Administrative bulletin: 2026-06-002 Quality information

Professional and facility Providers

Eye Exam for Patients with Diabetes (EED)

KEY POINT: Retinopathy is one of the most common and most serious diabetes related eye complications and is the leading cause of preventable blindness. Annual retinal eye exams are a HEDIS^® requirement for patients ages 18–75 with diabetes and are essential to early detection and timely treatment.

Measure description:

This measure evaluates the percentage of members 18–75 years of age with diabetes (type 1 or type 2) who have had screening or monitoring for diabetic retinal disease.

Note: Documentation does not have to state specifically “no diabetic retinopathy” to be considered negative for retinopathy; however, it must be clear that the patient had a dilated or retinal eye exam by an eye care professional (optometrist or ophthalmologist) and that retinopathy was not present. Notation limited to a statement that indicates “diabetes without complications” does not meet criteria.

• Hypertensive retinopathy is not handled differently from diabetic retinopathy when reporting this measure; for example, an eye exam documented as positive for hypertensive retinopathy is counted as positive for diabetic retinopathy, and an eye exam documented as negative for hypertensive retinopathy is counted as negative for diabetic retinopathy.
• Blindness is not an exclusion for a diabetic eye exam because it is difficult to distinguish between individuals who are legally blind but require a retinal exam, and those who are completely blind and therefore do not require an exam.

Best practices:

• Utilize monthly action report files with EED tabs for open and closed gaps and non-compliant population.
• Refer members to the Digital diabetes platforms of Omada and Virta and they can check their eligibility for the programs.
• A negative retinal screening in prior year to measurement year will make the member compliant.

Exclusions:

• Bilateral absence of eyes (SNOMED CT code 15665641000119103) any time during the member’s history through December 31 of the measurement year.
• Bilateral eye enucleation at any time during the member’s history through December 31 of the measurement year.
• Members who died during the measurement year.
• In hospice or using hospice services anytime during the measurement year.
• Receiving palliative care during the measurement year.
• Members 66 years of age and older living in long-term institution settings, advanced illness, and frailty.

Resources:

American Diabetes Association - EyeHealth_Resources_Retinopathy_rev-1.pdf

Glycemic Status Assessment for Patients with Diabetes (GSD)

KEY POINT: Diabetes isn't just a disease — it's an epidemic, affecting over 40 million Americans with devastating consequences. 1.5M Americans are diagnosed each year, and 115+M Americans are living with prediabetes. From a HEDIS^® perspective, ongoing glycemic assessment is foundational to HEDIS® diabetes measures and plays a vital role in preventing disease progression, complications, and avoidable healthcare utilization.

Measure description:

This measure was formerly named the Hemoglobin A1c Control for Patients with Diabetes (HBD). This measure evaluates the percentage of members 18–75 years with diabetes (types 1 and 2) whose most recent glycemic status hemoglobin A1c (HbA1c) or glucose management indicator (GMI) was at the following levels during the measurement year:

• Glycemic Status < 8%
• Glycemic Status > 9%

Best practices:

• Continuous glucose monitoring (CGM) data is acceptable.
• If multiple tests were performed in the measurement year, the result from the last test is required.
• CPTII codes can be billed by any provider type.
• GMI results collected by the member and documented in the member’s medical record are eligible for use in reporting (provided the GMI does not meet any exclusion criteria). There is no requirement that there be evidence the GMI was collected by a PCP or specialist.
• Ranges and thresholds do not meet criteria for this indicator. A distinct numeric result is required for numerator compliance. “Unknown” is not considered a result/finding.
• Recommend use of Capital’s Digital Diabetes Platforms–Omada and Virta.
• Submit records through Theon™.

Exclusions:

• Members who died during the measurement year.
• In hospice or using hospice services anytime during the measurement year.
• Receiving palliative care during the measurement year.
• Members 66 years of age and older living in long-term institution settings, advanced illness, and frailty.

Resources:

Diabetes Research, Education, Advocacy | ADA

Kidney Health Exam for Patients with Diabetes (KED)

KEY POINT: Despite guideline recommendations, fewer than 50% of adults with diabetes receive an annual kidney health evaluation. The leading cause of kidney disease is diabetes.

Measure description:

This measure evaluates the percentage of members aged 18–85 years old with type 1 or type 2 diabetes who received a kidney health evaluation, including both an estimated glomerular filtration rate (eGFR) and a urine albumin-creatinine ratio (uACR), during the measurement year.

Best practices:

• Requires both eGFR and uACR during the measurement year on the same day or different dates of service.
• Assess and update coding used for this measure to capture eGFR and uACR.
• Utilize the Clinical Results Package sent on a monthly basis with non-compliant members, and determine which portion is missing for the member to be compliant for this measure. Also, use Theon™ Open Not Addressed Report for Kidney Health Evaluation for Patients with Diabetes (KED) to close gaps in this measure.
• Using EMR system to set reminder flags for providers to speak with members about the need for these and any other diabetic tests.
• Referral to Care Management services.
• Refer member to check for eligibility in the digital diabetes programs from Capital Blue Cross called Omada and Virta.

Exclusions:

• Members with evidence of ESRD or Dialysis anytime during the member's history on or prior to December 31 of the measurement year.
• Persons 66–80 years of age by the last day of the measurement period, with both frailty and advanced illness.
• Frailty - At least two indications of frailty with different dates of service during the measurement period.
• Advanced illness - Either of the following during the measurement period or the year prior to the measurement period: Advanced illness on at least two different dates of service. Or Dispensed dementia medication (Donepezil, Donepezil/Memantine, Galantamine, Memantine, Rivastigmine).
• Enrolled in an SNP(I-SNP) during the measurement year.
• Living long-term in an institution anytime during the measurement year.
• Members 66–80 years of age and older as of December 31 of the measurement year with frailty and advanced illness.
• Members 81 years of age and older as of December 31 of the measurement year with frailty during the measurement year.
• In hospice or using hospice services anytime during the measurement year.
• Receiving palliative care during the measurement year.

Resources:

American Diabetes Association - Kidney Health Evaluation for Patients With Diabetes (KED) - NCQA