WCHQ Ambulatory Measure Specification WCHQ 5 – Diabetes Care: Kidney Function Monitored Measurement Period: 01/01/2015 – 12/31/2015 Process Measure Type NQS Domain: Clinical Process/Effectiveness

MEASURE DESCRIPTION This measure assesses the percentage of patients who were screened and or treated for kidney disease within the last 12 months [Measurement Period].

Disclaimer: Measures reported by WCHQ healthcare organizations represent a specific aspect of care in relation to an evidence- based standard, but are not clinical guidelines and do not establish standards of care. All providers should have an individual care plan established with their patient.

GENERAL INFORMATION/RATIONALE In an effort to align with National Quality Form (NQF) endorsed diabetes measures, and referencing the 2013 American Diabetes Association (ADA) guidelines, the following goals for people with diabetes are measured by the WCHQ:  Screening and/or treatment for kidney disease annually

References: American Diabetes Association Clinical Practice Recommendations 2013: http://care.diabetesjournals.org/content/36/Supplement_1/S4.full

DEFINITIONS 12 Months: Measurement Period 24 Months: Measurement Period + Prior Year Office Visit: Office visit in an outpatient, non-urgent care setting PCP: For WCHQ measure purposes, a primary care provider is defined as any General Practice, Internal Medicine, Family Medicine, Pediatrics provider with the following degree types (MD, DO, PA, and NP), and any other practitioners identified by the healthcare system as primary care practitioners. The rationale for the additional practitioner(s) must be documented and must be applied consistently across all preventive care and chronic care measures by the organization.  Measure Specific Specialist: As part of the denominator population for this measure visits to an Endocrinologist qualify as office visits for the denominator population. Age Range 18-75: Patients born between 01/01/1940 and 01/01/1997.

DENOMINATOR DESCRIPTION Patients with diabetes 18-75 years of age and alive as of the last day of the MP. A minimum of two diabetes coded office visits and must be seen by a PCP / Endocrinologist for two office visits in 24 months and one office visit in 12 months. Gestational Diabetes (code 648.8) is excluded. Patients whose age at the beginning of the one year measurement period is at least 18 and whose age at the end of the measurement period is less than 76 and are alive as of the last day of the Measurement Period. Expired patients for whom a specific date of expiration cannot be found are excluded from the denominator population

The rationale for the denominator population is built from the following criteria: [Question 1] – Is this a patient with the disease or condition? [Question 2] – Is this a patient whose care is managed within the physician group? [Question 3] – Is this a patient currently managed in our system?

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1 WCHQ Ambulatory Measure Specification WCHQ 5 – Diabetes Care: Kidney Function Monitored Measurement Period: 01/01/2015 – 12/31/2015 Process Measure Type NQS Domain: Clinical Process/Effectiveness

ENCOUNTER DATA Patients eligible for inclusion in the denominator include: [Question 1] – Is this a patient with the disease, or condition? Those who had a minimum of two diabetes coded (including any diagnoses coded for the visit) – (Table D-1) office visits (Table D-2), with any provider (MD, DO, PA, NP) in the Physician Group with different dates of service in an ambulatory setting during the last 24 Months [Measurement Period + Prior Year], and

[Question 2] – Is this a patient whose care is managed within the physician group? Patients who had at least two office visits (Table D-2), regardless of diagnosis code, on different dates of service, to a PCP and/or Endocrinologist in the past 24 months. If the Endocrinologist is not considered a PCP, at least one of the two office visits must be to a PCP.

[Question 3] –Is this a patient current in our system? Those who had at least one office visit (Table D-2), regardless of diagnosis code, with a PCP and/or an Endocrinologist during the last 12 Months [Measurement Period].

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NUMERATOR DESCRIPTIONS

M ONITORING FOR DIABETIC NEPHROPATHY – Screening or demonstration of treatment for kidney disease within the measurement period. This measures the number of patients in the denominator who are being monitored or treated for nephropathy. The numerator may include patients who have had the appropriate screening lab test or patients who already have evidence of nephropathy as demonstrated through any of the following:

 Administrative Data 1. Screening for nephropathy a. A microalbuminuria test (Table D-6) during the last 12 months [Measurement Period]. Medical record must include date of test and result. Tests included: 24-hour urine for microalbuminuria, time urine for microalbuminuria, spot urine for microalbuminuria, microalbumin/creatinine ratio. 2. Evidence of nephropathy a. Evidence of diagnoses or treatment for nephropathy (Table D-5) during the last 12 months [Measurement Period]. b. A nephropathy diagnosis (Table D-5: ICD-9-CM Diagnosis Codes) from an ICD-9 based problem list. The problem must be ACTIVE. There is no limit on the look back date, but the date of documentation or onset date must occur prior to the end of the measurement period. c. A visit to a nephrologist (can include a nephrology NP or PA) (no restriction on the diagnoses or procedure codes for that visit) during the last 12 months [Measurement Period]. d. A positive gross proteinuria test (Table D-7) during the last 12 months [Measurement Period]. Medical record must include date of test and result. Tests included: positive urinalysis, positive urine dipstick, and positive tablet reagent. Note: ‘Trace’ gross proteinuria results are not considered numerator compliant. Trace is defined as results that return stating, “Trace” or those with a negative value. All positive numeric values or the word “positive” are not considered “Trace” and are numerator compliant.

 Medical Record Review (refer to Medical Record Review for Numerator Inclusion/Denominator Exclusion section)

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INTERNALLY DEVELOPED CODES – DATA TRANSLATION/MAPPING REQUIREMENTS If a medical group utilizes internally generated codes to identify specific services or events required for a given WCHQ performance measure, the group may translate or map the information to the WCHQ performance measurement specifications. The medical group must assure that the internally generated code matches the clinical specificity of the standard (ICD-9, CPT) codes included in the WCHQ performance measurement specifications.

In order to use internally developed codes for WCHQ performance measure reporting, the medical group needs to document the translation/mapping to the codes in the specifications. This documentation should include the internally generated code, a description of the internally developed code, any additional clinical information for the internally developed code, and the equivalent standard code with description from the WCHQ performance measurement specifications. Once the translation/ mapping documentation is established, the medical group’s WCHQ performance measurement team must review the mapping on a yearly basis and document that internally developed codes have not changed and are being used in the manner described in the translation/ mapping document.

The medical group must have documented processes in place for adding codes to the medical group’s administrative data system and procedures to implement the internally developed codes.

MEDICAL RECORD REVIEW FOR NUMERATOR INCLUSION/DENOMINATOR EXCLUSION If appropriate, and/or when necessary, every organization may complement their electronic capture of patient medical history with electronic or manual record review. The following criteria apply only to data captured/reviewed during medical record review.

For WCHQ Chronic Condition Measures, proof of Numerator compliance requires:  Date test was performed.  Documentation identifying evidence of monitoring or treatment for Nephropathy. Medical record must include a note indicating medical attention during the last 12 Months [Measurement Period] for: o A nephrologist visit (can include a nephrology NP or PA) (no restriction on the diagnoses or procedure codes for that visit), OR o Notes referencing one of the following:  diabetic nephropathy,  a microalbuminuria test or a positive gross proteinuria test result,  end-stage renal disease (ESRD),  chronic renal failure (CRF), renal insufficiency,  chronic kidney disease (CKD)  acute renal failure (ARF),  dialysis, hemodialysis or peritoneal dialysis.  Date of Documentation for evidence of Nephropathy

Denominator Exclusion For all WCHQ Measures, proof of Denominator exclusion requires:

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 Existence of exclusion criteria.

This data may be retrieved, in whole or in part, from any of the following:  Notation in Progress Note  Notation in Medical History or Surgical History  Flag/Field in Electronic Medical Record  Documentation in patient chart

FIELDS REQUIRED FOR MEASURE VALIDATION Validation of this measure will require patient level data files for Administrative Data and/or for Manual Review. The following indicates fields needed for validation, which may be helpful to consider when querying the measure:

Denominator Data File fields: 1. Patient Identifier (can be medical record number or other ID) 2. Office Visit Dates 3. Provider Specialty 4. Patient Date of Birth 5. Diabetes Diagnosis Codes

Numerator Data File fields:

1. Kidney Function Monitored within the last 12 months  Patient Identifier (De-Identified)  Lab Date(s) of Service (identify whether collection date versus test date)  Lab ID Code(s)  Lab Test Result(s)  Evidence of Nephropathy Demonstrated by Diagnosis or Treatment Code(s) or by Medical Record Documentation  Evidence of Nephropathy Documentation Date  Nephrologist Visit

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Appendix A

Primary Payer In keeping with the changing atmosphere of quality measurement and reporting, WCHQ would like for participating organizations to include the primary payer source with their data submissions for the ambulatory care measures.

The primary payer source should be identified in the denominator upon answering the question, “Is this patient current in our system?” Once it has been determined that a patient is current because of a visit to their physician within the specified time period (12 months for chronic care measures and 24 months for preventive care measures), the payer should be “pulled” into the query. The primary payer should be the payer at the most recent office visit within the measurement period.

There will be four categories of primary payer that will need to be submitted to WCHQ via the data submission tool: Medicare FFS, Medicaid (all types), Commercial (including Medicare HMO) and Uninsured/Self-Pay. The raw numbers for the denominator and numerator should be included for all three types of data submission, total population, hybrid, and sample.

Rationale Opportunities exist for WCHQ to collect and report data on specific populations, like the Medicare population, through grant applications to begin to understand the disparities in quality of care. The purpose of this is to begin to understand the challenges of putting in additional data elements and complexities of data display for public reporting. At this time, the primary payer information will not be publicly reported.

Definitions: Commercial: All plans not Medicaid or Medicare FFS (Includes VA, DoD, etc.) FFS Medicare: FFS plans, not Medicare HMO (Medicare Railroad is FFS Medicare) Medicaid: All Medicaid plans including those managed by commercial plans Uninsured: Self-pay individuals

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APPENDIX B

TABLE D-1: Diagnosis Codes to Identify Patients with Diabetes ICD-9-CM Description Diagnosis Codes 250.xx Diabetes mellitus 250.00 Diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled 250.01 Diabetes mellitus without mention of complication, type i [juvenile type], not stated as uncontrolled 250.02 Diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled 250.03 Diabetes mellitus without mention of complication, type i [juvenile type], uncontrolled 250.10 Diabetes with ketoacidosis, type ii or unspecified type, not stated as uncontrolled 250.11 Diabetes with ketoacidosis, type i [juvenile type], not stated as uncontrolled 250.12 Diabetes with ketoacidosis, type ii or unspecified type, uncontrolled 250.13 Diabetes with ketoacidosis, type i [juvenile type], uncontrolled 250.20 Diabetes with hyperosmolarity, type ii or unspecified type, not stated as uncontrolled 250.21 Diabetes with hyperosmolarity, type i [juvenile type], not stated as uncontrolled 250.22 Diabetes with hyperosmolarity, type ii or unspecified type, uncontrolled 250.23 Diabetes with hyperosmolarity, type i [juvenile type], uncontrolled 250.30 Diabetes with other coma, type ii or unspecified type, not stated as uncontrolled 250.31 Diabetes with other coma, type i [juvenile type], not stated as uncontrolled 250.32 Diabetes with other coma, type ii or unspecified type, uncontrolled 250.33 Diabetes with other coma, type i [juvenile type], uncontrolled 250.40 Diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled 250.41 Diabetes with renal manifestations, type i [juvenile type], not stated as uncontrolled 250.42 Diabetes with renal manifestations, type ii or unspecified type, uncontrolled 250.43 Diabetes with renal manifestations, type i [juvenile type], uncontrolled 250.50 Diabetes with ophthalmic manifestations, type ii or unspecified type, not stated as uncontrolled 250.51 Diabetes with ophthalmic manifestations, type i [juvenile type], not stated as uncontrolled 250.52 Diabetes with ophthalmic manifestations, type ii or unspecified type, uncontrolled 250.53 Diabetes with ophthalmic manifestations, type i [juvenile type], uncontrolled 250.60 Diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled 250.61 Diabetes with neurological manifestations, type i [juvenile type], not stated as uncontrolled

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250.62 Diabetes with neurological manifestations, type ii or unspecified type, uncontrolled 250.63 Diabetes with neurological manifestations, type i [juvenile type], uncontrolled 250.70 Diabetes with peripheral circulatory disorders, type ii or unspecified type, not stated as uncontrolled 250.71 Diabetes with peripheral circulatory disorders, type i [juvenile type], not stated as uncontrolled 250.72 Diabetes with peripheral circulatory disorders, type ii or unspecified type, uncontrolled 250.73 Diabetes with peripheral circulatory disorders, type i [juvenile type], uncontrolled 250.80 Diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled 250.81 Diabetes with other specified manifestations, type i [juvenile type], not stated as uncontrolled 250.82 Diabetes with other specified manifestations, type ii or unspecified type, uncontrolled 250.83 Diabetes with other specified manifestations, type i [juvenile type], uncontrolled 250.90 Diabetes with unspecified complication, type ii or unspecified type, not stated as uncontrolled 250.91 Diabetes with unspecified complication, type i [juvenile type], not stated as uncontrolled 250.92 Diabetes with unspecified complication, type ii or unspecified type, uncontrolled 250.93 Diabetes with unspecified complication, type i [juvenile type], uncontrolled 357.2 Polyneuropathy in diabetes 362.0x Diabetic retinopathy 362.01 Background diabetic retinopathy 362.02 Proliferative diabetic retinopathy 362.03 Nonproliferative diabetic retinopathy nos 362.04 Mild nonproliferative diabetic retinopathy 362.05 Moderate nonproliferative diabetic retinopathy 362.06 Severe nonproliferative diabetic retinopathy 362.07 Diabetic macular edema 366.41 Diabetic cataract 648.0x Complication of pregnancy, diabetes mellitus, excluding gestational diabetes 648.00 Diabetes mellitus of mother complicating pregnancy childbirth or the puerperium unspecified as to episode of care 648.01 Diabetes mellitus of mother with delivery 648.02 Diabetes mellitus of mother with delivery with postpartum complication 648.03 Antepartum diabetes mellitus 648.04 Postpartum diabetes mellitus

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Effective 10/01/2015 ICD-10-CM Diagnosis Description Codes E11.9 Type 2 diabetes mellitus without complications E10.9 Type 1 diabetes mellitus without complications E11.65 Type 2 diabetes mellitus with hyperglycemia E10.65 Type 1 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E10.10 Type 1 diabetes mellitus with ketoacidosis without coma E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma E10.69 Type 1 diabetes mellitus with other specified complication E11.641 Type 2 diabetes mellitus with hypoglycemia with coma E10.11 Type 1 diabetes mellitus with ketoacidosis with coma E10.641 Type 1 diabetes mellitus with hypoglycemia with coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E10.29 Type 1 diabetes mellitus with other diabetic kidney complication E11.21 Type 2 diabetes mellitus with diabetic nephropathy E10.21 Type 1 diabetes mellitus with diabetic nephropathy E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.36 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene

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E11.618 Type 2 diabetes mellitus with other diabetic arthropathy E11.620 Type 2 diabetes mellitus with diabetic dermatitis E11.621 Type 2 diabetes mellitus with foot ulcer E11.622 Type 2 diabetes mellitus with other skin ulcer E11.628 Type 2 diabetes mellitus with other skin complications E11.630 Type 2 diabetes mellitus with periodontal disease E11.638 Type 2 diabetes mellitus with other oral complications E11.649 Type 2 diabetes mellitus with hypoglycemia without coma E10.618 Type 1 diabetes mellitus with other diabetic arthropathy E10.620 Type 1 diabetes mellitus with diabetic dermatitis E10.621 Type 1 diabetes mellitus with foot ulcer E10.622 Type 1 diabetes mellitus with other skin ulcer E10.628 Type 1 diabetes mellitus with other skin complications E10.630 Type 1 diabetes mellitus with periodontal disease E10.638 Type 1 diabetes mellitus with other oral complications E10.649 Type 1 diabetes mellitus with hypoglycemia without coma E11.8 Type 2 diabetes mellitus with unspecified complications E10.8 Type 1 diabetes mellitus with unspecified complications E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E13.42 Other specified diabetes mellitus with diabetic polyneuropathy E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E08.36 Diabetes mellitus due to underlying condition with diabetic cataract E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract E10.36 Type 1 diabetes mellitus with diabetic cataract E13.36 Other specified diabetes mellitus with diabetic cataract O24.319 Other specified diabetes mellitus with diabetic cataract O24.32 Unspecified pre-existing diabetes mellitus in childbirth O24.911 Unspecified diabetes mellitus in pregnancy, first trimester O24.912 Unspecified diabetes mellitus in pregnancy, second trimester

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O24.913 Unspecified diabetes mellitus in pregnancy, third trimester O24.92 Unspecified diabetes mellitus in childbirth O24.93 Unspecified diabetes mellitus in the puerperium

TABLE D-2: Office Visit Encounter Codes (Outpatient) CPT Codes Description 99201-99205 Office or OPa visit E&Mb, new patient 99212-99215 Office or OP visit E&M, established patient 99241-99245 Office or other OP consultations 99347-99350 Home visit for evaluation and management of an established patient 99384-99387 Initial preventive medicine E&Mb 99394-99397 Periodic preventive medicine E&Mb 99401-99404 Preventive medicine counseling 99411 Preventive medicine counseling, group 99412 Preventive medicine counseling, group 99420 Risk assessment, admin and interpretation 99429 Unlisted preventive medicine service 99488 Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month. 99495 Transitional Care Management Services (Moderate Complexity) 99496 Transitional Care Management Services (High Complexity)

HCPCS Code Description

G0344 Initial preventive physical examination; face-to-face visit services limited to new (deleted 12/31/08) beneficiary during the first six months of Medicare enrollment G0402 Initial preventive physical examination; face-to-face visit, services limited to new (Effective beneficiary during the first 12 months of Medicare enrollment 01/01/09) G0438 Annual wellness visit; includes a personalized prevention plan of service, initial visit G0439 Annual wellness visit; includes a personalized prevention plan of service, subsequent visit a outpatient b evaluation and management

TABLE D-5: Evidence of Diagnosis or Treatment for Nephropathy CPT Codes Description 36147 Introduction of needle and/or catheter, arteriovenous shunt created for dialysis) 36800 Insertion on cannula for hemodialysis, other purpose; vein to vein 36810 Insertion of cannula – arteriovenous, external 36815 Insertion of cannula – arteriovenous, external revision, or closure 36818 Insertion of cannula – arteriovenous, external revision, or closure, upper arm 36819 Arteriovenous anastomosis, open, by upper arm basilic vein transposition

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36820 Hemodialysis access, forearm vein transportation 36821 Hemodialysis access direct, any site 36831 Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft 36832 Revision, open, arteriovenous fistula, without thrombectomy, autogenous or nonautogenous dialysis graft 36833 Revision, open, arteriovenous fistula with thrombectomy, autogenous or nonautogenous dialysis graft 50300 Donor nephrectomy, with preparation and maintenance of allograft, from cadaver donor 50320 Donor nephrectomy 50340 Recipient nephrectomy 50360 Renal allotransplantation, implantation of graft 50365 Renal allotransplantation, with recipient nephrectomy 50370 Removal of transplanted renal allograft 50380 Renal autotransplantation, reimplantation of kidney 90935 Hemodialysis procedure with single physician evaluation 90937 Hemodialysis procedure requiring repeat evaluations 90940 Hemodialysis access flow study to determine blood flow in grafts and arteriovenous fistulae by an indicator method (was previously reported as code 90939) 90945 Dialysis procedure other than hemodialysis with single physician evaluation 90947 Dialysis procedure other than hemodialysis requiring repeated physician evaluations 90957 ESRD Related Services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month 90958 ESRD Related Services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face physician visits per month 90959 ESRD Related Services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month 90960 ESRD Related Services monthly, for patients 20 years of age and older; with 4 or more face-to-face physician visits per month 90961 ESRD Related Services monthly, for patients 20 years of age and older; with 2-3 face-to-face physician visits per month 90962 ESRD Related Services monthly, for patients 20 years of age and older; with 1 face- to-face physician visit per month 90965 ESRD Related Services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents 90966 ESRD Related Services for home dialysis per full month, for patients 20 years of age and older 90969 ESRD related services for dialysis less than a full month of service, per day; for patients 12-19 years of age 90970 ESRD related services for dialysis less than a full month of service, per day; for patients 20 years of age and older 90989 Dialysis training, patient, completed course

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90993 Dialysis training, patient, course not completed 90997 Hemoperfusion 90999 Unlisted dialysis procedure, inpatient or outpatient 99512 Home visit for hemodialysis HCPCS Codes Description G0257 ESRD Services S9339 Home Therapy, Peritoneal Dialysis ICD-9-CM Procedure Description Codes 38.95 Venous catheterization for renal dialysis 39.27 Arteriovenostomy for renal dialysis 39.42 Revision of arteriovenous shunt for renal dialysis 39.43 Removal of shunt for renal dialysis 39.53 Repair of arteriovenous fistula 39.93 Insertion of vessel-to-vessel cannula 39.94 Replacement of vessel-to-vessel cannula 39.95 Hemodialysis 54.98 Peritoneal dialysis 55.4 Partial Nephrectomy 55.5x Complete Nephrectomy 55.51 Nephroureterectomy 55.52 Nephrectomy of remaining kidney 55.53 Removal of transplanted or rejected kidney 55.54 Bilateral nephrectomy 55.6x Transplant of Kidney 55.61 Renal autotransplantation 55.69 Other kidney transplantation

Effective 10/01/2015 ICD-10-PCS Description Procedure Codes

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5A1D00Z Performance of Urinary Filtration, Single 5A1D60Z Performance of Urinary Filtration, Multiple 3E1M39Z Irrigation of Peritoneal Cavity using Dialysate, Percutaneous Approach 0TB00ZZ Excision of Right Kidney, Open Approach 0TB03ZZ Excision of Right Kidney, Percutaneous Approach 0TB04ZZ Excision of Right Kidney, Percutaneous Endoscopic Approach 0TB07ZZ Excision of Right Kidney, Via Natural or Artificial Opening 0TB08ZZ Excision of Right Kidney, Via Natural or Artificial Opening Endoscopic 0TB10ZZ Excision of Left Kidney, Open Approach 0TB13ZZ Excision of Left Kidney, Percutaneous Approach 0TB14ZZ Excision of Left Kidney, Percutaneous Endoscopic Approach 0TB17ZZ Excision of Left Kidney, Via Natural or Artificial Opening 0TB18ZZ Excision of Left Kidney, Via Natural or Artificial Opening Endoscopic 0TB30ZZ Excision of Right Kidney Pelvis, Open Approach 0TB33ZZ Excision of Right Kidney Pelvis, Percutaneous Approach 0TB34ZZ Excision of Right Kidney Pelvis, Percutaneous Endoscopic Approach 0TB37ZZ Excision of Right Kidney Pelvis, Via Natural or Artificial Opening 0TB38ZZ Excision of Right Kidney Pelvis, Via Natural or Artificial Opening Endoscopic 0TB40ZZ Excision of Left Kidney Pelvis, Open Approach 0TB43ZZ Excision of Left Kidney Pelvis, Percutaneous Approach 0TB44ZZ Excision of Left Kidney Pelvis, Percutaneous Endoscopic Approach 0TB47ZZ Excision of Left Kidney Pelvis, Via Natural or Artificial Opening 0TB48ZZ Excision of Left Kidney Pelvis, Via Natural or Artificial Opening Endoscopic 0TT30ZZ Resection of Right Kidney Pelvis, Open Approach 0TT34ZZ Resection of Right Kidney Pelvis, Percutaneous Endoscopic Approach 0TT37ZZ Resection of Right Kidney Pelvis, Via Natural or Artificial Opening 0TT38ZZ Resection of Right Kidney Pelvis, Via Natural or Artificial Opening Endoscopic 0TT40ZZ Resection of Left Kidney Pelvis, Open Approach 0TT44ZZ Resection of Left Kidney Pelvis, Percutaneous Endoscopic Approach

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0TT47ZZ Resection of Left Kidney Pelvis, Via Natural or Artificial Opening 0TT48ZZ Resection of Left Kidney Pelvis, Via Natural or Artificial Opening Endoscopic 0TT00ZZ Resection of Right Kidney, Open Approach 0TT04ZZ Resection of Right Kidney, Percutaneous Endoscopic Approach 0TT10ZZ Resection of Left Kidney, Open Approach 0TT14ZZ Resection of Left Kidney, Percutaneous Endoscopic Approach 0TT60ZZ Resection of Right Ureter, Open Approach 0TT64ZZ Resection of Right Ureter, Percutaneous Endoscopic Approach 0TT67ZZ Resection of Right Ureter, Via Natural or Artificial Opening 0TT68ZZ Resection of Right Ureter, Via Natural or Artificial Opening Endoscopic 0TT70ZZ Resection of Left Ureter, Open Approach 0TT74ZZ Resection of Left Ureter, Percutaneous Endoscopic Approach 0TT77ZZ Resection of Left Ureter, Via Natural or Artificial Opening 0TT78ZZ Resection of Left Ureter, Via Natural or Artificial Opening Endoscopic 0TT20ZZ Resection of Bilateral Kidneys, Open Approach 0TT24ZZ Resection of Bilateral Kidneys, Percutaneous Endoscopic Approach 0TS00ZZ Reposition Right Kidney, Open Approach 0TS10ZZ Reposition Left Kidney, Open Approach 0TY00Z0 Transplantation of Right Kidney, Allogeneic, Open Approach 0TY00Z1 Transplantation of Right Kidney, Syngeneic, Open Approach 0TY00Z2 Transplantation of Right Kidney, Zooplastic, Open Approach 0TY10Z0 Transplantation of Left Kidney, Allogeneic, Open Approach 0TY10Z1 Transplantation of Left Kidney, Syngeneic, Open Approach 0TY10Z2 Transplantation of Left Kidney, Zooplastic, Open Approach ICD-9-CM Diagnosis Description Codes 250.4x Diabetes with renal manifestation 250.40 Diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled 250.41 Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled 250.42 Diabetes with renal manifestations, type ii or unspecified type, uncontrolled 250.43 Diabetes with renal manifestations, type i [juvenile type], uncontrolled 403.xx Hypertensive chronic kidney disease 403.00 Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified 403.01 Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease 403.10 Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified 403.11 Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease 403.90 Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified 403.91 Hypertensive chronic kidney disease, unspecified, with chronic kidney

Diabetes Care: Kidnet Function Monitored – QCDR Non-PQRS Measure 2014 This specification is updated annually; refer to previous versions for coding and other changes

15 WCHQ Ambulatory Measure Specification WCHQ 5 – Diabetes Care: Kidney Function Monitored Measurement Period: 01/01/2015 – 12/31/2015 Process Measure Type NQS Domain: Clinical Process/Effectiveness

disease stage V or end stage renal disease 404.xx Hypertensive heart and kidney disease 404.00 Hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified 404.01 Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified 404.02 Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified 404.03 Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage V or end stage renal disease 404.10 Hypertensive heart and chronic kidney disease, benign, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified 404.11 Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified 404.12 Hypertensive heart and chronic kidney disease, benign, without heart failure and with chronic kidney disease stage V or end stage renal disease 404.13 Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease stage V or end stage renal disease 404.90 Hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified 404.91 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified 404.92 Hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage V or end stage renal disease 404.93 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage V or end stage renal disease 405.01 Malignant Renovascular Hypertension–- initial episode 405.11 Benign Renovascular Hypertension 405.91 Secondary hypertension, renovascular 580.xx Acute Glomerulonephritis 580.0 With lesion of proliferative glomerulonephritis 580.4 With lesion of rapidly progressive glomerulonephritis 580.8 With other specified pathological lesion in kidney 580.81 Acute glomerulonephritis in diseases classified elsewhere 580.89 Other 580.9 Acute glomerulonephritis with unspecified pathological lesion in kidney 581.xx Nephrotic Syndrome 581.0 With lesion of proliferative glomerulonephritis 581.1 With lesion of membranous glomerulonephritis 581.2 With lesion of membranoproliferative glomerulonephritis 581.3 With lesion of minimal change glomerulonephritis 581.8 With other specified pathological lesion in kidney 581.81 Nephrotic syndrome in diseases classified elsewhere 581.89 Other 581.9 Nephrotic syndrome with unspecified pathological lesion in kidney

Diabetes Care: Kidnet Function Monitored – QCDR Non-PQRS Measure 2014 This specification is updated annually; refer to previous versions for coding and other changes

16 WCHQ Ambulatory Measure Specification WCHQ 5 – Diabetes Care: Kidney Function Monitored Measurement Period: 01/01/2015 – 12/31/2015 Process Measure Type NQS Domain: Clinical Process/Effectiveness

582.xx Chronic glomerulonephritis 582.0 With lesion of proliferative glomerulonephritis 582.1 With lesion of membranous glomerulonephritis 582.2 With lesion of membranoproliferative glomerulonephritis 582.4 With lesion of rapidly progressive glomerulonephritis 582.8 With other specified pathological lesion in kidney 582.81 Chronic glomerulonephritis in diseases classified elsewhere 582.89 Other 582.9 Chronic glomerulonephritis with unspecified pathological lesion in kidney 583.xx Nephritis and nephropathy, not specified as acute or chronic 583.0 With lesion of proliferative glomerulonephritis 583.1 With lesion of membranous glomerulonephritis 583.2 With lesion of membranoproliferative glomerulonephritis 583.4 With lesion of rapidly progressive glomerulonephritis 583.6 With lesion of renal cortical necrosis 583.7 With lesion of renal medullary necrosis 583.8 With other specified pathological lesion in kidney 583.81 With unspecified pathological lesion in kidney 583.89 Other 583.9 With unspecified pathological lesion in kidney 584.x Acute renal failure 584.5 Acute renal failure with lesion of tubular necrosis 584.6 Acute renal failure with lesion of renal cortical necrosis 584.7 Acute renal failure with lesion of renal medullary (papillary) necrosis 584.8 Acute renal failure with other specified pathological lesion in kidney 584.9 Acute renal failure unspecified 585 Chronic renal failure (Note: Deleted October 2005) 585.x Chronic Kidney Disease 585.1 Chronic kidney disease, stage I 585.2 Chronic kidney disease, stage ii (mild) 585.3 Chronic kidney disease, stage iii (moderate) 585.4 Chronic kidney disease, stage iv (severe) 585.5 Chronic kidney disease, stage v 585.6 End stage renal disease 585.9 Chronic kidney disease, unspecified 586 Renal Failure, Unspecified 587 Renal sclerosis, unspecified 588.xx Disorders resulting from impaired renal function 588.0 Renal osteodystrophy 588.1 Nephrogenic diabetes insipidus 588.81 Secondary hyperparathyroidism (of renal origin) 588.89 Other specified disorders resulting from impaired renal function 588.9 Unspecified disorder resulting from impaired renal function 753.0 Renal agensis and dysgenesis 753.1x Congenital anomalies of urinary system

Diabetes Care: Kidnet Function Monitored – QCDR Non-PQRS Measure 2014 This specification is updated annually; refer to previous versions for coding and other changes

17 WCHQ Ambulatory Measure Specification WCHQ 5 – Diabetes Care: Kidney Function Monitored Measurement Period: 01/01/2015 – 12/31/2015 Process Measure Type NQS Domain: Clinical Process/Effectiveness

753.10 Cystic kidney disease unspecified 753.11 Congenital single renal cyst 753.12 Polycystic kidney unspecified type 753.13 Polycystic kidney autosomal dominant 753.14 Polycystic kidney autosomal recessive 753.15 Renal dysplasia 753.16 Medullary cystic kidney 753.17 Medullary sponge kidney 753.19 Other specified cystic kidney disease 791.0 Proteinuria V42.0 Kidney transplant V45.1x Renal dialysis status V45.11 Renal dialysis status (postprocedural) V45.12 Noncompliance with renal dialysis

Effective 10/01/2015 ICD-10-CM Description Diagnosis Codes

Diabetes Care: Kidnet Function Monitored – QCDR Non-PQRS Measure 2014 This specification is updated annually; refer to previous versions for coding and other changes

18 WCHQ Ambulatory Measure Specification WCHQ 5 – Diabetes Care: Kidney Function Monitored Measurement Period: 01/01/2015 – 12/31/2015 Process Measure Type NQS Domain: Clinical Process/Effectiveness

E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E10.29 Type 1 diabetes mellitus with other diabetic kidney complication E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.65 Type 2 diabetes mellitus with hyperglycemia E10.21 Type 1 diabetes mellitus with diabetic nephropathy E10.65 Type 1 diabetes mellitus with hyperglycemia I12.00 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease I15.0 Renovascular hypertension N00.3 Acute nephritic syndrome with diffuse mesangial proliferative glomerulonephritis N01.3 Rapidly progressive nephritic syndrome with diffuse mesangial proliferative glomerulonephritis N08 Glomerular disorders in diseases classified elsewhere N00.8 Acute nephritic syndrome with other morphologic changes N00.9 Acute nephritic syndrome with unspecified morphologic changes N04.4 Nephrotic syndrome with diffuse endocapillary proliferative glomerulonephritis N02.2 Recurrent and persistent hematuria with diffuse membranous glomerulonephritis N04.3 Nephrotic syndrome with diffuse mesangial proliferative glomerulonephritis N04.0 Nephrotic syndrome with minor glomerular abnormality

Diabetes Care: Kidnet Function Monitored – QCDR Non-PQRS Measure 2014 This specification is updated annually; refer to previous versions for coding and other changes

19 WCHQ Ambulatory Measure Specification WCHQ 5 – Diabetes Care: Kidney Function Monitored Measurement Period: 01/01/2015 – 12/31/2015 Process Measure Type NQS Domain: Clinical Process/Effectiveness

N04.9 Nephrotic syndrome with unspecified morphologic changes N04.8 Nephrotic syndrome with other morphologic changes N03.2 Chronic nephritic syndrome with diffuse membranous glomerulonephritis N03.3 Chronic nephritic syndrome with diffuse mesangial proliferative glomerulonephritis N03.5 Chronic nephritic syndrome with diffuse mesangiocapillary glomerulonephritis N03.8 Chronic nephritic syndrome with other morphologic changes N03.9 Chronic nephritic syndrome with unspecified morphologic changes N05.9 Unspecified nephritic syndrome with unspecified morphologic changes N05.2 Unspecified nephritic syndrome with diffuse membranous glomerulonephritis N05.5 Unspecified nephritic syndrome with diffuse mesangiocapillary glomerulonephritis N17.1 Acute kidney failure with acute cortical necrosis N17.2 Acute kidney failure with medullary necrosis N05.8 Unspecified nephritic syndrome with other morphologic changes N17.0 Acute kidney failure with tubular necrosis N17.8 Other acute kidney failure N17.9 Acute kidney failure, unspecified N18.1 Chronic kidney disease, stage 1 N18.2 Chronic kidney disease, stage 2 (mild) N18.3 Chronic kidney disease, stage 3 (moderate) N18.4 Chronic kidney disease, stage 4 (severe) N18.5 Chronic kidney disease, stage 5 N18.6 End stage renal disease N18.9 Chronic kidney disease, unspecified N19 Unspecified kidney failure N26.9 Renal sclerosis, unspecified N25.0 Renal osteodystrophy N25.1 Nephrogenic diabetes insipidus N25.81 Secondary hyperparathyroidism of renal origin N25.89 Other disorders resulting from impaired renal tubular function N25.9 Disorder resulting from impaired renal tubular function, unspecified Q60.2 Renal agenesis, unspecified Q60.5 Renal hypoplasia, unspecified Q61.00 Congenital renal cyst, unspecified Q61.9 Cystic kidney disease, unspecified Q61.01 Congenital single renal cyst Q61.3 Polycystic kidney, unspecified Q61.2 Polycystic kidney, adult type Q61.19 Other polycystic kidney, infantile type Q61.4 Renal dysplasia Q61.5 Medullary cystic kidney Q61.02 Congenital multiple renal cysts Q61.8 Other cystic kidney diseases R80.3 Bence Jones proteinuria R80.9 Proteinuria, unspecified Z94.0 Kidney transplant status Z99.2 Dependence on renal dialysis

Diabetes Care: Kidnet Function Monitored – QCDR Non-PQRS Measure 2014 This specification is updated annually; refer to previous versions for coding and other changes

20 WCHQ Ambulatory Measure Specification WCHQ 5 – Diabetes Care: Kidney Function Monitored Measurement Period: 01/01/2015 – 12/31/2015 Process Measure Type NQS Domain: Clinical Process/Effectiveness

Z91.15 Patient's noncompliance with renal dialysis

UB-92 Revenue Description Codes 080x Inpatient Renal Dialysis 0800 Sessions Inpatient Renal Dialysis - General 0801 Sessions Inpatient Renal Dialysis – Inpatient Hemodialysis 0802 Sessions Inpatient Renal Dialysis – Inpatient Peritoneal (non-CAPD) 0803 Sessions Inpatient Renal Dialysis – Inpatient Continuous Ambulatory Peritoneal Dialysis (CAPD) 0804 Sessions Inpatient Renal Dialysis – Other Inpatient Dialysis 0809 Sessions Inpatient Renal Dialysis – Other Inpatient Dialysis 082x Hemodialysis-Outpatient or Home 0820 Sessions Hemodialysis – Outpatient or Home - General 0821 Sessions Hemodialysis – Outpatient or Home – Hemodialysis / Composite or Other Rate 0822 Sessions Hemodialysis – Outpatient or Home – Home Supplies 0823 Sessions Hemodialysis – Outpatient or Home – Home Equipment 0824 Sessions Hemodialysis – Outpatient or Home – Maintenance / 100% 0825 Sessions Hemodialysis – Outpatient or Home – Support Services 0829 Sessions Hemodialysis – Outpatient or Home - Other Outpatient Hemodialysis 083x Peritoneal Dialysis-Outpatient or Home 0830 Sessions Peritoneal Dialysis – Outpatient or Home - General 0831 Sessions Peritoneal Dialysis – Outpatient or Home – Peritoneal / Composite or Other Rate 0832 Sessions Peritoneal Dialysis – Outpatient or Home - Home Supplies 0833 Sessions Peritoneal Dialysis – Outpatient or Home – Home Equipment 0834 Sessions Peritoneal Dialysis – Outpatient or Home – Maintenance / 100% 0835 Sessions Peritoneal Dialysis – Outpatient or Home – Support Services 0839 Sessions Peritoneal Dialysis – Outpatient or Home - Other Outpatient Peritoneal Dialysis 084x CAPD-Outpatient or Home 0840 CAPD - Outpatient or Home - General 0841 CAPD - Outpatient or Home - CAPD / Composite or Other Rate 0842 CAPD - Outpatient or Home - Home Supplies 0843 CAPD - Outpatient or Home – Home Equipment 0844 CAPD - Outpatient or Home - Maintenance / 100% 0845 CAPD - Outpatient or Home – Support Services 0849 CAPD - Outpatient or Home - Other Outpatient CAPD 085x CCPD-Outpatient or Home 0850 CCPD - Outpatient or Home - General 0851 CCPD - Outpatient or Home - CCPD / Composite or Other Rate 0852 CCPD - Outpatient or Home - Home Supplies 0853 CCPD - Outpatient or Home – Home Equipment 0854 CCPD - Outpatient or Home - Maintenance / 100%

Diabetes Care: Kidnet Function Monitored – QCDR Non-PQRS Measure 2014 This specification is updated annually; refer to previous versions for coding and other changes

21 WCHQ Ambulatory Measure Specification WCHQ 5 – Diabetes Care: Kidney Function Monitored Measurement Period: 01/01/2015 – 12/31/2015 Process Measure Type NQS Domain: Clinical Process/Effectiveness

0855 CCPD - Outpatient or Home – Support Services 0859 CCPD - Outpatient or Home - Other Outpatient CCPD Dialysis 086X RESERVED FOR DIALYSIS (NATIONAL ASSIGNMENT) 087x RESERVED FOR DIALYSIS (NATIONAL ASSIGNMENT) 088x Miscellaneous Dialysis 0880 Sessions Miscellaneous Dialysis – General 0881 Sessions Miscellaneous Dialysis – Ultra filtration 0882 Sessions Miscellaneous Dialysis – Home Dialysis Aid Visit 0889 Sessions Miscellaneous Dialysis – Miscellaneous Dialysis Other UB Type of Bill Description Codes 721 Clinic-Hospital Based or Independent Renal Dialysis Center (Admit through Discharge Claim) 722 Clinic-Hospital Based or Independent Renal Dialysis Center (Interim-First Claim) 723 Clinic-Hospital Based or Independent Renal Dialysis Center (Interim-Continuing Claim) 724 Clinic-Hospital Based or Independent Renal Dialysis Center (Interim-Last Claim) 725 Clinic-Hospital Based or Independent Renal Dialysis Center (Late Charges Only Claim) 727 Clinic-Hospital Based or Independent Renal Dialysis Center (Replacement of Prior Claim) 729 Clinic-Hospital Based or Independent Renal Dialysis Center (Final Claim for a Home Health PPS Episode) MS DRG’s Description (effective October 1, 2007) 682 Renal Failure with MCC 683 Renal Failure with CC 684 Renal Failure without MCC or CC 685 Admission for Renal Dialysis

TABLE D-6: Codes to Identify Microalbuminuria Tests CPT Codes Description 82042 Serum albumin; urine or other source, quantitative, each specimen 82043 Serum albumin; urine, micro albumin, quantitative 82044 Serum albumin; urine, micro albumin, semi quantitative (e.g., reagent strip assay) 84156 Protein, total, except by refractometry, urine LOINC 1753-3, 1754-1, 1755-8, 1757-4, 2887-8, 2888-6, 2889-4, 2890-2, 9318-7, 11218-5, 12842-1, 13801-6, 14956-7, 14957-5, 14958-3, 14959-1, 13705-9, 14585-4, 18373-1, 20621-9, 21059-1, 21482-5, 26801-1, 27298-9, 30000-4, 30001-2, 30003-8, 32209-9, 32294-1, 32551-4, 34366-5, 35663-4, 40486-3, 40662-9, 40663-7, 43605-5, 43606-3, 43607-1, 44292-1, 47558-2, 49023-5, 50949-7, 53121-0, 53530-2, 53531-0, 53532-8, 56553-1, 57369-1, 58448-2, 58992-9, 59159-4 CPT Category II Description Codes **3060F Positive Microalbuminuria test result documented and reviewed **3061F Negative Microalbuminuria test result documented and reviewed **Codes can be included at the organization’s discretion. If included, the date the service was performed must be provided. If an 8P modifier is included with the CPT II code, it does

Diabetes Care: Kidnet Function Monitored – QCDR Non-PQRS Measure 2014 This specification is updated annually; refer to previous versions for coding and other changes

22 WCHQ Ambulatory Measure Specification WCHQ 5 – Diabetes Care: Kidney Function Monitored Measurement Period: 01/01/2015 – 12/31/2015 Process Measure Type NQS Domain: Clinical Process/Effectiveness

not qualify as numerator compliant.

TABLE D-7: Codes to Identify Gross Proteinuria Tests CPT Code Description 81000-81003 81000: urinalysis 81001: urinalysis automated, with microscopy 81002: urinalysis non-automated, without microscopy 81003: urinalysis, automated, without microscopy 81005 Urinalysis; qualitative or semi qualitative, except immunoassays LOINC 57735-3

Diabetes Care: Kidnet Function Monitored – QCDR Non-PQRS Measure 2014 This specification is updated annually; refer to previous versions for coding and other changes

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