ARIZONA LONG TERM CARE SYSTEM (ALTCS)
CLINICAL QUALITY PERFORMANCE INDICATORS FOR
DIABETES CARE
For the Measurement Period Ending September 30, 2002

Produced by the Division of Health Care Management, AHCCCS
November 2003
Anthony D. Rodgers
Director

Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)
CLINICAL QUALITY PERFORMANCE INDICATORS FOR DIABETES CARE
For the Measurement Period Ending September 30, 2002

I. EXECUTIVE SUMMARY .………………………………................................................. i
II. BACKGROUND …..………………………...…………………………........................... 1
III. PREVENTION OF DIABETES COMPLICATIONS .…..…………...…………….…... 2
IV. QUALITY INDICATORS ………..............................................................................….. 3
V. MEASUREMENT PERIOD .......................................……………...…………...……...... 4
VI. INDICATOR GOALS ....................................................................................................... 4
VII. RESULTS AND ANALYSIS .......................................................................................... 4
VII. COMPARISONS WITH OTHER STUDIES ………………………………………….. 5
VIII. DISCUSSION .....................................................………........................……….…..…. 6
IX. REFERENCES .................................................................................................................. 8
X. TABLES AND FIGURES ................................................................................................ 10

For questions or comments about this report, contact
Rochelle Tigner, Quality Improvement Manager, at
(602) 417-4683 or rttigner@ahcccs.state.az.us

Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)
CLINICAL QUALITY PERFORMANCE INDICATORS FOR DIABETES CARE
For the Measurement Period Ending September 30, 2002

EXECUTIVE SUMMARY
Diabetes is the sixth leading cause of death among Americans. The United States Department
of Health and Human Services (DHHS) estimates that almost 17 million Americans age 20
years and older have diabetes.1,2
Direct and indirect costs associated with diabetes in the United States, including lost
3
productivity, were estimated to be $132 billion in 2002. Diabetes is the leading cause of
end-stage kidney disease, lower extremity amputations, and new cases of blindness among
4
U.S. adults ages 20 to 74 years The prevalence of diabetes is higher among American
Hispanics, blacks and American Indians/Alaska natives, compared with non-Hispanic whites.
1
The prevalence of diabetes also is higher among older Americans. About 20 percent of all
people 65 and older have diabetes, compared with approximately 6 percent of the total
1
population.
The potential impact of this disease on the Arizona Long Term Care System (ALTCS) is of
significant concern to AHCCCS. Based on this and previous studies conducted by AHCCCS,
the prevalence of diabetes among ALTCS members is approximately 20 percent. With the
number of Arizonans age 65 and older increasing 40 percent in the last decade, the proportion
5
of ALTCS members with diabetes is likely to increase as well.
Most ALTCS members are covered by Medicare and may seek services outside AHCCCS
provider networks (at the end of the measurement period for this report, 81 percent of ALTCS
elderly and physically disabled members were “dually enrolled”). Because Medicare is the
primary payer for these beneficiaries, AHCCCS has not been able to determine to what extent
these members receive services. However, through a collaborative project with Health
Services Advisory Group (HSAG), a Quality Improvement Organization (QIO) contracted
with the federal government, AHCCCS received some data on diabetes care provided to
members who were covered by both Medicare and AHCCCS (Medicaid). Medicare data for
members receiving care on a fee-for-service basis was obtained by HSAG from the Centers
for Medicare and Medicaid Services (CMS).
AHCCCS used Health Plan Employer Data and Information Set (HEDIS®) 2002
specifications as a guideline for measurement of diabetes care services. This report includes
results for two indicators, Hb A1c testing and lipid profiles. AHCCCS had planned to report
data for retinal exams among ALTCS members with diabetes, but that information was not
available from CMS.

i

This study measured services provided from October 1, 2001, through September 30, 2002.
Three rates for each indicator were calculated: for members enrolled in AHCCCS through
Medicaid only, for members enrolled in AHCCCS who also were eligible for Medicare
(dually enrolled), and a combined rate of the two groups.
Overall results will be used to establish baseline rates for diabetes-care indicators and develop
new minimum performance standards and goals for care of ALTCS members with diabetes.
These standards will be used to evaluate performance of AHCCCS Contractors that serve
members enrolled in ALTCS.
This study included 2,127 ALTCS elderly and physically disabled (EPD) members who were
diagnosed with type 1 or type 2 diabetes, were 18 through 75 years of age, and were
continuously enrolled with one ALTCS Contractor for the entire measurement period (one
gap in enrollment, not exceeding 31 days, was allowed). The rates reported below were
derived from combined AHCCCS and CMS data, which includes services provided through
ALTCS Contractors and through the Medicare fee-for-service program.
Hb A1c testing - This indicator measured the percentage of AHCCCS members who had one
or more glycosylated hemoglobin, or Hb A1c, tests during the measurement period.
Findings
•
The overall rate of ALTCS members with diabetes (including Medicaid-only members
and those who were dually enrolled) who received an Hb A1c test was 47.3 percent.
•
Rates by Contractor ranged from 35.5 percent to 66.7 percent.
•
Pearson’s Chi-square revealed no difference in the rate of annual Hb A1c testing between
members enrolled only in Medicaid and dually enrolled members.
•
Four of seven Contractors exceeded the DHHS national Healthy People 2010 goal that 50
6
percent of adults with diabetes have an Hb A1c measurement at least once a year.
Lipid (LDL) screening - This indicator measured the percentage of AHCCCS members who
had one or more fasting lipid profiles performed during the measurement period or the
preceding year.
Findings
•
The overall rate of ALTCS members with diabetes (including both Medicaid-only
members and those who were dually enrolled) who had a lipid screening during the
measurement period or the preceding year was 43.4 percent.
•
Rates by Contractor ranged from 33.2 percent to 56.4 percent.
•
Pearson’s Chi-square revealed that, overall, there was no difference in the rate of lipid
screening between members enrolled only in Medicaid and dually enrolled members.
•
DHHS has not set an objective for biennial lipid profiles.

ii

It should be emphasized that Medicare data for dually enrolled ALTCS members obtained
from CMS reflects only encounters paid for on a fee-for-services basis, and does not include
services provided to members who are enrolled in managed care plans that contract with
Medicare (known as Medicare + Choice plans). These health plans serve nearly 30 percent of
7
all Medicare beneficiaries in Arizona, and AHCCCS data shows that about one-quarter of
ALTCS EPD members were enrolled in Medicare + Choice plans during the measurement
period. Thus, rates for the two diabetes indicators reported here may not fully reflect the
extent to which ALTCS members receive diabetes-related preventive-care services. AHCCCS
will consider ways to obtain additional data from Medicare managed-care plans in the future.
In order to assist ALTCS Contractors with quality improvement efforts, AHCCCS has
compiled information on barriers to effective diabetes management and successful strategies
for increasing the use of preventive-care practices. It is hoped that the following discussion
will assist Contractors in evaluating and refining existing diabetes-management efforts or, if
necessary, developing new interventions.
Because diabetes is frequently an asymptomatic disease, patients may not adhere to treatment
8
regimens or regular blood-glucose or lipid testing. Patients’ socioeconomic status also may
pose a barrier to use of preventive-care services. Lower levels of education are associated
with patients not adhering to recommendations for diabetes self management. This likely is
9,10
related to a lack of understandable or relevant patient education materials.
Physicians face barriers in ensuring that patients receive these services and have adequately
controlled glucose and lipid levels. Common physician barriers include confusion caused by
differing recommendations regarding testing and treatment, the need for frequent monitoring
8,10
and medication adjustments to achieve treatment goals, and time limitations.
Rates of Hb A1c and lipid testing can be improved by interventions such as easy-tounderstand and culturally relevant patient education materials, computer-generated patient
reminders or automated telephone disease-management systems with nurse follow up, chronic
disease self-management education programs, social support networks, and case management
10-16
services.
With more than half of ALTCS members living in home- and community-based
settings, these strategies may be especially useful in helping Contractors and providers to
better manage the care of those diabetics.
Even for those patients in whom the disease has progressed and adversely affects one or more
body systems, causing such comorbid conditions as kidney or heart disease, these
interventions may improve outcomes. Regular monitoring of blood-glucose and lipid levels
allows health care providers to take steps that can reduce the impact of the disease and
improve quality of life. The Chronic Care Model, developed by a national program of the
Robert Wood Johnson Foundation, may be a useful tool for health care systems, managed
17
care organizations and collaborative initiatives to improve the care of people with diabetes.

iii

AHCCCS will provide individual results to Contractors and will continue to work with ALTCS
Contractors to help them improve performance in these indicators. As noted, AHCCCS
contractual Minimum Performance Standards will be developed from the baseline rates for these
indicators. In the future, Contractors who do not meet these standards may be required to
implement corrective action plans and may face sanctions if they fail to show improvement in
their rates.
VIII.

REFERENCES

1

American Diabetes Association. National diabetes fact sheet. Available at:
http://www.diabetes.org/main/info/facts/facts_natl.jsp. Accessed March 19, 2003.
2
Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national
estimates on diabetes in the United States, 2000. Atlanta, Ga: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, 2002.
3
American Diabetes Association. Economic costs of diabetes in the US in 2002. Diabetes Care. 2003; 26:917932. Available at: http://www.care.diabetesjournals.org/cgi/content//full/26/3/917. Accessed March 19, 2003.
4
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health
Promotion. Chronic disease prevention: impact of diabetes. June 1, 1999. Available at:
http://www.cdc.gov/diabetes/pubs. Accessed March 5, 2002.
5
Arizona Health Care Cost Containment System. Five-year strategic plan: FY 2004-2008. Phoenix, Arizona:
AHCCCS, October 2002.
6
U. S. Department of Health and Human Services, Office of Public Health and Science: Healthy People 2010,
objectives for improving health, vol. I; November 2000
7
Health Services Advisory Group. Medicare population totals: Arizona, Maricopa, Pima and managed care
organizations, 1994 through 2002. Accessed September 15, 2003.
8
Larme AC, Pugh JA. Attitudes of primary care providers towards diabetes: barriers to guideline
implementation. Diabetes Care. 1998; 21(9):1391-1396.
9
El-Kebbi IM, Ziemer DC, Gallina, DI, et al. Identification of barriers to provider adherence to management
protocols. Diabetes Care. 1999; 22(10):1617-1620.
10
Zgibor JC, Songer TJ. External barriers to diabetes care: addressing personal and health systems issues.
Diabetes Spectrum. 2001; 14(1):23-28.
11
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/abstract/23/4. Accessed April 4, 2003.
12
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/abstract/full/24/2 Accessed April 4,
2003.
13
Brown SA, Garcia AA, Kouzekanani K, Hanis CA. Culturally competent diabetes self-management education
for Mexican Americans. Diabetes Care. 2002; 25(2):259-268. Available at:
http://care.diabetesjournals.org/cgi/content/full/25/2. Accessed April 4, 2003.
14
Gilliland SS, Azen SP, Perez GE, Carter JS. Strong in body and spirit: Lifestyle intervention for Native
American adults with diabetes in New Mexico. Diabetes Care. 2002; 25(1):78-83. Available at:
http://care.diabetesjournals.org/cgi/content/abstract/full/25/1 Accessed April 4, 2003.
15
Sadur CN, Moline N, Costa M, et al. Diabetes management in a health maintenance organization: efficacy of
care management using cluster visits. Diabetes Care. 1999; 22(12):2011-2017.
16
Deichmann RE, Castello E, Horswell R, Friday KE. Improvements in diabetic care as measured by Hb A1c
after physician education project. Diabetes Care. 1999; 22(10):1612-1616.
17
Improving Chronic Illness Care Web site. Overview of the Chronic Care Model. Available at:
http://www.improvingchroniccare.org/change/model/components.html. Accessed April 3, 2003.

iv

Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)
CLINICAL QUALITY PERFORMANCE INDICATORS FOR DIABETES CARE
For the Measurement Period Ending September 30, 2002

BACKGROUND
Diabetes is the sixth leading cause of death among Americans, and was a direct or
contributing cause of more than 209,000 deaths in 1999 (the most recent year for which
comprehensive national data is available).1,2 In Arizona, diabetes was the seventh leading
cause of death in 1999.3 More recent data indicates that diabetes continues to affect a
significant portion of the population. The United States Department of Health and Human
Services (DHHS) estimates that almost 17 million Americans age 20 years and older have
diabetes, with about one third of these cases undiagnosed.1,2
Diabetes is a chronic disease in which the body does not produce or properly use insulin.
Insulin is a hormone that is needed to convert carbohydrates into glucose, a simple sugar that
is a primary energy source. Both genetics and lifestyle, such as obesity and lack of exercise,
are associated with the disease.4
There are three major types of diabetes:4,5
• Type 1 diabetes, which results from the body’s failure to produce insulin and affects 10 to
15 percent of all diabetics. Type 1 diabetes most commonly develops in childhood or
adolescence.
• Type 2 diabetes, which results from insulin resistance, a condition in which the body fails
to use insulin properly, and affects 85 to 90 percent of diabetics. Type 2 diabetes is
usually diagnosed in people 30 years or older.
• Gestational diabetes, a form of glucose intolerance that is diagnosed in about 4 percent of
women during pregnancy. Gestational diabetes may be manifested later as type 2 diabetes.
Direct and indirect costs associated with diabetes in the United States, including lost
productivity, were estimated to be $132 billion in 2002.6 Diabetes is the leading cause of endstage kidney disease, lower extremity amputations, and new cases of blindness among U.S.
adults ages 20 to 74 years.7 Other complications of diabetes include heart disease, stroke,
high blood pressure, nervous system damage, and dental disease. People with diabetes have a
two- to four-fold increase in their risk of heart disease and stroke, compared with the general
population. People with diabetes also are more susceptible to many other illnesses, and are
more likely to die from pneumonia or influenza than people who do not have diabetes.1

1

The prevalence of diabetes is higher among American Hispanics, blacks and American
Indians/Alaska natives, compared with non-Hispanic whites.8 The prevalence of diabetes also
is higher among older Americans: approximately half of all diabetes cases occur in people
older than 55. About 20 percent of all people 65 and older have diabetes, compared with
approximately 6 percent of the total population.1,9
The potential impact of this disease on the Arizona Long Term Care System (ALTCS) is of
significant concern to AHCCCS. Based on this and previous studies conducted by AHCCCS,
the prevalence of diabetes among ALTCS members is approximately 20 percent. With the
number of Arizonans age 65 and older increasing 40 percent in the last decade, the proportion
of ALTCS members with diabetes is likely to increase as well. The complications of diabetes
can affect the ability of many elderly and physically disabled (EPD) members enrolled in
ALTCS to remain in their homes or a less intensive community-based care setting. This in
turn, impacts costs. ALTCS members account for approximately 4 percent of AHCCCS
enrollees, yet the cost to care for these members is approximately 21 percent of all AHCCCS
9
expenditures.
Most ALTCS members are covered by Medicare and may seek services outside AHCCCS
provider networks (at the end of the measurement period for this report, 81 percent of ALTCS
EPD members were “dually enrolled”). Because Medicare is the primary payer for these
beneficiaries, AHCCCS has not been able to determine to what extent these members receive
services. However, through a collaborative project with Health Services Advisory Group
(HSAG), a Quality Improvement Organization (QIO) contracted with the federal government,
AHCCCS received some data on diabetes care provided to members who were covered by
both Medicare and AHCCCS (Medicaid). Medicare data for members receiving care on a feefor-service basis was obtained by HSAG from the Centers for Medicare and Medicaid
Services (CMS).
PREVENTION OF DIABETES COMPLICATIONS
Control of hyperglycemia (increased blood sugar) is critical to preventing or minimizing
complications of diabetes. Sustained high blood sugars result in damage to the retina,
peripheral nerves and kidneys. 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. Thus, monitoring of blood-glucose levels and lipids are effective in reducing
both the incidence and progression of diabetes complications.
Physicians utilize a glycosylated hemoglobin, or Hb A1c, test to monitor patients’ blood
glucose levels. This test provides an indication of a person’s average glucose levels 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.10 Studies in the United States and abroad have
shown that improved glycemic control benefits people with either type 1 or type 2 diabetes.1,10
The United Kingdom Prospective Diabetes Study found that, for every percentage point
decrease in Hb A1c, there was a 35-percent reduction in the risk of developing microvascular
complications, which affect the eyes and kidneys.11

2

According to the American Diabetes Association (ADA), an Hb A1c test should be performed
twice a year in patients who have achieved glycemic control, and quarterly in patients whose
therapy has changed or who are not meeting glycemic goals.11
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
11
a history of cardiovascular problems.
Control of cholesterol and lipids can reduce
1
cardiovascular complications by 20 to 50 percent. A fasting lipid profile is performed to
measure total cholesterol (TC), high-density lipoproteins (HDL) and triglycerides. These
results are used to calculate and manage low-density lipoprotein (LDL) levels.
The ADA recommends testing for lipid disorders at least annually. In adults who achieve
certain goals for lipid levels, repeat testing can be performed every two years.11
Eye Care
Retinal damage, or retinopathy, is a frequent complication of both type 1 and type 2 diabetes.
Regular eye examinations by an ophthalmologist or optometrist are necessary for the early
detection and treatment of retinopathy to prevent vision loss. It is estimated that regular eye
exams and timely treatment, including laser surgery, could prevent up to 90 percent of
11
diabetes-related cases of blindness.
The ADA recommends that people with type 1 and type 2 diabetes have a comprehensive
dilated eye exam annually, or more frequently if retinopathy is progressing.12
Despite the benefits of services that may prevent or reduce complications of diabetes, many
people do not receive this care. According to the Centers for Disease Control and Prevention
(CDC), levels of preventive-care practices among persons with diabetes are lower than
national health objectives. Using the Behavioral Risk Factor Surveillance System (BRFSS), a
national telephone survey of adults conducted by state health departments, the CDC found
that only 24 percent of adults surveyed received an annual Hb A1c test in the years 1997 to
1999. The rate of annual Hb A1c testing in Arizona during that period was reported to be
about 21 percent. The BRFSS also found the rate of annual dilated eye exams to be 60
percent, both nationally and in Arizona. The BRFSS did not measure fasting lipid profiles.13
QUALITY INDICATORS
AHCCCS used the Health Plan Employer Data and Information Set (HEDIS®) 2002, which
was developed by the National Committee for Quality Assurance (NCQA), as a guideline for
measurement of diabetes care services.* HEDIS methodology includes six quality indicators
of performance related to diabetes. AHCCCS identified three indicators for measurement in
2003: Hb A1c testing, fasting lipid profiles, and dilated eye exams.
* It should be noted that the HEDIS indicators are based on clinical criteria, but should not be considered as
treatment guidelines. Thus, HEDIS specifications differ from ADA recommendations for frequency of testing.

3

This report includes results for two indicators, Hb A1c testing and lipid profiles; Medicare
data for the third indicator, dilated eye exams, was not available from CMS.
1)
Hb A1c testing
This indicator measured the percentage of ALTCS EPD members who:
•
were diagnosed with type 1 or type 2 diabetes,
•
were 18 through 75 years of age at the end of the measurement period,
•
were continuously enrolled with one ALTCS Contractor for the entire measurement
period (one gap in enrollment, not exceeding 31 days, was allowed), and
•
had one or more Hb A1c tests during the measurement period.
2)
Lipid (LDL) screening
This indicator measured the percentage of ALTCS EPD members who:
•
were diagnosed with type 1 or type 2 diabetes,
•
were 18 through 75 years of age at the end of the measurement period,
•
were continuously enrolled with one ALTCS Contractor for the entire measurement
period (one gap in enrollment, not exceeding 31 days, was allowed), and
•
had one or more fasting lipid profiles performed during the measurement period or the
preceding year.
Three rates for each of the above indicators were calculated: for members enrolled in
AHCCCS through Medicaid only, for members enrolled in AHCCCS who also were eligible
for Medicare (dually enrolled), and a combined rate of the two groups.
MEASUREMENT PERIOD
The measurement period for this study was October 1, 2001, through September 30, 2002.
INDICATOR GOALS
As part of its “Healthy People 2010” objectives, the U.S. Department of Health and Human
Services (DHHS) has established a goal that 50 percent of adults with diabetes have an Hb
14
A1c measurement at least once a year.
DHHS has not set an objective for biennial lipid
profiles.
This study will establish baseline rates for diabetes-care indicators, and will be used to
develop new minimum performance standards and goals for care of ALTCS members with
diabetes. These standards will be used to evaluate performance of AHCCCS Contractors that
serve members enrolled in ALTCS.
RESULTS AND ANALYSIS
This study included 2,127 ALTCS EPD members with diabetes. The rates reported below
were derived from combined AHCCCS and CMS data, which includes services provided
through ALTCS Contractors and through the Medicare fee-for-service program.

4

1)
Hb A1c testing
The overall rate of ALTCS members with diabetes who received an Hb A1c test during the
measurement period was 47.3 percent (Table 1). Rates by Contractor ranged from 35.5
percent to 66.7 percent. Four Contractors exceeded the Healthy People 2010 goal (Figure 1).
Data analysis using Pearson’s Chi-square revealed that, overall, there was no difference in the
rate of Hb A1c testing between members enrolled only in Medicaid and those who were dually
enrolled (p=.577), with rates of 48.4 percent and 47.0 percent, respectively.
2)
Lipid (LDL) screening
The overall rate of ALTCS members who had a fasting lipid profile during the measurement
period or the preceding year was 43.4 percent (Table 2). Rates by Contractor ranged from
33.2 percent to 56.4 percent (Figure 2). As noted, there is no comparable Healthy People goal
for lipid testing of diabetics.
Pearson’s Chi-square also revealed that there was no difference overall in the rate of lipid
screening between members enrolled only in Medicaid and those who were dually enrolled
(p=.430), with rates of 42.0 percent and 43.9 percent, respectively.
COMPARISONS WITH OTHER STUDIES
This study cannot be compared directly to other reports of utilization of diabetes services.
Because of differences in methodology, the performance indicator rates reported here are not
comparable to those reported by AHCCCS in prior years. For example, previous performance
indicator studies measured whether Hb A1c testing was performed twice a year, rather than
annually, and was based only on AHCCCS encounter data.
It should be noted that AHCCCS measured annual Hb A1c testing among members with
diabetes who were continuously enrolled with all Contractors in the period from October 1,
2000, through September 30, 2001, as part of a Quality Improvement Project (QIP). The QIP
baseline measure showed an overall rate among ALTCS Contractors of 60.2 percent. The
disparity in rates reported in these two studies likely reflects the difference in data sources: the
QIP baseline data was collected from encounter (claims) information, along with laboratory
and medical records, and data for this report was extracted solely from AHCCCS and CMS
encounter data.
NCQA has reported national averages for Medicaid managed-care plans for its HEDIS
diabetes measures. In 2000, the Medicaid rates were 68.5 percent for annual Hb A1c testing
15
and 59.6 percent for biennial lipid screening. While the NCQA measure is not specific to a
long-term-care population, these rates may be useful in establishing AHCCCS goals for
improvement.

5

DISCUSSION
Medicare data obtained from CMS reflects only encounters paid for on a fee-for-services
basis, and does not include services provided to members who are enrolled in managed care
plans that contract with Medicare (known as Medicare + Choice plans). These health plans
serve about 12 percent of the total Medicare population nationwide and nearly 30 percent of
16,17
all Medicare beneficiaries in Arizona.
AHCCCS data shows that approximately onequarter of ALTCS EPD members were enrolled in Medicare + Choice plans during the
measurement period. Thus, rates for the two diabetes indicators reported here may not fully
reflect the extent to which ALTCS members receive diabetes-related preventive-care services.
AHCCCS will consider possible ways to obtain data from Medicare managed-care plans in
the future. AHCCCS also will continue to attempt to obtain data on retinal exams from CMS,
in order to ensure use of that important service.
In order to assist ALTCS Contractors with quality improvement efforts, AHCCCS has
compiled information on barriers to effective diabetes management and successful strategies
for increasing the use of preventive-care practices. It is hoped that the following discussion
will assist Contractors in evaluating and refining existing diabetes-management efforts or, if
necessary, developing new interventions.
Barriers to Effective Diabetes Management
Health care providers state that diabetes is difficult to treat because of the involvement of
many body systems, requiring patients to adhere to daily and sometimes complex
18
interventions to control the disease.
For people with type 2 diabetes, control of blood
glucose involves following a careful diet and exercise program, losing excess weight, and
taking insulin and/or oral medication. Many people with diabetes also need to take
medications to control related conditions such as elevated cholesterol and high blood pressure.
Patients often face difficulty in altering their lifestyles to accommodate all these measures.
This may be especially true of people who are elderly and physically disabled.
Because diabetes is frequently an asymptomatic disease, patients may not adhere to treatment
18
regimens or regular blood-glucose testing. Patients’ socioeconomic status also may pose a
barrier to use of preventive-care services. Lower levels of education are associated with
patients not adhering to recommendations for diabetes self management. This likely is related
19,20
to a lack of understandable or relevant patient education materials.
Physicians also face barriers in ensuring that patients receive preventive-care services and
have adequately controlled glucose levels. Common physician barriers include confusion
caused by differing recommendations regarding testing and treatment, the need for frequent
18,20
monitoring and medication adjustments to achieve treatment goals, and time limitations.

6

Strategies to Improve Diabetes Care
Patient adherence to testing and treatment regimens can be improved by interventions such as:
easy-to-understand patient education materials, automated patient reminders by telephone,
social support networks that include lifestyle-management education, and nurse follow-up or
20-26
case management services.
With more than half of ALTCS members living in home- and
community-based settings, these strategies may be especially useful in helping Contractors
and providers to better manage the care of those diabetics. And, because of the increased
prevalence of diabetes among certain racial or ethnic groups, any intervention must take into
account the cultural values, beliefs and practices of those patients.
Specific physician- and practice-related interventions that have proven to be successful in
11,22,23
managing diabetic patients in a community setting include:
Practice guidelines, adopted with participation of providers in the process. Guidelines
•
should be readily accessible at the point of service, such as on patient charts, in examining
rooms or on office computer systems
•
Automated reminders of patients due for testing or specific identification by health plans
of patients with abnormal laboratory values
•
Flow sheets, used by providers to track Hb A1c levels and other test results
•
Practice changes, such as scheduling dedicated diabetes visits and group or “cluster” visits
•
Increased availability and involvement of expert consultants, such as endocrinologists and
diabetes educators
For those patients in whom the disease has progressed and adversely affects one or more body
systems, causing such comorbid conditions as kidney or heart disease, these interventions also
may improve outcomes. Regular monitoring of blood-glucose and lipid levels allows health
care providers to take steps that can reduce the impact of the disease and improve quality of
life. The Chronic Care Model, developed by a national program of the Robert Wood Johnson
Foundation, may be a useful tool for health care systems, managed care organizations and
27
collaborative initiatives to improve the care of people with diabetes.
Local Quality Improvement Initiatives
Through initiatives such as the Arizona State Diabetes Collaborative and the Arizona
Diabetes Initiative, a broad array of public agencies, private companies and professional
associations have joined together to improve the health and medical care of persons with
diabetes. Using the Chronic Care Model, the Arizona Diabetes Initiative has organized
workgroups to develop and implement interventions related to each of the model’s
components. The interventions include proven strategies mentioned above, such as a diabetes
flow sheet for provider use and a “Passport to Better Diabetes Health” for patients to use in
keeping track of tests and immunizations, and implementation of an Adult Preventive Health
Disease Registry to track patients with chronic disease, including those with diabetes. Several
AHCCCS Contractors are participating in this initiative.

7

Several Contractors have implemented quality improvement activities for better rates of
diabetes-management services. For example, one ALTCS Contractor serving a rural county
determined that approximately one-third of its members have diabetes. The health plan has
hosted dinner programs for clinicians on diabetes topics that offer continuing education
credits. It also has developed a “Diabetes Expectation Card” that urges diabetic members to
ask their doctors for a hemoglobin A1c test and other preventive tests and exams. The card,
printed in both English and Spanish, is being distributed by the Contractor’s case managers,
along with a teaching guide/sample script and diabetes information materials to support oneon-one patient education.
AHCCCS will provide individual results to Contractors and will continue to work with ALTCS
Contractors to help them improve performance in these indicators. As noted, AHCCCS
contractual Minimum Performance Standards will be developed from the baseline rates for these
indicators. In the future, Contractors who do not meet these standards may be required to
implement corrective action plans and may face sanctions if they fail to show improvement in
their rates.
VIII.

REFERENCES

1

American Diabetes Association. National diabetes fact sheet. Available at:
http://www.diabetes.org/main/info/facts/facts_natl.jsp. Accessed March 19, 2003.
2
Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national
estimates on diabetes in the United States, 2000. Atlanta, Ga: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, 2002.
3
Arizona Department of Health Services.1997 Arizona behavioral risk factor survey annual report. Available at:
http://www.hs.state.az.us/plan/brfs/reports.htm. Accessed March 14, 2003.
4
American Diabetes Association. Basic diabetes information. Available at:
http://www.diabetes.org/main/application/commercewf?origin=ybarticle.jsp&event=link(B). Accessed March
19, 2003.
5
Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ:
Merck Research Laboratories; 1999.
6
American Diabetes Association. Economic costs of diabetes in the US in 2002. Diabetes Care. 2003; 26:917932. Available at: http://www.care.diabetesjournals.org/cgi/content//full/26/3/917. Accessed March 19, 2003.
7
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health
Promotion. Chronic disease prevention: impact of diabetes. June 1, 1999. Available at:
http://www.cdc.gov/diabetes/pubs. Accessed March 5, 2002.
8
Centers for Disease Control and Prevention. Prevalence of diabetes and impaired fasting glucose in adults —
United States, 1999-2000. Morb Mortal Wkly Rep. 2003; 52(35):833-837. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5235.htm. Accessed September 8, 2003.
9
Arizona Health Care Cost Containment System. Five-year strategic plan: FY 2004-2008. Phoenix, Arizona:
AHCCCS, October 2002
10

American Diabetes Association. In the news, More people need to know about the test for A1c – or glycated
hemoglobin – that has revolutionized diabetes care. Available at:
http://ada.yellowbrix.com/pages/ada/Story.nsp?story_id=37436183&ID=ada. Accessed March 19, 2003.
11
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.
12
American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care.
2003 (Suppl. 1); 26:S33-S50.

8

13

Centers for Disease Control and Prevention. Levels of diabetes-related preventive-care practices — United
States, 1997-1999. Morb Mortal Wkly Rep. 2000; 49(42):954-958. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4942a2.htm. Accessed March 19, 2003.
14

U. S. Department of Health and Human Services, Office of Public Health and Science: Healthy People 2010,
objectives for improving health, vol. I; November 2000

15

National Committee for Quality Assurance. The state of health care quality. Available at:
http://www.ncqa.org/Communications/News/sohc2002.htm. Accessed April 9, 2003.
16
U. S. Department of Health and Human Services, Centers for Medicare and Medicaid Services: Fact sheet:
The Medicare+Choice payment methodology. Available at: http://www.cms.gov/media/press/release.asp?
Accessed August 15, 2003.
17
Health Services Advisory Group. Medicare population totals: Arizona, Maricopa, Pima and managed care
organizations, 1994 through 2002. Accessed September 15, 2003.
18
Larme AC, Pugh JA. Attitudes of primary care providers towards diabetes: barriers to guideline
implementation. Diabetes Care. 1998; 21(9):1391-1396.
19
El-Kebbi IM, Ziemer DC, Gallina, DI, et al. Identification of barriers to provider adherence to management
protocols. Diabetes Care. 1999; 22(10):1617-1620.
20
Zgibor JC, Songer TJ. External barriers to diabetes care: addressing personal and health systems issues.
Diabetes Spectrum. 2001; 14(1):23-28.
21
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/abstract/23/4. Accessed April 4, 2003.
22
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/abstract/full/24/2 Accessed April 4,
2003.
23
Brown SA, Garcia AA, Kouzekanani K, Hanis CA. Culturally competent diabetes self-management education
for Mexican Americans. Diabetes Care. 2002; 25(2):259-268. Available at:
http://care.diabetesjournals.org/cgi/content/full/25/2. Accessed April 4, 2003.
24
Gilliland SS, Azen SP, Perez GE, Carter JS. Strong in body and spirit: Lifestyle intervention for Native
American adults with diabetes in New Mexico. Diabetes Care. 2002; 25(1):78-83. Available at:
http://care.diabetesjournals.org/cgi/content/abstract/full/25/1 Accessed April 4, 2003.
25
Sadur CN, Moline N, Costa M, et al. Diabetes management in a health maintenance organization: efficacy of
care management using cluster visits. Diabetes Care. 1999; 22(12):2011-2017.
26
Deichmann RE, Castello E, Horswell R, Friday KE. Improvements in diabetic care as measured by Hb A1c
after physician education project. Diabetes Care. 1999; 22(10):1612-1616.
27
Improving Chronic Illness Care Web site. Overview of the Chronic Care Model. Available at:
http://www.improvingchroniccare.org/change/model/components.html. Accessed April 3, 2003.

9

Table 1
Arizona Health Care Cost Containment System/Arizona Long Term Care System
ANNUAL Hb A1c TESTING BY CONTRACTOR (1)
Measurement Period: October 1, 2001, through September 30, 2002

Contractor

Number of
Members

Number of Members
with Hb A1c Tests

Percent of Members
with Hb A1c Tests

Cochise Health Systems

117

50

42.7%

Evercare Select

277

149

53.8%

Maricopa LTC

753

267

35.5%

Mercy Care LTC

393

240

61.1%

Pima Health System LTC

395

201

50.9%

Pinal/Gila County LTC

114

48

42.1%

78

52

66.7%

2127

1007

47.3%

Yavapai County LTC
TOTAL

(1) Rates are based on a combination of AHCCCS encounter data and Medicare fee-for-service data
obtained from the Centers for Medicare and Medicaid Services.

10

Figure 1
Arizona Health Care Cost Containment System/Arizona Long Term Care System
ANNUAL Hb A1c TESTING BY CONTRACTOR (1)
Measurement Period: October 1, 2001, through September 30, 2002

80%

70%

60%

Healthy People 2010 Goal

50%

40%

30%

20%

10%

0%
Cochise Health
Systems

Evercare Select

Maricopa LTC

Mercy Care LTC

Pima Health
System LTC

Pinal/Gila County
LTC

(1) Rates are based on a combination of AHCCCS encounter data and Medicare fee-for-service data.

11

Yavapai County
LTC

Table 2
Arizona Health Care Cost Containment System/Arizona Long Term Care System
BIENNIAL LIPID (LDL) SCREENING BY CONTRACTOR (1)
Measurement Period: October 1, 2001, through September 30, 2002

Contractor

Number of
Members

Number of Members
with LDL Screens

Percent of Members
with LDL Screens

Cochise Health Systems

117

59

50.4%

Evercare Select

277

136

49.1%

Maricopa LTC

753

250

33.2%

Mercy Care LTC

393

214

54.5%

Pima Health System LTC

395

162

41.0%

Pinal/Gila County LTC

114

59

51.8%

78

44

56.4%

2127

924

43.4%

Yavapai County LTC
TOTAL

(1) Rates are based on a combination of AHCCCS encounter data and Medicare fee-for-service data
obtained from the Centers for Medicare and Medicaid Services.

12

Figure 2
Arizona Health Care Cost Containment System/Arizona Long Term Care System
BIENNIAL LIPID (LDL) SCREENING BY CONTRACTOR (1)
Measurement Period: October 1, 2001, through September 30, 2002
80%

70%

60%

50%

40%

30%

20%

10%

0%
Cochise Health
Systems

Evercare Select

Maricopa LTC

Mercy Care LTC

Pima Health System
LTC

Pinal/Gila County Yavapai County LTC
LTC

(1) Rates are based on a combination of AHCCCS encounter data and Medicare fee-for-service data.

13

APPENDIX

Methodology and Technical Specifications:
Diabetes Management Performance Indicator
For the Measurement Period Ending September 30, 2002
Population
All elderly and physically disabled (E/PD) members in the Arizona Long Term Care System
(ALTCS)
Inclusion Criteria
Members ages 18 through 75 years as of September 30, 2002
Enrollment criteria:
•
Enrolled as of September 30, 2002
•
Continuously enrolled with one ALTCS Contractor with no more than one gap in enrollment,
not exceeding 31 days
Diagnosis (identified by pharmacy data, claims or encounters):*
•
Pharmacy - National Drug Codes (NDC)
•
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 younger than 18 years of age
•
Members older than 75 years of age
•
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
•
Members with the following diagnoses:
Description
Steroid Induced Diabetes
Gestational Diabetes

ICD-9-CM Codes
251.8, 962.0
648.8

Sample Frame
All ALTCS members with a diagnosis of diabetes mellitus who met the denominator inclusion
criteria.
Sample Selection
The entire sample frame was included in the study. Random sampling was not utilized.
14

Sample Frame Stratification
The sample frame was stratified by type of enrollment (i.e., Medicaid, dually enrolled and
combined Medicaid and dually enrolled populations). The sample frame was further stratified by
ALTCS Contractor.
Data Source
Only administrative (encounter, enrollment, and analytic) data from the Centers for Medicare and
Medicaid Services (CMS) and AHCCCS was used to identify the sample frame and indicator
inclusion rates for this study.
Data Collection
AHCCCS and Health Services Advisory Group (HSAG) utilized existing encounter, analytic, and
enrollment data to identify members who met the eligibility criteria. Encounter data was used to
identify diabetic care and visits.
•
•

•
•

•

The AHCCCS Information Services Division extracted existing enrollment data. HSAG then
merged AHCCCS enrollment data with CMS enrollment data.
The Clinical Research and Data unit in the AHCCCS Division of Health Care Management
developed parameters for extraction of encounter data to determine diagnosis and compliance
with indicators.
Encounter data was sent to HSAG using a secure file transfer protocol (FTP) line.
HSAG merged AHCCCS encounter data with CMS analytic data. The merged data was
analyzed using a custom Statistical Analysis System (SAS) program to determine denominator
inclusion based on Health Plan Employer Data and Information Set (HEDIS®) 2002 criteria.
HSAG analyzed all data to determine if individual indicators were met.

Data Validation
HSAG compared AHCCCS data with CMS data to identify discrepancies between data sets. After
combining data sources, the most complete record was used.
Denominators
1. The total number of members who were identified as diabetics
2. The number of members who were identified as dually enrolled diabetics
3. The number of members who were identified as diabetics enrolled only in Medicaid
Numerators
1. The number of members in denominator No. 1 who had a biennial retinal exam
2. The number of members in denominator No. 2 who had a biennial retinal exam
3. The number of members in denominator No. 3 who had a biennial retinal exam
Note: retinal exams were not reported because Medicare data was not available from CMS.
4. The number of members in denominator No. 1 who had an annual Hb A1c blood test
5. The number of members in denominator No. 2 who had an annual Hb A1c blood test
6. The number of members in denominator No. 3 who had an annual Hb A1c blood test

15

7. The number of members in denominator No. 1 who had a biennial fasting lipid profile
8. The number of members in denominator No. 2 who had a biennial fasting lipid profile
9. The number of members in denominator No. 3 who had a biennial fasting lipid profile
Analysis
•
The overall prevalence of ALTCS members diagnosed with type 1 or type 2 diabetes was
calculated.
•
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, as well as by Medicaid-only and dually enrolled members.
•
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 “Healthy People 2010” Goals.
Deviations from HEDIS®
This study was based on HEDIS 2002 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 data and CMS analytical data to determine
denominators, numerators, and indicator rates.
Deviations from Previous Methodology
Previous AHCCCS studies of diabetes care included indicators different from those that comprise
the current study. Diabetes care measures for the most recent study, conducted in 2002, included:
•
Biannual Hb A1c blood tests
•
Annual lipid profiles
•
Biannual foot exams
This study included services received through and paid for by Medicare, as well as those paid for
through the ALTCS program. This allowed AHCCCS to report indicator rates that more accurately
reflect services received by members who are dually enrolled in Medicare and Medicaid. Medicare
services included in this study are those provided on a fee-for-service basis, and do not include
those provided through Medicare managed care organizations (known as Medicare+Choice plans).
In the previous study, AHCCCS provided a sample of members and data collection tools for each
sample member to Contractors. Each Contractor was able to use a combination of medical record
and administrative data to identify services provided according to indicator criteria.
Because of these deviations from previous study methodologies, results from the current study will
not be comparable to prior years.

16

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.

17

TECHNICAL SPECIFICATIONS
Diagnosis
May be identified by pharmacy data, claims or encounters
Pharmacy:
List of National Drug Codes (NDC) available at:
http://www.ncqa.org/Programs/HEDIS/hedis2002NDClists.htm

Claims/Encounter Data:
•
Two face-to-face encounters with different dates of service in an ambulatory setting or nonacute 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. Diabetes was
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,
99301-99303, 9931199313, 99321-99323,
99331-99333, 9934199355, 99381-99387,
99391-99397, 9940199404, 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

HEDIS® 2002 Criteria for Hb A1c
•
One (or more) Hb A1c test(s) conducted during the measurement year, denoted by CPT code
83036

18

HEDIS® 2002 Criteria for Eye Exam
•
A retinal exam performed during the measurement year
•
A retinal exam performed during the measurement year or year prior to the measurement year
and two of the three following conditions were satisfied:
1. The member was not prescribed or dispensed insulin during the measurement year
2. The member’s most recent Hb A1c level (performed during the measurement year) was less
than 8 percent
3. The member had a retinal examination with no evidence of retinopathy during the year prior
to the measurement year (negative diagnosis must be verified by medical record)
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, 95.0295.04, 95.11, 95.12,
95.16, V80.2

Note: Rates for retinal exams were not reported because data was not available from CMS.
HEDIS® 2002 Criteria 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
Gestational Diabetes

ICD-9-CM Codes
251.8 - 962.0
648.8

19

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

20

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

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
AHCCCSS system
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

SSN

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

21

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
•
51X…. Clinic

22

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

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
•
21X…. Coronary Care

23

•
•
•
•
•
•

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)
•
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

24

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*
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

25

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.
•
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

26

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 cholestero.l.
Excluded Condition (s)
251.8…Steroid induced diabetes
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

27