Close Care Gaps

By closing care gaps we transform our community by lowering health care costs, increasing the quality of the care provided and helping our members achieve the best health outcomes possible. Specifically, partnering in this initiative can:

  • reduce patient out of pocket costs and improve health outcomes
  • improve patient satisfaction and efficiencies
  • reduce risk and improve cost control

Care Gap Closure Best Practices

  • use appropriate documentation and correct coding
  • maintain appointment availability for patients with recent emergency department visits
  • explain the importance of follow-up appointments to your patients
  • contact patients who do not keep initial appointments and reschedule them as soon as possible
  • encourage follow-up visits via telehealth when appropriate to the principal diagnosis
  • submit claims and encounter data timely

Diagnoses Coding Documentation Guidelines

  • Document and code diagnoses to the highest specificity of the patient’s condition:

Example: Patient has diabetes type 2 with CKD stage 4:

❌ Less specificity: E11.8 (DM2 w/unspecified complications.

✔️ Highest specificity: E11.22 (DM2 w/CKD), N18.4 (CKD Stage 4)

  • All diagnoses submitted must be accurate and completely documented in the medical record
  • Ensure all diagnoses documented and coded during the encounter are included on the claim

Ref: CMS - Centers for Medicare and Medicaid Services; ICD-10-CM - International Classification of Diseases, Tenth Revision, Clinical Modification

Annual Wellness Visit and Annual Routine Physical Exam

Comprehensive Care Gap Guide for Medicare and Medicaid, All Measures

Medicare

Medicaid

Data Exchange File Specifications