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 Healthcare Effectiveness Data and Information Set (HEDIS) and 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.
Star Rating measure What is needed to close gap
Adult body mass index BMI assessment

Document BMI, height and weight measurement in the current year or the previous year

Submit medical record through the CGMA or report on a claim using ICD-10 codes Z68.1 to Z68.45.
Breast cancer screening Submit claim for screening completed between October 1 of the previous year two years before December 31 of the current year
Colorectal cancer screening

Perform the screening or submit evidence of a:

  • Fecal occult blood test (gFOBT or iFOBT) in the measurement year
  • FIT DNA (and) or Cologuard test performed in the measurement year or the four years prior
  • Flexible sigmoidoscopy or CT colonography performed in the measurement year or the four years prior
  • Colonoscopy performed in the measurement year or nine years prior
Controlling blood pressure

Blood pressure has not been documented this year or last year and/or prior screening indicates the member's blood pressure is outside controlled range. Blood pressure is considered controlled if readings are <140/90 for all patients ages 18 to 85, diabetic and non-diabetic. Evidence of hypertension either has to be in current measurement year (2019) or one year prior (2018). Most recent BP reading must be after the second diagnosis and must be in the measurement year (2019).

Submit documentation of most recent blood pressure reading on the CGMA or via monthly EMR data extract. Compliance is determined based on the reading documented in the medical record corresponding with the patient's last outpatient encounter date with any provider.
Diabetes care - blood sugar control (HbA1c)

Screening has not been completed this year and/or indicates level >9%. Submit lab results on the CGMA, monthly EMR data extract or on a claim using CPT category II codes 3044F or 3046F to reflect current HbA1c level.

Note: Only 3044F and 3045F illustrate controlled HbA1c.

Compliance is determined based on the lab value corresponding with the patient's last HbA1c screening of the year, by any provider.
Diabetes care - eye examination Eye care professional (optometrist or ophthalmologist) must conduct screening in the current year or submit documentation of negative retinopathy in the current year or previous year.
Diabetes care – kidney disease monitoring Conduct nephropathy screening or provide evidence of ACE/ARB therapy in current year.
Medication reconciliation post-discharge

Patient was recently discharged from hospital or other inpatient setting. Reconcile discharge medications with the most recent outpatient medication list within 30 days post-discharge and do one of the following:

  • Submit a claim with CPT code 99495, 99496, or CPT II code 1111F, or
  • Attach documentation with evidence of medication reconciliation.  Documentation must include date of review, whether there are any differences between discharge medication list and current outpatient medication list, what action was taken to reconcile the differences and provider signature.
Note: Patients transferring from a hospital to a skilled nursing facility or other inpatient setting do not require this reconciliation until they are discharged from the inpatient setting.
Osteoporosis management in women who have had a fracture Submit a claim for a bone density test or prescription to treat osteoporosis within 180 days of a bone fracture. Claim must include fracture diagnosis in addition to the appropriate CPT code. 
Rheumatoid arthritis management Prescribe a disease-modifying antirheumatic medication (DMARD) for a patient with a diagnosis of rheumatoid arthritis, if appropriate.
Medication management measures What is needed to close gap
Statin use for persons with diabetes Verify diabetes diagnosis and prescribe a statin to reduce cardiovascular risk, if appropriate.
Statin therapy for patients with cardiovascular disease Verify diagnosis of atherosclerotic cardiovascular disease and initiate moderate- or high‑intensity statin therapy, if appropriate.
High-risk medications (HRM) Patient has claims for HRM(s). Please discuss with patient and prescribe safer alternatives if clinically appropriate.