Improve HEDIS® Rates

for the Annual Children &

Adolescent Wellness

Measures

HEDIS® Measures

• HEDIS® is a widely used set of standardized

performance measures, which are developed

and maintained by the National Committee for

Quality Assurance (NCQA), and utilized by more

than 90 percent of America's health plans to

measure performance on quality of care and

service indicators.

Low Performing Measure

• Gold Coast Health Plan’s (GCHP) HEDIS® 2012 & 2013

measurement year rates for the following two children

and adolescent wellness measures fell below NCQA’s

25th percentile and the Department of Healthcare

Services (DHCS) Minimum Performance Level (MPL):

Well-Child Visits in the 3rd, 4th, 5th & 6th Years of

Life (W34)

Weigh Assessment & Counseling for Nutrition and

Physical Activity in Children & Adolescents (WCC)

2012 & 2013 HEDIS® Rates

Measure 2012 Rate 2012 MPL 2013 Rate 2013 MPL

W34 61.80 65.51 64.23 67.40

WCC: BMI 42.09 29.20 43.80 37.96

WCC: Nutrition 42.09 42.82 43.31 47.45

WCC: Physical Activity 30.41 61.63 28.71 34.55

W34 = Well-Child Visit in the 3rd, 4th, 5th, and 6th Years of Live WCC = Counseling for Nutrition & Physical Activity in Children & Adolescents MPL = Minimum Performance Level (25th Percentile) Rates in Red < MPL/25th Percentile

HEDIS® Definitions for

the WCC & W34 Measures

Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life (W34)

• This measure evaluates the percentage of members, 3-6 years of

age, who had one or more well-child visits with a PCP during the

measurement year and the provider of care assessed and

documented ALL of the following:

► Health and developmental history

► Physical Exam

► Health education and anticipatory guidance

• One rate reported

• Data audited to identify compliance with measure:

► Claims and encounter data

► Medical records

Codes to Identify W34

Description ICD-9-CM

Diagnosis

CPT HCPCS

Routine Child Health Exam V20.2

Routine Medical Exam V70.0

Medical Exam, NEC V70.3

Health Exam, Group Survey V70.5

Health Exam, Pop. Survey V70.6

General Medical Exam, NEC V70.8

General Medical Exam, NOS V70.9

Annual Wellness Visit G0438, G0439

Office Visit 99381-99385, 99391-99395, 99461

Weight Assessment & Counseling for

Nutrition & Physical Activity in Children & Adolescents (WCC)

• This measure evaluates the percentage of members, 3-17 years of age, who had an outpatient visit with a PCP or OB/GYN and who received ALL of the following three services during the measurement year. ► BMI percentile (ages 3-15) or BMI value (ages 16-17)

► Counseling for nutrition

► Counseling for physical activity

• Three separate rates are reported for each service.

• Data reviewed to identify compliance with measure: ► Claims and encounter data

► Medical records

Codes to Identify WCC

Description ICD-9-CM

Diagnosis

CPT HCPCS UB Revenue

Body Mass Index, Pediatric V85.5

BMI Percentile, Pediatric <5% V85.51

BMI Percentile, Pediatric 5% to

<80%

V85.52

BMI Percentile, Pediatric 85% to

<95%

V85.53

BMI Percentile, Pediatric ≥ 95% V85.54

Counseling for Nutrition V65.3 97802-97804 G0270-G0271,

G0447, S9449,

S9452, S9470

Counseling for Physical Activity V65.41 G0447, S9451

Outpatient Visits 99201-99205, 99211- 99215,

99241-99245, 99341-99345,

99347-99350, 99381-99387,

99391-99397, 99401-99404,

99411-99412, 99420, 99429,

99455-99456

G0402, G4038,

G4039

0510-0523,

0526-0529,

0982-0983

How to Improve HEDIS®

Rates for the

Annual Children &

Adolescent Wellness Measures

Improve HEDIS® Rates GCHP Practitioners can improve their HEDIS® rates for these two measures by:

1. Scheduling patients for their annual children and adolescent wellness exams.

2. Recording the appropriate clinical documentation in the medical records.

Assess children aged 3-6 years of age for all of the following:

►Health and developmental history

►Physical Exam

►Health education and anticipatory guidance

Assess children and adolescents aged 3-17 years of age for all of the following:

►BMI percentile (ages 3-15) or BMI value (ages 16-17)

►Counseling for nutrition

►Counseling for physical activity

3. Timely submission of claims and encounter data with the appropriate billing codes.

HEDIS® Questions?

Please email any HEDIS® questions to

hedis@goldchp.org