The first care gap list of the year usually arrives as a spreadsheet attached to an email from a plan's quality team, sometime in February. It lists your attributed patients and the measures each one is "open" for: no colorectal cancer screening on record, no HbA1c result, blood pressure not controlled, no statin for a diabetic. A 2,000-patient panel across four plans produces several hundred rows. In most practices somebody opens it, feels tired, and closes it.
That is a mistake, and not mainly because of the quality bonus. Roughly a third of the rows on a typical gap list are not care gaps at all. They are documentation gaps: the colonoscopy happened in 2023 at a facility that never sent the report, the A1c was drawn but the result was never coded, the blood pressure was recorded but the CPT II code that tells the plan the value was never billed. Those rows are closed with a code, not a visit. The remaining rows are real gaps, and they are the patients the practice should be calling anyway.
Key takeaways
- Reconcile every gap list against the chart before anyone calls a patient; roughly a third of the rows are documentation gaps, not care gaps.
- Documentation gaps close with CPT Category II codes on the next claim or a supplemental data file, at no cost and with no visit.
- Sort real gaps by patient, not by measure, so a patient with three open measures gets one visit and one call.
- A closed gap counts only when the plan sees it; check each plan's refreshed list monthly to confirm your closures dropped off.
- The same workflow is the evidence for several PCMH population health criteria, so build it once and use it twice.
Why February matters more this year
The Medicare Advantage Advance Notice released January 26 proposes to exclude diagnoses from audio-only encounters from risk adjustment, and the plans' Star Ratings depend on measures that need documented clinical results. Both point the same direction: plans will push harder for in-person and video visits with documented results in 2026, and they will push through you. A practice that works its gap lists in February sets its own schedule for that. A practice that waits gets the plan's care coordinators calling its patients in October.
Step one: reconcile before you outreach
Take each plan's list and match it against the chart before anyone picks up the phone. For each row, one of four things is true.
| Finding | Example | Action |
|---|---|---|
| Service done and documented, never reported to the plan | Colonoscopy in 2023 in the chart; plan has no claim | Send the plan supplemental data (the report or a data file); no visit needed |
| Result in the chart, never coded | A1c 7.2 recorded in the visit note; no CPT II code on the claim | Bill the CPT II code on the next claim or submit supplemental data |
| Patient no longer yours | Moved, deceased, changed PCP | Tell the plan to correct attribution |
| Real gap | No mammogram in the record or the plan's data | Outreach and schedule |
The reconciliation usually takes a medical assistant or care coordinator a few hours per plan the first time and less afterward. It is the highest-value step and the one most practices skip.
A typical result, from a list we worked through with a three-physician practice: 412 rows from one MA plan. After reconciliation, 96 were services already in the chart with no claim or data sent to the plan, 71 were results in the chart with no CPT II code on the claim, 38 were patients who had moved, died or changed primary care, and 207 were real gaps spread across 164 patients. So the plan's 412 problems became 164 patients to reach, 167 rows to close from the desk, and 38 attribution corrections. The care coordinator finished the reconciliation in a day and a half. The plan's own outreach team, had the practice waited, would have called all 412, including the 38 who were no longer patients.
Step two: close documentation gaps with codes
Several common measures are closed by CPT Category II codes on a claim, which cost nothing and tell the plan the result without a records request.
- HbA1c control: 3044F (less than 7.0), 3051F (7.0 to 7.9), 3052F (8.0 to 9.0), 3046F (greater than 9.0).
- Blood pressure: 3074F (systolic under 130), 3075F (130 to 139), 3077F (140 or higher); 3078F (diastolic under 80), 3079F (80 to 89), 3080F (90 or higher).
- Eye exam for diabetics: 2022F, 2024F, 2026F depending on findings and who performed it, or 3072F for a negative exam in the prior year.
These go on the claim for the visit where the result was obtained, with a nominal or zero charge. Ask your EHR vendor whether the codes can be generated from the flowsheet automatically; several systems do it, and most practices have never turned it on. For screenings performed elsewhere, most plans accept supplemental data submissions: the report, or a structured file in the plan's format. Ask each plan's quality contact for the process and the deadline; supplemental data submitted after the plan's cutoff, often late in the year or early the next, does not count.
Step three: outreach for the real gaps
Sort the real gaps by patient rather than by measure. A patient with three open measures needs one visit, not three calls. Then prioritize: patients with an appointment already scheduled (add the gap to the pre-visit plan), patients due for an annual wellness visit (schedule it and close the gaps during it), and patients with no visit planned (call, text or portal message, in that order of effectiveness in our experience). Write the script. "Your care team noticed you are due for your colon cancer screening and your yearly diabetes labs. Dr. Patel would like to see you in the next few weeks; can we find a time?" is enough.
Track outreach attempts and outcomes in one place. Three attempts by two methods before you mark a patient unreachable is a reasonable standard, and it is roughly what the plans themselves use.
Step four: close the loop with the plan
A closed gap only counts when the plan sees it. Claims with the right codes do that automatically. Supplemental data needs to be sent. Attribution corrections need to be requested. Schedule a monthly check of each plan's updated list against your tracking to confirm the rows you closed have dropped off. When they have not, ask why; the usual answer is a claim that did not carry the CPT II code or a supplemental file that was rejected for format.
How this connects to PCMH
Practices recognized as patient-centered medical homes already do most of this under the population health and care management standards, and the annual reporting asks for evidence of it. If your practice is working toward recognition, the gap list workflow described here is the evidence for several criteria at once: identifying patients needing services, outreach, and measuring performance. Our PCMH recognition and annual review teams build the workflow this way so it serves both purposes, and our closing gaps in care service does the reconciliation and outreach for practices that do not have the staff.
Questions we hear
The plan's list says a patient is ours but we have never seen them. What do we do?
Tell the plan. Attribution is often based on a single claim or on the patient's selection at enrollment, and plans correct it when asked. Do not do outreach to a patient you have no relationship with; it confuses the patient and does nothing for your measures.
Do CPT II codes pay anything?
No. They are tracking codes with no fee. Their value is that they close measures on the plan's side without a records request, which matters for quality bonuses in your contracts and for the plan's pressure on your practice later in the year.
How late in the year can a gap be closed and still count?
For most HEDIS measures the measurement year is the calendar year, so a service on December 31 counts for that year. The catch is the plan's data deadline: claims have to be received and processed, and supplemental data has to be submitted and accepted, before the plan locks its data early the following year. Ask each plan for its supplemental data cutoff and put it on the calendar. In practice a visit in late December closes the gap only if the claim goes out promptly and carries the right codes, which is one more reason to do this work in February rather than in the fourth quarter.
What to do this month
- Collect the gap lists from every plan that sent one, and ask the plans that have not sent one when to expect it.
- Reconcile each list against the chart into the four categories above.
- Turn on CPT II code generation in the EHR, or add the codes to the coder's checklist for diabetic and hypertensive visits.
- Submit supplemental data for services documented but not reported.
- Build the outreach list by patient and begin calls, starting with patients who already have an appointment.
- Set a monthly reconciliation date to confirm closed gaps are dropping off the plans' lists.
