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5 Ways to boost your HEDIS Scores and Star Ratings for Comprehensive Diabetes Care

Starting the New Year the Right Way: 5 Ways to boost your HEDIS Scores and Star Ratings for Comprehensive Diabetes Care


Most New Year's resolutions are related to health goals; keeping fit, losing weight, and eating well are all in the top 5 most common resolutions each year. While patients have a primary responsibility towards their own health and self-care, HEDIS measures help ensure that healthcare providers are fulfilling their own obligation to monitor the health and well-being of their patients. This includes screening for potential complications and assisting patients in achieving control over their conditions.


The main goal of a quality measurement program like HEDIS is to assist physicians in improving healthcare and promoting better patient outcomes. Due to the complex nature of diabetes and its particularly high prevalence in the US, unique indicators have been created to measure diabetes management. Proper management and care of diabetes is crucial for improving patient outcomes and attaining diabetes quality measures.


Comprehensive Diabetes Care has been defined by HEDIS using 6 quality measures, with special emphasis on diabetic eye care.


1. Eye exam (retinal) screening

The development of diabetic retinopathy (DR) occurs in nearly all patients with diabetes over their lifetime, and remains a leading cause of vision impairment worldwide.

Based on recommendations from the American Academy of Ophthalmology (AAO), as well as other bodies, CMS recommends that patients receive yearly specialist screenings, which commonly require a dilated fundus examination. Patients are typically referred to an ophthalmologist or retinal specialist during their yearly checkup, however, research shows that less than 50% of patients adhere to their annual diabetic retinal exam due to a lack of social and financial accessibility. This has resulted in DR becoming the leading cause of blindness in American working-age adults, even though it is a preventative and treatable condition.

With advances in technology and growing recognition of the importance of closing the diabetic retinal exam care gap, point-of-care screening is growing in popularity. There are currently two options for point-of-care diabetic eye exams: teleretinal screening and AI-based diagnostic screening.


Teleretinal Screening

Teleretinal screening is a two-part procedure - the primary care provider first obtains retinal images from the patient, after which the images are interpreted by a remote specialist. Unlike AI-based diagnostic screening, it may take up to a few weeks to receive diagnostic results, and in some cases, the images may be determined to be of insufficient quality, in which case the patient must be returned to the clinic for re-imaging.


AI-based Diagnostic Screening

AI-based diagnostic screening is a highly accurate, FDA-cleared technology that allows AI software to diagnose patients for DR instead of a specialist. As a result, annual diabetic eye exams can be performed at primary care locations, instead of referring patients to specialists. The most striking benefit of point-of-care screening is the ability to ensure that patients are actually screened. Additional benefits are real-time results and feedback, ensuring patients receive crucial diagnoses promptly and patients that need re-imaging do not have to be returned to the clinic. Furthermore, primary care providers can receive reimbursement for performing the procedure, using dedicated CPT code 92229, as well as improving their diabetes quality measures.


AEYE Diagnostic Screening (AEYE-DS)

AEYE-DS enables primary caregivers to easily screen and diagnoses patients for diabetic retinopathy. Using AI, patients can receive an instant diagnosis, providing opportunities for treatment and vision loss prevention while closing care gaps. Ensuring that your clinic has the means to screen on-site for DR is key to keeping up your excellent quality of care and improving patient outcomes. With no lock-in contracts, the subscription offers a bundle providing a camera and access to the software for unlimited exams. The exams are reimbursable with a dedicated CPT code, 92229, with a national reimbursement average of ~$60. With AEYE - DS you could screen your patients, preventing vision loss, while closing care gaps, receiving reimbursements, and directly addressing the HEDIS metric for diabetic eye exams.




2. Blood pressure control

About 6 out of 10 people who have diabetes have high blood pressure. Given the significant health risks of hypertension, especially in combination with diabetes, it is crucial to attain blood pressure control. Quality indicators define blood pressure control as the percentage of persons with diabetes during the measurement year who had blood pressure <140/90 mm Hg. Blood pressure control relies on recorded blood pressure measurements lower than 140/90 mm Hg.


Blood sugar testing and control

As one of the most important indicative tests for diabetes, HEDIS has dedicated 3 measures related to glycated hemoglobin A1c (HbA1c), the first related to regular tests and the following two to control levels:


3. Hemoglobin A1c (HbA1c) testing

Evaluate and document HbA1c every 3-6 months.


4. HbA1c poor control (>9.0%)

Establish a process to identify and reach out to patients with HbA1c >9 who have not had a test in more than four months.


5. HbA1c control (<8.0%)

Measure the percentage of plan members who had an HbA1c test during the year and demonstrate good control.

6. Medical attention for nephropathy

Record both an eGFR and a uACR tests for each patient during the current measurement year.


After identifying how HEDIS scores are measured for diabetes care, here are the top 5 tips for keeping on track and boosting your quality measures:

  1. Ensure that necessary follow-up appointments, lab work, and referrals are scheduled for patients in a timely manner.

  2. Ensure that screening is accessible to patients by either following up with referrals or bringing diagnostic screening into your clinic.

  3. Coordinate care with specialists for referrals, treatment, and engagement - endocrinologists, nephrologists, eye specialists, etc.

  4. Explain the importance of following medication schedules and medical care adherence to your patients.

  5. Organize your filing, billing, and coding for all products and services, and submit them in a timely manner to ensure you’re receiving the reimbursement and quality scores you deserve.


Patients, providers, and payers all play a role in diabetes care and quality measures to ensure timely and appropriate care is received for better patient outcomes. By following these tips and taking steps to follow HEDIS recommendations, you can benefit both your clinic and your patients in the new year.




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