hedis® 2017 measure: appropriate treatment for …

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HEDIS®2017MEASURE:APPROPRIATETREATMENTFORCHILDRENWITHUPPERRESPIRATORYINFECTION(URI)

Children3months-18yearsofagewhowerediagnosedwithupperrespiratoryinfection(URI)andwerenotdispensedanantibioticprescriptiononorthreedaysaftertheepisode.Inclusionintothemeasurecanincludethefollowingtwoevents:� Childrenwhowerenotprescribedordispensedaprescriptionforantibioticmedicationonor

within3daysaftertheURIepisodedate.� Children3months-18yearsofagewhohadanoutpatientorEDvisitwithonlyadiagnosisofupper

respiratoryinfection(URI)duringthemeasurementperiod.– Todetermineeligibilityforinclusioninthedenominator,lookinTable1belowforanyofthe

listedantibioticdrugsinthe30dayspriortothevisitwiththeURIdiagnosis.Aslongastherearenoprescriptionsforthelistedantibioticsduringthistimeperiod,thepatientiseligiblefordenominatorinclusion.

Exclusions:� Claims/encounterswithmorethanonediagnosiscodeandEDvisitsorobservationvisitsthatresult

inaninpatientstay.� EpisodeDateswithevidenceofantibioticmedication30dayspriortotheEpisodeDate.� EpisodeDateswherethepatienthadaclaim/encounterwithacompetingdiagnosisonorthree

daysaftertheEpisodeDate.� Membersinhospicecareareexcludedfromtheeligiblepopulation.

HOWTOIMPROVEYOURHEDISSCORE:• UsecompleteandaccurateValueSetCodes.• Timelysubmitclaimsandencounterdata.• Excludeclaims/encounterswithmorethanonediagnosiscodeandEDvisitsorobservationvisitsthat

resultinaninpatientstay.• DonotprescribeanantibioticforaURIdiagnosisonly.• IfprescribinganantibioticforachildwithaURI—whoalsohasanadditionaldiagnosisotherthan

Pharyngitis—besuretodocumenttheproperdiagnosiscodeontheclaim.Thiswillensurethatthememberisremovedfromthenon-compliantlist(duetohavingmorethan1diagnosisontheclaimotherthanPharyngitis)andyouwon’tbeinappropriatelycountedasprescribinganantibioticforURI.

• Documentallelementsoftheexamincludingdiagnosis,patientcounseling,andcomfortmeasures.• Educatepatientoncomfortmeasures(e.g.acetaminophenforfever,rest,extrafluids)andadvise

parenttocallbackifsymptomsworsen(antibioticcanbeprescribedifnecessaryafter3daysofinitialdiagnosis).

• Useappropriatetestingandsymptomdocumentationtojustifyantibioticuse.

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• Havea“ViralURICare”(http://www.cdc.gov/getsmart/campaign-materials/pediatric-treatment.html)

brochureinyourofficewaitingroomandexamroomstohelpwithtalkingpoints. • Educatepatientsonthedifferencebetweenbacterialandviralinfections;educateyourpatientsand

caregiversthatmostURIs,alsoknownasthecommoncold,arecausedbyvirusesthatrequirenoantibiotictreatment.

• Asthepatient’sprimarycarephysician(PCP),yourpatientcountsinyourHEDISrateevenifthepatientwasseenbyyourassociate,anurgentcarecenter,orintheemergencyroom.

• Refertotheillnessasa“chestcold”orviralupperrespiratoryinfection(URI)andsuggestat-hometreatments,suchas:

o Usingover-the-countercoughmedicineandanti-inflammatorymedicine.o Drinkingextrafluidsandresting.o Usinganasalirrigationdeviceorsteamyhotshowerfornasalandsinuscongestionrelief.

• Remindpatientsthatmucusthatisyelloworgreendoesnotnecessarilyindicateabacterialinfection.• Ifthepatientorcaregiverinsistsonanantibiotic:

o Reviewtheabsenceofbacterialinfectionsymptomswiththepatientandcaregiverandeducatethatantibioticswillnothelpwithviralinfections.

o Discussthesideeffectsoftakingantibiotics.o Arrangeforanearlyfollow-upvisit,eitherbyaphonecallorre-examination.

CodesusedtoidentifyUpperRespiratoryInfection(URI)Description ICD-10-CM HCPCS

URI J00(Acutenasopharyngitis),J06.0(Acutelaryngopharyngitis),J06.9(AcuteURI)

Patientnotprescribedordispensedantibiotic

G8708(*Performancemet)

Patientprescribedordispensedantibiotic

G8710(*Performancenotmet)

Codesusedtoidentifyvisits

TYPE CPT HCPCS

OUTPATIENT

99201-99205,99211-99215,99241-99245,99341-99345,99347-99350,99381-99387,99391-99397,99401-99404,99411,99412,99420,99429,99455,99456

G0402,G0438,G0439,G0463,T1015

OBSERVATION 99217-99220 ED 99281-99285

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Codesusedtoidentifyexclusions

Exclusion ICD-10-CM HCPCSPharyngitis,streptococcaltonsillitis,oracutetonsillitis(competingdiagnosis)

J02.0,J02.8,J02.9,J03.00,J03.01,J03.80,J03.81,J03.90,J03.91

Acutesinusitis(competingdiagnosis) J01.80,J01.90

Chronicsinusitis(competingdiagnosis) J32.8,J32.9

Otitismedia(competingdiagnosis) H66.009,H66.019,H67.9

Pneumonia(competingdiagnosis) J13-J18

MEDICALDIAGNOSISEXCLUSION(Patientprescribedordispensedantibioticfordocumentedmedicalreason(s))

G8709

HospiceServices G9702

Table1