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Diabetes Statin Intolerance

Star Ratings

Star Ratings is a quality measurement tool the Centers for Medicare & Medicaid Services (CMS) uses to rate the quality of medical care and services provided by Medicare Advantage health plans. In the 2018 Star Ratings, Health Alliance and Health Alliance Northwest earned 4 out of 5 stars for our Illinois and Washington HMO and POS plans. We have a goal of 5 stars, and we need your help to make this a reality!

Here is one area of focus for 2018–2019:

Diabetes Care

There are four measures related to people with diabetes:

  1. Yearly eye exam
  2. Yearly kidney function test
  3. Yearly A1C lab test showing average blood sugar is controlled
  4. One statin fill per year

Documentation in the patient’s electronic medical record and accurate coding are key to ensuring all patients receive the diabetes care they need.

Statin Intolerance

If a patient is not able to take a statin, this must be documented and coded annually to exclude them from the diabetes measures listed above.

Exclusions include:

  • Pregnancy
  • Having in vitro fertilization procedure
  • Current prescription for clomiphene
  • End-stage renal disease
  • Cirrhosis
  • Myalgia
  • Myositis
  • Myopathy
  • Rhabdomyolysis

Below is a list of suggested codes for these excluded conditions. This is for your reference but is not an all-inclusive list.

Code Definition
G72.0 Drug-induced myopathy
G72.2 Myopathy due to other toxic agent
G72.9 Myopathy, unspecified
K74.60 Cirrhosis of the liver, unspecified
M60.9 Myositis, unspecified
M62.82 Rhabdomyolysis (Idiopathic)
M79.1 Myalgia
N18.6 End-Stage Renal Disease
T46.6X5A Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, initial encounter
T46.6X5D Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, subsequent encounter
T46.6X5S Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, sequela
Z31.83 Encounter for Assisted Reproductive Fertility Procedure Cycle

Disclaimer: Every year, Medicare evaluates plans based on a 5-star rating system.