This form will segment your patient with diabetes
into one of these categories based on their score.

GREEN
ZONE

Minimal support needed. Overall Stratification
Score < 3

Yellow
ZONE

Moderate support needed. Overall Stratification
Score 3 - 6

Red
ZONE

Maximum support needed. Overall Stratification
Score > 6

PATIENT ASSESSMENT Points CPT Codes
1. PATIENT A1C* Points CPT Codes
2. BLOOD PRESSURE Points CPT Codes

*Patient A1C Points are based on the widely recognized goal of < 7%. In some instances, the goal may not be warranted or safe, in which case the goal would be set at 8% and all data sets would be adjusted upward (+1% to each parameter)

Reference:

Christopher R, Trudnak T, Hemenway R, et al. Health care transformation initiatives in type 2 diabetes care: A qualitative study in the Cincinnati Beacon Community. Diabetes Spectrum. 2015;28(2):132-140. http://spectrum.diabetesjournals.org/content/28/2/132. Accessed May 2, 2016.

3. STATIN USE/LDL Points CPT Codes
4. TOBACCO STATUS Points CPT Codes
5. PHQ SCORE Points CPT Codes
scoring points
  1. Patient A1C*
  2. Blood Pressure
  3. Statin Use/LDL
  4. Tobacco Status
  5. PHQ Score