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Gap closure instructions

These instructions will help you close gaps for the Medicare Quality Incentive Program easily and accurately.

Care Gap Management Application (CGMA)

The CGMA allows you to manage diagnosis and medical care gaps for each of your Medicare Advantage members and track your progress toward earning incentives in the Medicare Quality Incentive Program. The application includes all gaps related to the measures identified in these instructions.

Closing diagnosis gaps

All International Classification of Diseases (ICD) codes for existing and chronic conditions should be documented in a face-to-face visit with a Medicare-qualified provider at least once a year. The CGMA and care reminders include members who have at least one diagnosis with a reporting gap in the past two years.

During the patient's next office visit:

  • Verify and confirm the status of the diagnosis gaps
  • Evaluate conditions marked as "suspect" for applicability.

  • Review diagnosis gaps flagged with an asterisk "*" for late effects and document any applicable effects.

Diagnosis gaps may be closed in one of the following ways:

  • For active diagnoses, submit a claim with all applicable diagnosis codes and results for the office visit. Complete a full assessment, incorporate the diagnoses into the patient visit through monitoring, evaluation, assessing and/or treating (MEAT) the identified diagnosis, as well as documenting conditions and treatment plans in the chart notes.

  • For inactive or incorrect diagnoses, following a face-to-face encounter during the calendar year and after consulting with other providers involved in the patient's care, notify us that your patient does not have the condition we listed by identifying the invalid diagnosis on the CGMA.

Closing medical care gaps

Gaps for the HEDIS Medicare Star Ratings measures may be closed by:

  • Submitting a claim with complete diagnosis and procedure coding for the services and associated results of an office visit. You can submit a supplemental claim for the same date of service in the amount of $0.01 for a CPT category II code.
  • Submitting test results and other clinical data through a monthly electronic medical record (EMR) data extract. For more information, please email us.
  • For gaps that were closed prior to the current year, submit supporting documentation for gap closure on the CGMA.