hedis 2017-18 reference guide - mclaren health care · 2017-05-12 · hedis 2017 is comprised of 91...

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HEDIS 2017-18 Reference Guide

The Healthcare Effectiveness Data and Information Set (HEDIS®) is the most widely

used set of performance measures in the managed care industry. HEDIS measures

are used for reporting and improving the quality of care provided to patients.

Please use this reference guide to code the quality care that you continue to

provide to your patients.

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Table of ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Annual HEDIS Chart Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Key Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Preventive Care (Adult) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Adult BMI (ABA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Care for Older Adults (COA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Preventive Care (Pediatric) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) . . . . . . . . . . . . . .8

Well-Care Visits (W15, W34) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Adolescent Well-Care Visits (AWC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Children’s Access to a PCP (CAP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Lead Screening Children (LSC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Cancer Screening (Adult) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Breast Cancer (BCS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Cervical Cancer (CCS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Colorectal Cancer (COL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Diabetes Care (Adult) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Diabetes (CDC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

A1C Testing and Control (CDC-HbA1C) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Blood Pressure Control (CBP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Eye Exams (CDC-Eye) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Nephropathy Screening (CDC-Nephro) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Immunizations (Pediatric) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Adolescent Immunizations (IMA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Childhood Immunization Status (CIS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Musculoskeletal (Adult) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

DMARD Therapy for Rheumatoid Arthritis (ART) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Osteoporosis Management in Women Who Had a Fracture (OMW) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Behavioral Health (Adult and Pediatric) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Antidepressant Medication Management (AMM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Follow-Up Care for Children Prescribed ADHD Medication (ADD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Reproductive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Chlamydia Screening in Women (CHL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Frequency of Ongoing Prenatal Care (FPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Prenatal and Postpartum Care (PPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Respiratory (Pediatric and Adult) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Pharmacotherapy Management for COPD Exacerbation (PCE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Use of Spirometry Testing in the Assessment and Diagnosis of Chronic Obstructive Pulmonary Disease (COPD) (SPR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Medication Management for People with Asthma (MMA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Appropriate Testing for Children with Pharyngitis (CWP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Appropriate Treatment for Children with Upper Respiratory Infection (URI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Medication Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Medication Reconciliation Post Discharge (MRP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

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Introduction

You already provide excellent care . However, without the correct data, your performance may not be measured accurately .

The Healthcare Effectiveness Data and Information Set (HEDIS®) is the most widely used set of performance measures in the

managed care industry . HEDIS measures are used for reporting and improving the quality of care provided to patients .

HEDIS is maintained by the National Committee for Quality Assurance (NCQA) . The measure set is updated on an annual basis

in adherence with best practices . HEDIS 2017 is comprised of 91 measures across 7 domains of care . HAP uses key measures

from this set to assess quality throughout the provider community . Providing excellent care and needed services is only half

of the performance measurement equation . Without the appropriate data these measures cannot be calculated accurately .

There are three ways to ensure that HAP receives the necessary data for measurement:

• Medical and Pharmacy Claims

– This is the primary source for identifying which members belong to which populations . This guide provides

information on the diagnosis and procedure codes required to meet measure guidelines .

• Electronic Data Sources

– Some information isn’t available through billed claims . Electronic Medical Records, and sources like state registries,

are the next most important component of measurement and help to fill these gaps in information . These sources

could include valuable information such as lab and vital sign results . HAP incentivizes provider organizations to

provide this data . This guide provides specifications for the data that is shared between us . HAP also collects

information from the following sources:

• Joint Venture Hospital Laboratories (JVHL) offers lab services for many of HAP’s affiliated providers . The

results of these lab services are sent to HAP .

• Michigan Care Improvement Registry (MCIR) is a statewide registry for collecting information on immunizations

for all children and adolescents . Payers and Providers can query MCIR for services that are due .

• Chart Collection allows HAP to collect information which may not be in any of the above sources . This takes place in

two different phases:

– Ongoing Supplemental Chart Collection: Throughout the year, HAP collects medical records for information that

may still not be available via EMR feeds or medical claims . The primary focus of this initiative is to collect cancer

screenings and exclusions to measures, where the service dates may predate EMR implementation .

– Annual Hybrid Chart Review: Many measures are difficult to collect all of the information needed, even after

all of the above sources are exhausted . A sample of the HAP population is drawn and HAP is allowed to do more

targeted medical record review . HAP may fax medical record requests, or even visit offices in person, during the

first part of the year for review of the prior year’s results . This guide provides information on the specific measures

and data elements that HAP is seeking during this review period .

Your HEDIS results are not only important to HAP for data accuracy, but to your patients as well . HAP uses HEDIS data to

determine which members are in need of screenings and to provide educational programs and materials . Your participation

in transmitting HEDIS data is vital to our mission of enhancing the health and well-being of the lives we touch . Additional

questions regarding coding and FTP connectivity can be directed to HAP’s Provider Relations department at (313) 664-8075 .

HEDIS Measures & Guide Contacts:

Michael Wilson

Manager of Performance Measurement

(313) 664 - 8614

mwilson3@hap .org

Jeff Taylor

Manager of Performance Measurement,

Improvement and Public Reporting & Analytics

(810) 733 - 8969

jetaylor@hap .org

Please note, the light gray highlighted area of the guide are HEDIS measures that require a medical record

review. This area includes specific resources, common chart deficiencies to improve your HEDIS scores.

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Annual HEDIS Chart Review

Why chart reviews?

Many of the performance measures found in this guide are collected using administrative data from health care service

claims . However, there are many measures that must also be supplemented with hybrid data through the abstraction or

review of medical records .

We thank you and your office staff for your support and cooperation in the success of this endeavor .

When does this occur?

January–May of each year .

What measures are reviewed?

In the following pages, each measure will be listed along with descriptions of what type of information is being reviewed .

Why the January–May timeline?

This is a non-negotiable timeframe set by NCQA .

What is the process?

HAP contracts with a vendor to conduct the medical record reviews on its behalf . HAP provides a random sample of physician

offices to the vendor, who will then schedule and conduct the medical record reviews .

The vendor will:

• Contact each physician office directly to schedule an onsite review of selected member medical records or to request

that a record be faxed back

• Scan or copy records for data validation

• Provide all of the medical record data collected to HAP

HAP will:

• Work closely with the vendor to ensure that it conducts all reviews in accordance with HIPAA and HAP’s

confidentiality standards

What about HIPAA?

The HIPAA Privacy Rule allows HAP and its contracted vendors to review and collect this information without member

consent, as it pertains to treatment, payment and health care operations .

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Key Measures

Preventive Care (Adult)

Adult BMI (ABA)

Members between 18 and 74 years old who had an outpatient visit and whose body mass index (BMI) was documented

during the measurement year or the year prior .

Codes to identify BMI:

Description ICD-10-CM

BMI less than 19 Z68 .1

BMI between 20-29 .9 Z68 .20-Z68 .29

BMI between 30-39 .9 Z68 .30-Z68 .39

BMI between 40-49 .9 Z68 .41, Z68 .42

BMI between 50-59 .9 Z68 .43

BMI between 60-69 .9 Z68 .44

BMI 70 or greater Z68 .45

BMI Percentile Z68 .5-Z68 .54

Dated documentation (annually) of height, weight and BMI percentile for adults age 18-19

Dated documentation (annually) of weight and BMI value for adults age 20-74

Common Chart Deficiencies:

• Height and/or weight are documented but there is no calculation of BMI value, the BMI percentile or plotted

on an age growth chart

• A range was given or threshold to be met . Each patient must have a distinct BMI value, percentage or plotted

on an age growth chart

Care for Older Adults (COA)

Members 66 years and older who had each of the following during the measurement year:

• Advance Care Planning

• Medication Review

• Functional Status Assessment and

• Pain Assessment

Codes to Identify Care for Older Adults:

CPT/HCPCS

90863, 99497, 99605, 99606, 1125F, 1126F, 1157F, 1158F, 1159F, 1160F, 1170F, S0257, G8427

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Dated documentation of:

• Advance care planning includes a discussion about preferences for resuscitation, life sustaining treatment

and end of life care . Examples include:

– Advance directives

– Actionable medical orders

– Documentation of care planning discussion

– Living Will

– Surrogate decision maker

– Notation that member has previously executed an Advance Care Plan

• Medication review includes at least one (1) medication review with:

– Presence of a medication list and date the review was performed or

– Dated notation that the member is not taking any medication

• Functional status assessment-one (1) of following:

– Notation that ADLs were assessed, or at least five of the following were assessed: bathing, dressing,

eating, transferring, using toilet, walking

– Notation that IADLs were assessed, or at least four of the following were assessed: shopping for groceries,

driving or using public transportation, using the telephone, meal preparation, housework, home repair,

laundry, taking medications, handling finances

– Results of assessment using a standardized functional assessment tool (SF-36, Bayer ADL Scale, Barthel

Index, etc .)

– Notation that 3 out of 4 were assessed (Cognitive or ambulation status, Hearing vision and speech,

exercise, or ability to perform a job)

• Pain Assessment-one (1) of following:

– Notation that patient was assessed for pain

– Results of assessment using a standardized pain assessment tool (Numeric rating scales, FLACC scale,

verbal descriptor scales, pain thermometer, etc .)

Tips:

• Asking a member if an Advance Care Plan is in place and member stating it is not in place is

not sufficient

• Medication review must be by a prescribing practitioner and/or pharmacist

• Review of a side effects for a single medication at time of prescription does not meet criteria

• Functional status assessment limited to an acute or single condition, event or body system does not meet

criteria

• Notation of pain management plan alone does not meet criteria

• Notation of pain treatment plan alone does not meet criteria

• Notation of screening of chest pain alone or documentation of chest pain does not meet criteria .

• Should be done annually

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Preventive Care (Pediatric)Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

Members between 3 and 17 years old who had an outpatient visit with a primary care physician or OB/GYN and who had

annual evidence of these:

• Body mass index (BMI) percentile plotted on an age growth chart

• Counseling for nutrition

• Counseling for physical activity

Codes to identify BMI Assessment and Counseling Type:

Description CPT/HCPCS ICD-10-CM

BMI Percentile Z68 .51-Z68 .54

Counseling for Nutrition97802-97804, G0270, G0271, G0447, S9470, S9452, S9449

Z71 .3

Counseling for Physical Activity S9451, G0447 Z02 .5

Weight Assessment for Children and Adolescents

Dated documentation (annually) of height, weight and BMI percentile. Either of these meets criteria for BMI

percentile:

• Weight and BMI as a percentile (no approximations)

• BMI percentile plotted on an Age Growth Chart


• BMI documented as value (number) not as percentile

• BMI growth charts not submitted

Documentation of Counseling for Nutrition for Children/Adolescents

Dated documentation (annually) of any of these:

• Current nutrition behaviors, including:

– Fruit and vegetable consumption

– Portion sizes

– Breakfast habits

• Checklist indicating that nutrition education was addressed

• Counseling or referral for nutrition education

• Handouts on nutrition given to patient during a face-to-face visit

• Anticipatory guidance for nutrition

• Weight or obesity counseling


• Anticipatory guidance does not always address nutrition and physical activity

• Developmental milestones are not acceptable

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Documentation of Counseling for Physical Activity for Children and Adolescents

Dated documentation (annually) of any of these:

• Current physical activity behaviors, including:

– Exercise routine

– Exam for sports activity

– Participation in sports

• Checklist indicating that physical activity was addressed

• Counseling or referral for physical activity

• Handouts on physical activity given to patient during a face-to-face visit

• Anticipatory guidance for physical activity

• Weight or obesity counseling


• Anticipatory guidance does not always address nutrition and physical activity

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Well-Child and Adolescent Well-Care Visits (W15, W34)

Well Child Visits are measures across three different age groups:

• Six or more visits within first 15 months

• Members between 3 and 6 years old once annually

A well-child visit includes a health and developmental history (physical and mental), a physical exam, and health education

and anticipatory guidance

Codes to identify Adolescent Well Care Visits:

CPT/HCPCS ICD-10-CM

99381-99385, 99391-99395, 99461, G0438, G0439 Z00 .00, Z00 .01, Z00 .110, Z00 .111, Z00 .121, Z00 .129, Z00 .5, Z00 .8, Z02 .0, Z02 .1-Z02 .6, Z02 .71, Z02 .79, Z02 .81, Z02 .82, Z02 .83, Z02 .89, Z02 .9

Well-Child Visits in the First 15 Months of Life

Dated documentation of well-care visits including:

• Health history

• Developmental history physical

• Developmental history mental

• Physical exam

• Health education/anticipatory guidance


• Lack of documentation of required elements

• Adolescents being seen for sick visits and the required elements are not addressed

Tips:

• Preventive services may be rendered on visits other than well-care visits .

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life


• Health history



• Physical exam





Tips:

• Preventive services may be rendered on visits other than well-care visits .

11

Well-Care Visits Adolescent


• Health history



• Physical exam





Tips:

• Preventive services may be rendered on visits other than well-care visits

• Should be done annually

12

Adolescent Well-Care Visits 12—21 years (AWC)

Members between 12 and 21 years old should receive at least one annual well-child visit with a primary care physician or an

OB/GYN annually . A well-care visit includes a health and developmental history (physical and mental), a physical exam, and

health education and anticipatory guidance .

Codes to identify Adolescent Well-Child Visits:

CPT/ HCPCS ICD-10-CM

99381-99385, 99391-99395, 99461, G0438, G0439 Z00 .00, Z00 .01, Z00 .110, Z00 .111, Z00 .121, Z00 .129, Z00 .5, Z00 .8, Z02 .0, Z02 .01, Z02 .1-Z02 .6, Z02 .9, Z02 .71, Z02 .79, Z02 .81-Z02 .83, Z02 .89, Z02 .9

Children’s Access to a PCP (7—11 years) — (CAP)

Members between 7 and 11 years old who had a visit with a primary care physician at least once in the last two years .

Codes to identify Ambulatory or Preventive Care Visits:

Description CPT/ HCPCS ICD-10-CM

Outpatient services 99201-99205, 99211-99215, 99241-99245

Home services 99341-99345, 99347-99350

Preventive Medicine99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, G0438, G0439

General Medical Examination

Z00 .00, Z00 .01, Z00 .110, Z00 .111, Z00 .121, Z00 .129, Z00 .5, Z00 .8, Z02 .0, Z02 .01, Z02 .1-Z02 .6, Z02 .9, Z02 .71, Z02 .79, Z02 .81-Z02 .83, Z02 .89, Z02 .9

Lead Screening Children (LSC)

Children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning on or before their second

birthday

Codes to identify Lead Screening in Children:

CPT

83655

Documentation in the medical chart must include a notation indicating the date the test was performed of one or more

capillary or venous lead blood test for lead poisoning by their second birthday, with results and finding .


• Tests ordered but not done

• Lab results not found

Tips:

• Lead assessment does not constitute a lead screening

13

Cancer Screening (Adult)Breast Cancer (BCS)

Women between 50 and 74 years old should receive a mammogram at least once every two years . Patients will be excluded

with proof of either of these at any time during their history:

• Bilateral mastectomy

• Unilateral mastectomy with a bilateral modifier . Codes must be on the same claim .

• Two unilateral mastectomies on different dates of service

Codes to identify Breast Cancer Screening:

CPT/ HCPCS UB Revenue

77055-77057, G0202, G0204, G0206 0401, 0403

Cervical Cancer (CCS)

Women between 21 and 29 years of age should have a Pap test to screen for cervical cancer every three years . Women

between 30 and 64 years of age should have a Pap test to screen for cervical cancer every three years or should have Pap test

with HPV co-testing every five years .

Patients will be excluded with proof of hysterectomy with no residual cervix during their history .

Codes to identify Cervical Cancer Screening:

CPT HCPCS

88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175

G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091

Exclusion to measure at any time during the measurement year:

• Hysterectomy with no residual cervix

Dated documentation of cervical cancer screening with result, including either:

• Cervical Cytology (every 3 years)

• Cervical Cytology and HPV test on same date of service (every 5 years)


• Pap Smear test results not found in PCP charts

• Pap and HPV testing not done on same day (waiting until positive Pap)

• Incomplete documentation related to hysterectomy

Tips:

• Specify if cervix was removed

• Test Pap and HPV on the same day

14

Colorectal Cancer (COL)

Members between 50 and 75 years old should be screened for colorectal cancer via one or more of these methods:

• Annual fecal occult blood test (FOBT)

• Flexible sigmoidoscopy every five years

• Colonoscopy every ten years

• CT Colonography (Virtual Colonoscopy) during the measurement year or the four years prior to the measurement year .

• FIT-DNA test (Cologuard) during the measurement year or the two years prior to the measurement year .

Patients will be excluded with proof of either of these at any time during their history:

• Colorectal cancer

• Total Colectomy

Codes to identify Colorectal Cancer Screening:

Description CPT/HCPCS

FOBT 82770, 82274, G0328

Flexible sigmoidoscopy 45330-45335, 45337-45342, 45345-45350, G0104

Colonoscopy44388-44394, 44397, 44401-44408, 45355, 45378-45393, 45398, G0105, G0121

CT Colonography 74263

FIT-DNA G0464

Dated documentation of colorectal screening with result, including either:

• Colonoscopy (every 10 years)

• Sigmoidoscopy (every 5 years)

• CT Colonography — Virtual Colonoscopy (every 5 years)

• FIT — DNA — Cologuard (every 3 years)

• Annual Fecal Blood Testing in a lab (gFOBT) (iFOBT)(FIT)

• Personal history of colorectal cancer or evidence of total colectomy


• Not documenting colorectal screenings in the health history

• Not documenting history of colorectal cancer or total colectomy

• Not providing the health history with the note and/or test results

• FOBT test performed in an office setting or performed during a digital rectal exam do not meet criteria

15

Diabetes Care (Adult)

Diabetes (CDC)

Members between 18 and 75 years old with diabetes (types 1 and type 2) should have each of these performed annually:

hemoglobin (HbA1c) testing, retinal eye exam, nephropathy screening and blood pressure monitoring .

Codes to identify Diabetes:


Diabetes E10, E11 , E13 , O24

HbA1c Testing and Control (CDC — HbA1c)

Diabetic members who have had HbA1c testing, and the percent of members whose latest HbA1c results were under control .

Control values are measured at 7, 8 and 9 percent .

Codes to identify HbA1c Testing and Control:

Description CPT

Testing 83036, 83037

HbA1c > 9 .0% 3046F

HbA1c 7 .0 – 9 .0% 3045F

HbA1c < 7 .0% 3044F

Note: There is no CPT Code for A1C between 7 and 8 percent . For this control measure, results must be received from JVHL or

an EMR Feed

Blood Pressure Control (CBP)

Diabetic members whose latest BP values were < 140/90

Description CPT

Diastolic < 80 3078F

Diastolic 80 – 89 3079F

Diastolic >= 90 3080F

Systolic < 130 3074F

Systolic 130 – 139 3075F

Systolic >= 140 3077F

Require both to be present in the patient’s record:

• Documented diagnosis of high blood pressure in the office note, problem list section or history section, prior

to 6/30/2016

• Dated documentation of date of blood pressure readings with the results from each visit


• Repeat BP reading not documented in chart

• Diagnosis date of hypertension is not clearly documented

Tips:

• Notation of hypertension should be documented in every visit

16

Eye Exams (CDC-Eye)

Diabetic members who have received a screening for diabetic retinal disease . The following codes can be billed by a PCP, if the

images are read by an Eye Care Professional:

Codes to Identify CDC- Eye Exams:

CPT/HCPCS

2022F, 2024F, 2026F, 3072F*

Nephropathy Screening (CDC-Nephro)

The percent of diabetic members who have had nephropathy screening, or evidence of nephropathy, in the past year .

Codes to Identify CDC - Nephropathy:


Urine Protein Tests3060F, 3061F, 3062F, 81000, 81001, 81002, 81003, 81005, 82042, 82043, 82044, 84156

Treatment for nephropathy

36147, 36800, 36810, 36815, 36818-36821, 36831-36833, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512, G0257, S9339, Z91 .15, Z99 .2

E08 .21, E08 .22, E08 .29, E09 .21, E09 .22, E09 .29, E10 .21, E10 .22, E10 .29, E11 .21, E11 .22, E11 .29, E13 .21, E13 .22, E13 .29, I12 .0, I12 .9, I13 .0, I13 .10, I13 .11, I13 .2, I15 .0, I15 .1, N00 .0-N00 .9, N01 .0-N01 .9, N02 .0-N02 .9, N03 .0-N03 .9, N04 .0-N04 .9, N05 .0-N05 .9, N06 .0-N06 .9, N07 .0-N07 .9, N08 .0, N14 .0-N14 .4, N17 .0-N17 .9, N18 .1-N18 .9, N19, N25 .0, N25 .1, N25 .81, N25 .89, N25 .9, N26 .1, N26 .2, N26 .9, Q60 .0-Q60 .6, Q61 .00-Q61 .02, Q61 .11, Q61 .19, Q61 .2-Q61 .5, Q61 .8, Q61 .9, R80 .0-R80 .3, R80 .8, R80 .9

* CPT Category II code 3072F can only be used if the claim or encounter was during the measurement year because it indicates the member had “no evidence of retinopathy in the prior year .” Additionally, because the code definition itself indicates results were negative, an automated result is not required .

17

Description Prescriptions

Angiotensin converting enzyme inhibitors

• Benazepril

• Captopril

• Enalapril

• Fosinopril

• Lisinopril

• Moexipril

• Perindopril

• Quinapril

• Ramipril

• Trandolapril

Angiotensin II inhibitors

• Azilsartan

• Candesartan

• Eprosartan

• Irbesartan

• Losartan

• Olmesartan

• Telmisartan

• Valsartan

Antihypertensive combinations

• Aliskiren-valsartan

• Amlodipine-benazepril

• Amlodipine-hydrochlorothiazide-valsartan

• Amlodipine-hydrochlorothiazide-olmesartan

• Amlodipine-olmesartan

• Amlodipine-telmisartan

• Amlodipine-valsartan

• Azilsartan-chlorthalidone

• Benazepril-hydrochlorothiazide

• Candesartan-hydrochlorothiazide

• Captopril-hydrochlorothiazide

• Enalapril-hydrochlorothiazide

• Eprosartan-hydrochlorothiazide

• Fosinopril-hydrochlorothiazide

• Hydrochlorothiazide-irbesartan

• Hydrochlorothiazide-lisinopril

• Hydrochlorothiazide-losartan

• Hydrochlorothiazide-moexipril

• Hydrochlorothiazide-olmesartan

• Hydrochlorothiazide-quinapril

• Hydrochlorothiazide-telmisartan

• Hydrochlorothiazide-valsartan

• Trandolapril-verapamil

Annual documentation of each of the following, with results:

• HbA1c Testing

• Blood Pressure

• Nephropathy Screening

• Eye exam


• Tests ordered but not done

• Lab results not found

• Consult reports not found

• Repeat BP reading not documented in chart

18

Immunizations (Pediatric)Adolescent Immunizations (IMA)

Children should receive the following immunizations prior to their 13th birthday:

One dose of meningococcal vaccine

One tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus

Three doses of human papillomavirus (HPV)

Codes to identify Adolescent Immunizations:

Immunization CPT Code

Meningococcal 90644, 90734

Tdap 90715

Td 90714, 90718

Tetanus 90703

Diphtheria 90719

HPV 90649, 90650, 90651

Documentation of these immunizations that must be given by age 13:

• One Meningococcal

• One Tdap/Td

• Three HPV


• Immunizations received after specified timeframes or after 13th birthday

• PCP charts do not contain immunization records if received at Health Department or school

• No documentation of allergies or contraindications

Tips:

• Documentation of parental refusal

• Documentation of contraindications or allergies

• If vaccines are obtained at a different location, please include a copy in the chart

19

Childhood Immunization Status (CIS)

Children should receive four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and

rubella (MMR); three H influenza type B (HiB); three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate

(PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday .

Codes to identify Childhood Immunization Status:

Immunization CPT/HCPCS

DTaP 90698, 90700, 90721, 90723

HiB 90644, 90645, 90646, 90647, 90648, 90698, 90721, 90748, 90721, 90748

Hepatitis A 90633

Hepatitis B 90723, 90740, 90744, 90747, 90748, G0010

Polio (IPV) 90698, 90713, 90723

Influenza 90655, 90657, 90661, 90662, 90673, 90685,90687, G0008

Measles 90705

Measles, Mumps and Rubella (MMR) 90707, 90710

Measles/Rubella 90708

Mumps 90704

Pneumococcal Conjugate 90669, 90670, G0009

Rotavirus Vaccine (2 Dose Schedule) Administered 90681

Rotavirus Vaccine (3 Dose Schedule) Administered 90680

Rubella 90706

Varicella Zoster (VZV) 90710, 90716

Documentation of the following immunizations that must be given by age 2:

• Four diphtheria, tetanus and acellular pertussis (DTaP)*

• Three polio (IPV)*

• One measles, mumps and rubella (MMR)

• Three H influenza type B (HiB)*

• Three hepatitis B (HepB)

• One chicken pox (VZV)

• Four pneumococcal conjugate (PCV)*

• One hepatitis A (HepA)

• Two or three rotavirus (RV)*

• Two influenza (Flu)**


• Immunizations received after the 2nd birthday

• PCP charts do not contain immunization records if

received at Health Department or school

• PCP charts do not contain immunization records

given in the hospital at birth

• No documentation of allergies or

contraindications

Tips:

If missing any immunization please include:

• Documentation of parental refusal

• Documentation of request for delayed

immunization schedules

• Immunizations given at health departments

• Immunizations given in the hospital at birth

• Documentation of contraindications or allergies

• If vaccines are obtained at a different location,

please include a copy in the chart

*These vaccinations cannot be administered prior to 42 days after birth . **Influenza must be administered at least 180 days after birth .

20

Musculoskeletal (Adult)DMARD Therapy for Rheumatoid Arthritis (ART)

Members aged 18 or older, who were diagnosed with rheumatoid arthritis and were dispensed at least one medication for a

disease-modifying anti-rheumatic drug (DMARD) .

Codes to identify DMARD Therapy for Rheumatoid Arthritis:

CPT/HCPCS

J0129, J0135, J0717, J1438, J1600, J1602, J1745, J3262, J7502, J7515-J7518, J9250, J9260, J9310

Table to identify DMARD Therapy for Rheumatoid Arthritis:

Description Prescription

5-Aminosalicylates • Sulfasalazine

Alkylating agents • Cyclophosphamide

Aminoquinolines • Hydroxychloroquine

Anti-rheumatics

• Auranofin

• Leflunomide

• Penicillamine

• Gold sodium-thiomalate

• Methotrexate

Immunomodulators

• Abatacept

• Adalimumab

• Anakinra

• Certolizumab

• Certolizumab pegol

• Etanercept

• Golimumab

• Infliximab

• Rituximab

• Tocilizumab

Immunosuppressive agents

• Azathioprine

• Cyclosporine

• Mycophenolate

Janus kinase (JAK) inhibitor • Tofacitinib

Tetracyclines • Minocycline

Codes to identify Rheumatoid Arthritis:


Rheumatoid arthritis M05 . M06 .

Codes to identify Visit Type:

Description CPT UB Revenue ICD-10-CM

Outpatient*

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

0510-0517, 0519-0523, 0526-0529, 0982-0983

*Outpatient visit with any diagnosis of rheumatoid arthritis

21

Osteoporosis Management in Women Who Had a Fracture (OMW)

Women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or a prescription for

a drug to treat or prevent osteoporosis in the six months after the fracture .

Special attention should be taken not to submit claims with acute fracture diagnoses for old (healed) fractures . This will

ensure that the appropriate population is selected and the reported rate is accurate .

ICD-10-CM provides specific codes to capture a history of a fracture that is now healed . They can be located under the

following term and subterms in the ICD-10-CM Alphabetic Index:

History

• Personal (of)

• Fracture (healed)

• There are multiple code choices based on the documented cause of the healed fracture such as osteoporosis,

traumatic, stress, etc .

For current, acute fractures that are receiving active treatment or are still in the healing stages and receiving subsequent

treatment, ICD-10 provides specific codes to capture details of the fracture including the type and location of the injury,

encounter, stage of healing, and any complications . All codes assigned must be supported by the provider’s documentation in

the medical record . Please refer to the ICD-10-CM Official Guidelines for Coding and Reporting for further instructions .

Osteoporosis Therapies:


Biphosphonates

• Alendronate

• Alendronate-cholecalciferol

• Calcium Carbonate-risedronate

• Ibandronate

• Risedronate

• Zoledronic acid

Estrogens

• Conjugated estrogens

• Conjugated estrogens synthetic

• Esterified estrogens

• Estradiol

• Estradiol acetate

• Estradiol cypionate

• Estradiol valerate

• Estropipate

Other agents

• Calcitonin

• Denosumab

• Raloxifene

• Teriparatide

Sex hormone combinations

• Conjugated estrogens-medroxy-progesterone

• Estradiol-levonorgestrel

• Estradiol-norethindrone

• Estradiol-norgestimate

• Ethinyl estradiol-norethindrone

22

Codes to identify Bone Mineral Density Test:

CPT/ HCPCS ICD-10-PCS

76977, 77078, 77080-77082, 77085, 77086, G0130BP48ZZ1, BP49ZZ1, BP4GZZ1, BP4LZZ1, BP4MZZ1, BP4NZZ1, BP4PZZ1, BQ00ZZ1, BQ01ZZ1, BQ03ZZ1, BQ04ZZ1, BR00ZZ1, BR07ZZ1, BR09ZZ1, BR0GZZ1

Codes to identify Fracture:*

CPT/HCPCS ICD-10-PCS

21800, 21805, 21810-21813, 21820, 21825, 22305, 22310, 22318, 22319, 22520, 22521, 22523, 22524, 23500, 23505, 23515, 23570, 23575, 23585, 23600, 23605, 23615, 23616, 23620, 23625, 23630, 23665, 23670, 23675, 23680, 24500, 24505, 24515, 24516, 24530, 24535, 24538, 24545, 24546, 24560, 24565, 24566, 24575, 24576, 24577, 24579, 24582, 24620, 24635, 24650, 24655, 24665, 24666, 24670, 24675, 24685, 25500, 25505, 25515, 25520, 25525, 25526, 25530, 25535, 25545, 25560, 25565, 25574, 25575, 25600, 25605, 25606, 25607, 25608, 25609, 25622, 25624, 25628, 25630, 25635, 25645, 25650, 25651, 25652, 25680, 25685, 26600, 26605, 26607, 26608, 26615, 27193, 27194, 27200, 27202, 27215, 27216, 27217, 27218, 27220, 27222, 27226, 27227, 27228, 27230, 27232, 27235, 27236, 27238, 27240, 27244, 27246, 27248, 27254, 27267-27269, 27500, 27503, 27506-27511, 27513, 27514, 27520, 27524, 27530, 27532, 27535, 27536, 27538, 27540, 27750, 27752, 27756, 27758 -27760, 27762, 27766-27769, 27780, 27781, 27784, 27786, 27788, 27792, 27808, 27810, 27814, 27816, 27818, 27822-27828, 28400, 28405, 28406, 28415, 28420, 28430, 28435, 28436, 28445, 28450, 28455, 28456, 28465, 28470, 28475, 28476, 28485, 29850, 29851, 29855, 29856, S2360

M48 .4, M84 .3, S12 . S22 . S32, S42, S49, S52, S59, S62, S72, S79, S82, S89 .S92

Codes to identify Osteoporosis Visit Type:

Description CPT UB Revenue

Outpatient

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

0510-0517, 0519-0523, 0526-0529, 0982-0983

Non — acute inpatient 99304-99310, 99315, 99316, 99318, 99324 -99328, 99334-99337

0118, 0128, 0138, 0148, 0158, 0190-0194, 0199, 0524, 0525, 0550-0552, 0559-0663, 0669

Acute inpatient

99221-99223, 99231-99233, 99238, 99239, 99251-99255, 99291

0100, 0101, 0110-0114, 0119-0124, 0129-0134, 0139-0144, 0149-0154, 0159, 0160, 0164, 0167, 0169, 0200-0204, 0206-0214, 0219, 0720-0724, 0729, 0987

ED 99281-99285 0450-0452, 0456, 0459, 0981

*Fractures of finger, toe, face and skull are not included in this measure

23

Behavioral Health (Adult and Pediatric)

Antidepressant Medication Management (AMM)

Members 18 years and older who were treated with antidepressant medication, had a diagnosis of major depression and who

remained on an antidepressant medication treatment . Two rates are reported .

1 . Effective Acute Phase Treatment: The percentage of treated members who remained on an antidepressant

medication for at least 84 days (12 weeks)

2 . Effective Continuation Phase Treatment: The percentage of treated members who remained on an antidepressant

medication for at least 180 days (6 months)

Codes to identify Major Depression:


Major Depression F32 .0-32 .4, F32 .9, F33 .0-F33 .3, F33 .41, F33 .9

Qualifying AMM Medications:


Miscellaneous antidepressants

• Bupropion

• Vilazodon

• Vortioxetine

Phenylpiperazine antidepressants• Nefazodon

• Trazodone

Psychotherapeutic combinations

• Amitriptyline-chlordiazepoxide

• Amitriptyline-perphenazine

• Fluoxetine-Olanzapine

SNRI antidepressants

• Desvenlafaxine

• Duloxetine

• Venlafaxine

• Levomilnacipran

SSRI antidepressants

• Citalopram

• Escitalopram

• Fluoxetine

• Fluvoxamine

• Paroxetine

• Sertraline

Tetracyclic antidepressants• Maprotilin

• Mirtazapine

Tricyclic antidepressants

• Amitriptyline

• Amoxapine

• Clomipramine

• Desipramine

• Desipramine

• Imipramine

• Imipramine pamoate

• Nortriptyline

• Protriptyline

• Trimipramine

Monoamine oxidase inhibitors

• Isocarboxazid

• Phenelzine

• Selegiline

• Tranylcypromine

24

Follow-Up Care for Children Prescribed ADHD Medication (ADD)

Children between 6 and 12 years old who receive a new prescription for an ADHD medication should complete a follow-up visit

with their doctor within 30 days of filling the prescription . Children who remain on the medications for at least 10 months

should complete two additional follow-up visits . A diagnosis of ADHD is not required for inclusion in this measure .

Qualifying ADHD Medications:


CNS stimulants

• Amphetamine-dextroamphetamine

• Dexmethylphenidate

• Dextroamphetamine

• Lisdexamfetamine

• Methamphetamine

• Methylphenidate

Alpha—2receptoragonists • Clonidine

• Guanficine

Miscellaneous ADHD medications • Atomoxetine

Codes to identify Follow-Up Care for Children Prescribed ADHD Medication:

CPT HCPCS POS

90804-90815, 96150-96154, 98960-98962, 98966-98968, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99381-99384, 99391-99394, 99401-99404, 99411-99412, 99441-99443, 99510, 90791-90792, 90801-90802, 90816-90819, 90821-90824, 90826-90829, 90832-90834, 99221-99223, 99231-99233, 99238-99239,

G0155, G0176, G0177, G0409-G0411, H0002, H0004, H0031, H0034-H0037, H0039-H0040, H2000-H2001, H2010-H2020,M0064, S0201, S9480, S9484-S9485

03, 05, 07, 09, 11-15, 20, 22, 33, 49, 50, 52, 53, 71, 72

25

Reproductive Care

Chlamydia Screening in Women (CHL)

Women between 16 and 24 years old who are sexually active should have an annual chlamydia screening .

Codes to identify Chlamydia Tests:

CPT/HCPCS

87110, 87270, 87320, 87490, 87491, 87492, 87810

Frequency of Ongoing Prenatal Care (FPC)

This measure looks at the use of prenatal care services . It tracks women who had live births during the past year to determine

the percentage of recommended prenatal visits they had .

Visits should follow a schedule:

• Every 4 weeks for the first 28 weeks of pregnancy

• Every 2–3 weeks for the next 7 weeks

• Weekly thereafter until delivery

Codes to identify Frequency of Ongoing Prenatal Care:

CPT ICD-10-CM

86900, 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620, 59622

000 .0, 000 .1, 000 .2, 000 .8, 000 .9, 001 .0, 001 .1, 001 .9, 002 .0, 002 .1, 002 .81, 002 .89, 002 .9, 003 .0, 003 .1, 003 .2, 003 .30-003 .39, 003 .4, 003 .5, 003 .6, 003 .7, 003 .80-003 .89, 003 .9, 004 .5, 004 .6, 004 .7, 004 .80-004 .89, 007 .0-007 .2, 007 .30-007 .39, 007 .4, 008 .0-008 .7, 008 .81-008 .83, 008 .89, 008 .9, 10D00Z0-10D00Z2, 10D07Z3-10D07Z8, 10E0XZZ

Date and documentation of all prenatal visits

Documentation in the medical chart must include a note indicating the date when the prenatal care visit occurred

and evidence of at least one of these:

• A basic physical obstetrical exam that includes:

– Auscultation for fetal heart tone

– Pelvic exam with obstetric observations

– Measurement of fundal height (a standardized prenatal flow sheet may be used)

• Evidence that a prenatal care procedure was performed, such as:

– Screening test in the form of an obstetric panel

– TORCH antibody panel alone

– A rubella antibody test/titer with an Rh

incompatibility (ABO/Rh) blood typing

– Echography of a pregnant uterus

• Documentation of LMP or EDD in conjunction with either of the following:

– Prenatal risk assessment and counseling and

education, or

– Complete obstetrical history


• A note that testing was completed but no results in chart .

• Prenatal care not provided (patient noncompliance)

Tips:

• Information is found on the ACOG form

• ACOG recommends 14 visits for a 40 week pregnancy

26

Prenatal and Postpartum Care (PPC)

Prenatal Care

The percentage of deliveries that received a prenatal care visit in the first trimester

Documentation in the medical chart must include a note indicating the date when the prenatal care visit

occurred and evidence of at least one of these:

A basic physical obstetrical exam that includes:

• Auscultation for fetal heart tone

• Pelvic exam with obstetric observations

• Measurement of fundal height (a standardized

prenatal flow sheet may be used)

Evidence that a prenatal care procedure was performed, such as:

• Screening test in the form of an obstetric panel

• TORCH antibody panel alone

• A rubella antibody test/titer with an Rh

incompatibility (ABO/Rh) blood typing

• Echography of a pregnant uterus

Documentation of LMP or EDD in conjunction with either of the following:

• Prenatal risk assessment and counseling and

education, or

• Complete obstetrical history


• Prenatal care not done within timeframe • A note that testing was completed but no results

in chart .

Tips:

• Information is found on the ACOG form

Postpartum Care

The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery .

Prenatal and Postpartum codes can be billed as a part of a bundle of care including delivery:


Prenatal and Postpartum Care 59510, 59610, 59618, 59400

Postpartum Care 57170, 58300, 59430, 99501, 0503F, G0101 Z01 .411, Z01 .419, Z01 .42, Z30 .430, Z39 .1, Z39 .2

Prenatal Care99201-99205, 99211-99215, 99241-99245, G0463, T1015

Postpartum visit documented in the medical chart on or between 21 and 56 days after delivery. The documentation

must include a note indicating the date when a postpartum visit occurred and at least one of these:

• Pelvic exam

• Evaluation of weight, BP, breasts and abdomen

• Notation of “breastfeeding” is acceptable for the

“evaluation of breasts” component

• Notation of postpartum care, including, but not

limited to:

– Notation of “postpartum care,” “PP care,” “PP

check,” “six-week check”

– A preprinted postpartum care form in which

information was documented during the visit


• No Postpartum care visit

Tips:

• Incision check for post C-section does not constitute a postpartum visit

27

Prenatal and Postpartum codes can be billed as a part of a bundle of care including delivery:

Description CPT/HCPCS

Stand Alone Prenatal Visits 0500F, 0501F, 0502F, 99500, H1000, H1001, H1002, H1003, H1004

Other Prenatal Visits Must also include Pregnancy Diagnosis or one of the following:

99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, G0463, T1015

Obstetric Panel 80055

Prenatal Ultrasound76801, 76805, 76811, 76813, 76815, 76816, 76817, 76818, 76819, 76820, 76821, 76825, 76826, 76827, 76828

Toxoplasma, Rubella, Cytomegalovirus and Herpes Simplex Antibodies

Description

1 . Cytomegalovirus

2 . Herpes Simplex

3 . Rubella

4 . Toxoplasma

CPT/HCPCS

1 . 86644

2 . 86694, 86695, 86696

3 . 86762

4 . 86777, 86778

Rubella Antibody, with either:Description

1 . ABO

2 . Rh

CPT/HCPCS

1 . 86900

2 . 86901

Postpartum Care, if performed outside of bundled reimbursement:


Postpartum Visits 0503F, 57170, 58300, 59430, 99501, G0101 Z01 .411, Z01 .419, Z01 .42, Z30 .430, Z39 .1, Z39 .2

Cervical Cytology

88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091

28

Respiratory (Pediatric and Adult)

Pharmacotherapy Management for COPD Exacerbation (PCE)

Members aged 40 years and older who have been diagnosed with COPD exacerbations, have been discharged from acute

inpatient or ED visit on or between January 1–November 30 and were dispensed the appropriate medications .

Dispensed Systemic Corticosteroid within 14 days of discharge:


Glucocorticoids

• Betamethasone

• Dexamethasone

• Hydrocortisone

• Methylprednisolone

• Prednisolone

• Prednisone

Dispensed a bronchodilator within 30 days of discharge:


Anticholinergic agents

• Albuterol-ipratropium

• Aclidinium-bromide

• Ipratropium

• Tiotropium

• Umeclidinium

Beta 2-agonists

• Albuterol

• Arformoterol

• Budesonide-formoterol

• Fluticasone-salmeterol

• Fluticasone-vilanterol

• Formoterol

• Indacaterol

• Levalbuterol

• Mometasone-formoterol

• Metaproterenol

• Olodaterol hydrochloride

• Olodaterol-tiotropium

• Pirbuterol

• Salmeterol

• Umeclidinium-vilanterol

Methylxanthines

• Aminophylline

• Dyphylline-guaifenesin

• Guaifenesin-theophylline

• Dyphylline

• Theophylline

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Use of Spirometry Testing in the Assessment and Diagnosis of Chronic Obstructive Pulmonary Disease (COPD) (SPR)

Members 40 and older with a new diagnosis or a newly active COPD should receive appropriate spirometry testing to confirm

the diagnosis . Spirometry testing must occur at least two years prior to diagnosis date through six months after diagnosis

date .

Codes to Identify COPD:


Chronic bronchitis J41, J42

Emphysema J43

COPD J44

Codes to Identify Spirometry Testing:


Spirometry 94010, 94014—94016, 94060, 94070, 94375, 94620

Medication Management for People with Asthma (MMA)

Members between 5 and 85 years old who were identified as having persistent asthma (ICD—9 Code 493) and were dispensed

appropriate medication that they remained on during the treatment period . Persistent asthma is present if at least one of

these four criteria is met:

• At least one Emergency Department (ED) visit with asthma as the principal diagnosis, or

• At least one acute inpatient encounter with asthma as the principal diagnosis, or

• At least four outpatient asthma visits, with asthma as one of the listed diagnoses and at least two asthma medication

dispensing events, or

• At least four asthma medication dispensing events

Two rates are reported:

1 . The percentage of members who remained on an asthma controller medication for at least 50 percent of their

treatment period

2 . The percentage of members who remained on an asthma controller medication for at least 75 percent of their

treatment period

Codes to identify Asthma:


Asthma J45 .2—J45 .5, J45 .9

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Asthma Medications:


Anti-asthmatic combinations• Dyphylline-guaifenesin


Antibody inhibitor • Omalizumab

Inhaled steroid combinations

• Budesonide-formoterol

• Fluticasone-salmeterol

• Mometasone-formoterol

Inhaled corticosteroids

• Beclomethasone

• Budesonide

• Ciclesonide

• Flunisolide

• Fluticasone CFC free

• Mometasone

Leukotriene modifiers

• Montelukast

• Zafirlukast

• Zileuton

Mast cell stabilizers • Cromolyn

Methylxanthines

• Aminophylline

• Dyphylline

• Theophylline

Short-acting, inhaled beta-2 agonists

• Albuterol

• Levalbuterol

• Pirbuterol

Asthma Controller Medications:


Antiasthmatic combinations • Dyphylline-guaifenesin


Antibody inhibitor • Omalizumab

Inhaled steroid combinations

• Budesonide-Formoterol

• Fluticasone-Salmeterol

• Mometasone-Formoterol

Inhaled corticosteroids

• Beclomethasone

• Budesonide

• Ciclesonide

• Flunisolide

• Fluticasone CFC free

• Mometasone

• Triamcinolone

Leukotriene modifiers

• Montelukast

• Zafirlukast

• Zileuton

Mast cell stabilizers • Cromolyn

Methylxanthines

• Aminophylline

• Dyphylline

• Theophylline

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Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)

Members between 18 and 64 years old with a diagnosis of acute bronchitis who were not

dispensed an antibiotic prescription .

Codes to identify Acute Bronchitis:


Acute Bronchitis J20 .3-J20 .9

Codes to identify Visit Type:

Description CPT/ HCPCS UB Revenue

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

0510-0517, 0519-0523, 0526-0529, 0982-0983

ED* 99281-99285 0450-0452, 0456, 0459, 0981

Observation 99217-99220

Appropriate Testing for Children with Pharyngitis (CWP)

Children between 2 and 18 years old who are diagnosed with pharyngitis should be dispensed an antibiotic and a group A

streptococcus (strep) test .

Codes to identify Pharyngitis:


Acute Pharyngitis JO2 .8, JO2 .9

Acute Tonsillitis JO3 .90, JO3 .00, JO3 .80, JO3

Strep Sore throat JO2 .0

CPT Codes

87070, 87071, 87081, 87430, 87650—87652, 87880

Appropriate Treatment for Children with Upper Respiratory Infection (URI)

Children between 3 months and 18 years old who are diagnosed with an upper respiratory infection (URI) should not be

dispensed an antibiotic prescription until at least three days after diagnosis .

Codes to identify Appropriate Treatment for Children with Upper Respiratory Infection:


Acute Nasopharyngitis (common cold) J00

URI J06 .0, J06 .9

*Do not include ED visits that result in an inpatient admission

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Medication Management

Medication Reconciliation Post Discharge (MRP)

The percentage of discharges from January 1–December 1 of the measurement year for members 18 years of age and older for

whom medications were reconciled on or within 30 days of discharge .

Codes to identify Medication Reconciliation Post Discharge:

CPT

99495, 99496, 1111F

Documentation in the medical chart must include a notation indicating medication were reconciled the date of

discharge through 30 days after discharge:

• Medications prescribed upon discharge were reconciled with the current medication in the outpatient record

-or-

• A medication list in a discharge summary that is present in the outpatient chart and evidence of a

reconciliation with the current medications -or-

• Notation that no medications were prescribed upon discharge

Tips:

• An outpatient visit is not required, only documentation in the outpatient record that the medication was

reconciled meets criteria

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©2017 Health Alliance Plan of Michigan, A Nonprofit Company XXM 2/17 16-796 1028

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