Medicare only

Measure description

Members 18-75 years of age with diabetes (Type 1 or Type 2) who had a nephropathy screening or monitoring test or evidence of nephropathy during the measurement year.

Diagnosis codes and CPT codes to close the gap

Urine protein test

81000, 81001, 81002, 81003, 81005, 82042, 82043, 82044, 84156, 3060F, 3061F, 3062F.

Nephropathy treatment

3066F, 4010F, for more diagnosis codes that will meet this requirement, please refer to the performance measures guide available in the Theon® welcome kit on Care Collaborator® or Care Optimizer®.

CKD Stage 4


ESRD diagnosis

N18.5, N18.6, Z99.2.

Dialysis procedure

90935, 90937, 90945, 90947, 90997 90999, 99512, G0257, S9339, 3E1M39Z, 5A1D00z, 5A1D60Z, 5A1D70Z, 5A1D80Z, 5A1D90Z.


50340, 50370, 0TB00ZX, 0TB00ZZ, 0TB03ZX, 0TB03ZZ, 0TB04ZX, 0TB04ZZ, 0TB07ZX, 0TB07ZZ, 0TB08ZX, 0TB08ZZ, 0TB10ZX, 0TB10ZZ, 0TB13ZX, 0TB13ZZ, 0TB14ZX, 0TB14ZZ, 0TB17ZX, 0TB17ZZ, 0TB18ZX, 0TB18ZZ.

Kidney transplant

50360, 50365, 50380, S2065, 0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY10Z2, 55.61, 55.69.

A visit with a nephrologist, as identified by the organization’s specialty provider codes (no restriction on the diagnosis or procedure code submitted).

At least one ACE inhibitor or ARB dispensing event (ACE inhibitor and ARB medications list).

ACE inhibitor

ARB medications list

Angiotensin converting enzyme inhibitors

Benazepril, Captopril, Enalapril, Fosinopril, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril, Trandolapril

Angiotensin II inhibitors

Azilsartan, Candesartan, Eprosartan, Irbesartan, Losartan, Olmesartan, Telmisartan, Valsartan

Antihypertensive combinations

Amlodipine-benazepril, Amlodipine-hydrochlorothiazide-valsartan, Amlodipine-hydrochlorothiazide-olmesartan, Amlodipine-olmesartan, Amlodipine-perindopril, Amlodipine-telmisartan, mlodipine-valsartan, Azilsartan-chlorthalidone, Benazepril-hydrochlorothiazide, Candesartan-hydrochlorothiazide, Captopril-hydrochlorothiazide, Enalapril-hydrochlorothiazide, Fosinopril-hydrochlorothiazide, Hydrochlorothiazide-irbesartan, Hydrochlorothiazide-lisinopril, Hydrochlorothiazide-losartan, Hydrochlorothiazide-moexipril, Hydrochlorothiazide-olmesartan, Hydrochlorothiazide-quinapril, Hydrochlorothiazide-telmisartan, Hydrochlorothiazide-valsartan, Nebivolol-valsartan, Sacubitril-valsartan, Trandolapril-verapamil

Supplemental data requirements to close the gap

Any of the following during the measurement year meet criteria for a nephropathy screening or monitoring test or evidence of nephropathy.

A urine test for albumin or protein (at a minimum, a note indicating the date when a urine test was performed, and the result or finding):

  • 24-hour urine for albumin or protein.
  • Timed urine for albumin or protein.
  • Spot urine (e.g. urine dipstick or test strip) for albumin or protein.
  • Urine for albumin/creatinine ratio.
  • 24-hour urine for total protein.
  • Random urine for protein/creatinine ratio.

Documentation of a visit to a nephrologist, a renal transplant, or of a nephrectomy.

Documentation of medical attention for any of the following (no restriction on provider type):

  • Diabetic nephropathy
  • ESRD
  • Chronic renal failure (CRF)
  • Chronic kidney disease (CKD)
  • Renal insufficiency
  • Proteinuria
  • Albuminuria
  • Renal dysfunction
  • Acute renal failure (ARF)
  • Dialysis, hemodialysis, or peritoneal dialysis
  • Evidence of ACE inhibitor/ARB therapy

Medical record must include documentation of one of the following:

  • Documentation that a prescription for an ACE inhibitor/ARB was written during the measurement year.
  • Documentation that a prescription for an ACE inhibitor/ARB was filled during the measurement year.
  • Documentation that the member took an ACE inhibitor/ARB during the measurement year.