
8
8
1
2
2
1
8
8
1
8
8

vii

Start
Column
1
7
32
52
62
63
72
81
89
97
98
99
101
126
151
171
173
182
186
187
188
191
199
207
213
221
229
230
232
234
235
243
251
252
260

End Column
6
31
51
62
62
71
80
77
96
97
98
100
125
150
170
172
181
185
186
187
190
198
206
212
220
228
229
231
233
234
242
250
251
259
267

Description of Variables
Variable Name
Health Plan ID
Health Plan Name
Last Name
First Name
Middle Initial
AHCCCS ID

Description
Six-digit Contractor ID number that indicates with which Contractor
The AHCCCS recipient was enrolled
Name of Contractor with which the AHCCCS recipient was enrolled
Last name of recipient as listed in AHCCCS system

SSN
Date of Birth

First name of recipient as listed in AHCCCS system
Middle initial of recipient as listed in AHCCCS system
Nine-digit alpha numeric number assigned to a recipient upon
enrollment in AHCCCS
Nine digit Social Security number assigned to recipient listed in the
Date of members birth MM/DD/YYYY

Date of Death

The date of death for the AHCCCS recipient (if applicable)

Sex

One character designating gender of the AHCCCS recipient

Marital Status

Marital status of AHCCCS recipient

Ethnicity

Ethnicity of the AHCCCS recipient

Street 1

Street address of the AHCCCS recipient

Street 2

Additional street address of the AHCCCS recipient

City

City where the AHCCCS recipient lives

State

State where the AHCCCS recipient lives

Zip Code

Zip code where the AHCCCS recipient lives

Rate Code

The capitation rate code applied to the AHCCCS recipient

Current Placement

Placement of the AHCCCS recipient

Residential Code

Code designating facility of residence determined by case management

Current Location

Type of location where the AHCCCS recipient receives care

Enrollment Date

Date the recipient was enrolled in the AHCCCS system

Disenrollment Date

Date the recipient was disenrolled from the AHCCCS system

Facility ID

Six-digit code identifying the facility in which the recipient was
hospitalized during the period and the two-digit location code of the
facility

Placement Begin
Indicates the date that the recipient’s placement in a facility began
Date
Placement End Date Date that the recipient’s placement in a facility ended

viii

Eligibility Type

The AHCCCS program for which the recipient is eligible

Fiscal County
Residence County

The county paying for services received by the recipient
The county in which the recipient resides

Medicare Part A

Indicates if the recipient is entitled to receive Medicare Part A benefit.

Part A Begin Date

The date the recipient started participating in Medicare Part A

Part A End Date

The date that recipient participation in Medicare Part A ended

Medicare Part B
Part B Begin Date

Indicates if the recipient is eligible to participate in Medicare Part B
The date that the recipient started participating in Medicare Part B

Part B End Date

The date that recipient participation in Medicare Part B ended

Included condition(s)
250….Diabetes Mellitus
• 250.0x….Diabetes Mellitus without mention of complications
• 250.1x….Diabetes with ketoacidosis
• 250.2x….Diabetes with hyperosmolarity
• 250.3x….Diabetes with other coma
• 250.4x….Diabetes with renal manifestations
• 250.5x….Diabetes with ophthalmic manifestations
• 250.6x….Diabetes with neurological manifestations
• 250.7x….Diabetes with peripheral circulatory disorders
• 250.8x….Diabetes with other specified manifestations
• 250.9x….Diabetes with unspecified complications
357….Inflammatory and toxic neuropathy
• 357.2x….Polyneuropathy in diabetes
362….Other retinal disorders
• 362.0x….Diabetic retinopathy
366….Cataract
• 366.41….Diabetic cataract
648….Other current conditions in the mother classifiable elsewhere but complicating
pregnancy, childbirth, or the puerperium
• 648.0x….Diabetes Mellitus (classifiable to 250)
UB-92 Revenue Codes
Outpatient/non-acute inpatient:
49X…. Ambulatory Surgical Care
50X…. Outpatient Services

ix

51X…. Clinic
52X..... Free-Standing Clinic
53X..... Osteopathic Services
55X..... Skilled Nursing
56X..... Medical Social Services
57X..... Home Health – Home Health Aide
58X..... Home Health – Other Visits
59X..... Home Health – Units of Service
65X…. Hospice Service
66X..... Respite Care (HHA only)
76X..... Treatment/Observation Room
82X..... Hemodialysis – Outpatient or Home
83X..... Peritoneal Dialysis – Outpatient or Home
84X..... Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home
85X..... Continuous Cycling Peritoneal Dialysis (CCPD)
88X..... Miscellaneous Dialysis
92X..... Other Diagnostic Services
94X..... Other Therapeutic Services
96X..... Professional Fees
972….. Professional Fees - Radiology - Diagnosis
973….. Professional Fees - Radiology - Therapeutic
974….. Professional Fees - Radiology – Nuclear Medicine
975….. Professional Fees - Operating Room
976….. Professional Fees - Respiratory Therapy
977...... Professional Fees - Physical Therapy
978.…. Professional Fees - Occupational Therapy
979.…. Professional Fees - Speech Pathology
982….. Outpatient Services
983.…. Clinic
984….. Medical Social Services
985...... EKG
986...... EEG
988….. Consultation
989….. Professional Fees: Private Duty Nurse
UB-92 Revenue Codes
Outpatient/non-acute inpatient:
10X…. All Inclusive Rate
11X…. Room & Board – Private (Medical or General)
12X…. Room & Board – Semi-Private Two Bed (Medical and General)
13X…. Room & Board – Semi-Private—Three & Four Beds
14X…. Room & Board – Private (Deluxe)
15X…. Room & Board – Ward (Medical or General)
16X…. Room & Board - Other
20X…. Intensive Care

x

21X…. Coronary Care
22X…. Special Charges
45X…. Emergency Room
72X…. Labor Room/Delivery
80X…. Inpatient Renal Dialysis
981….. Professional Fees – Emergency Room
987….. Professional Fees –Hospital Visit
In conjunction with CPT Codes – HCFA 1500
Outpatient/non-acute inpatient:
92002-92014….General Ophthalmological Services (New & Established Patient)
99201-99205….New Patient: Office or other outpatient visit
99211-99215….Established Patient: Office or other outpatient visit
99217-99220….Observation Care Discharge Services and Initial Observation Care (New or
Established Patients
99241-99245….Office or Other Outpatient Consultations (New or Established Patients)
99241-99245….Office or Other Outpatient Consultations (New or Established Patients)
99271-99275….Confirmatory Consultations (New or Established Patients)
99301-99303….Evaluation and Management (New or Established Patients)
99311-99313….Subsequent Nursing Facility Care (New or Established Patients)
99321-99323….Domiciliary Rest Home or Custodial Care Services (New Patient)
99331-99333….Domiciliary Rest Home or Custodial Care Services (Established Patient)
99341-99355….Home Services & Prolonged Services (New or Established Patients)
99381-99387….Preventive Medicine (New Patient)
99391-99397….Preventive Medicine (Established Patient)
99401-99404….Preventive Medicine (Individual Counseling)
99411…………Preventive Medicine - Group Counseling (30 minutes)
99412…………Preventive Medicine - Group Counseling (approx. 60 minutes)
99420-99429….Other Preventive Medicine Services
99499…………Other Evaluation and Management Services
CPT Codes
Acute inpatient/ED:
99221-99223…..Initial Hospital Care (New or Established Patient)
99231-99233…..Subsequent Hospital Care
99238-99239…..Hospital Discharge Services
99251-99255…..Initial Inpatient Consultations (New or Established Patient)
99261-99263…..Follow-up Inpatient Consultations (Established Patient)
99281-99288…..Emergency Department Services and Physician Direction
99291-99292…..Critical Care Services
99356-99357…..Prolonged Physician Service – Inpatient Setting*

xi

CPT Code for Hb A1c
83036….Hemoglobin; glycated
CPT Codes for identification of Eye Exams
67101….Repair of retinal detachment, one or more sessions; cryotheraphy or diathermy,with
or without drainage of subretinal fluid
67105….Repair of retinal detachment, one or more sessions; photocoagulation, with or
without drainage of subretinal fluid
67107.…Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection,
imbrication or encircling procedure), with or without implant, with or without cryotheraphy,
photocoagulation, and drainage of subretinal fluid
67108....Repair of retinal detachment; with vitrectomy, any method, with or without air or gas
tamponade, focal endolaser photocoagulation, cryotheraphy, and drainage of subretinal fluid,
scleral buckling and/or removal of lens by same technique
67110….Repair of retinal detachment; by injection of air or other gas (eg. Pneumatic
retinopexy)
67112.…Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having
previous ipsilateral retinal detachment repair(s) using scleral buckling or vitrectomy
techniques
67141.…Prophylaxis of retinal detachment (eg. retinal break, lattice degeneration) without
drainage, one or more sessions; cryotheraphy, diathermy
67145.…Prophylaxis of retinal detachment (eg. retinal break, lattice degeneration) without
drainage, one or more sessions; photocoagulation (laser or xenon arc)
67208….Destruction of localized lesion of retina (eg. macular edema, tumors), one or more
session; cryotheraphy, diathermy
67210....Destruction of localized lesion of retina (eg. macular edema, tumors), one or more
sessions; photocoagulation
67218….Destruction of localized lesion of retina (eg. macular edema, tumors), one or more
session; radiation by implantation of source (includes removal of source)
67227….Destruction of extensive or progressive retinopathy (eg. diabetic retinopathy), one or
more sessions; cryotheraphy, diathermy
67228….Destruction of extensive or progressive retinopathy (eg. diabetic retinopathy), one or
more sessions; photocoagulation (laser or xenon arc)
92002….Ophthalmological services: medical examination and evaluation with initiation of
diagnostic and treatment program; intermediate, new patient
92004….Ophthalmological services: medical examination and evaluation with initiation of
diagnostic and treatment program; comprehensive, new patient, one or more visits
92012….Ophthalmological services: medical examination and evaluation with initiation or
continuation of diagnostic and treatment program; intermediate, established patient
xii

92014.…Ophthalmological services: medical examination and evaluation with initiation or
continuation of diagnostic and treatment program; comprehensive, established patient, one or
more visits
92019….Ophthalmological examination and evaluation, under general anesthesia, with or
without manipulation of globe for passive range of motion or other manipulation to facilitate
diagnostic examination; limited
99204….Office or other outpatient visit (45 minutes face-to-face with patient and/or family)
92018….Ophthalmological examination and evaluation, under general anesthesia, with or
without manipulation of globe for passive range of motion or other manipulation to facilitate
diagnostic examination; complete
99205….Office or other outpatient visit (60 minutes face-to-face with patient and/or family)
99214….Office or other outpatient visit (25 minutes face-to-face with patient and/or family)
99215….Office or other outpatient visit (40 minutes face-to-face with patient and/or family)
99242….Office consultation for new or established patient (30 minutes face-to-face with
patient and/or family)
99243….Office consultation for new or established patient (40 minutes face-to-face with
patient and/or family)
99244....Office consultation for new or established patient (60 minutes face-to-face with
patient and/or family)
99245….Office consultation for new or established patient (80 minutes face-to-face with
patient and/or family)
ICD-9-CM Codes
14.1…..Diagnostic procedures on retina, choroids, vitreous and posterior chamber
14.2.….Destruction of lesion of retina and choroids
14.3.….Repair of retinal tear
14.4…..Repair of retinal detachment with scleral buckling and implan
14.5.….Other repair of retinal detachment
14.9…...Other operations on retina, choroid, and posterior chamber
95.02….Comprehensive eye examination
95.03….Extended ophthalmologic work-up
95.04….Eye examination under anesthesia
95.11….Fundus photography
95.12….Fluorescein angiography or angioscopy of eye
95.16….P32 and other tracer studies of eye
V80.2….Other eye conditions

xiii

CPT Codes for LDL-C Screening
80061.…Lipid Panel
83715.…Lioprotein, blood; electrophoretic separation and quantitation
83716….Lioprotein, blood; high resolution fractionation and quantitation of lipoprotein
cholesterols (eg, electrophoresis, nuclear magnetic resonance, ultracentrifugation)
83721.…Lipoprotein, direct measurement; LDL cholesterol
Excluded Condition (s)
251.8…Steroid induced diabetes
256.4…Polycystic Ovaries
648..….Other current conditions in the mother classifiable elsewhere, but complicating
pregnancy, childbirth, or the puerperium
648.8x ..Gestational diabetes (classifiable to 790.2)
775……Endocrine and metabolic disturbances specific to the fetus and newborn
775.1x…Neonatal Diabetes Mellitus
790……Nonspecific findings on examination of blood
790.2….Abnormal glucose tolerance test
790.6….Hyperglycemia NOS
962.0….Adrenal and anabolic congeners

xiv