hedis 2013 & cms star ratings- quick reference guide 1 · micro albumin, random urine...

HEDIS 2013 & CMS Star Ratings- Quick Reference Guide 1

Revised 1/9/2013

Breast Cancer Screening (BCS) (Administrative- Claims Data Only)

STAR RATING: Percentage of female plan members aged 40-69 who had a mammogram during the past 2 years. Test Performed by: Jan 01- Dec 31 of CY or (CY-1)

HEDIS: Percentage of women 42-69 years of age as of December 31 who had a mammogram to screen for breast cancer during the measurement year or the year prior to the measurement year. Exclusions: Women who had a bilateral mastectomy. Continuous Enrollment: Measurement year and year prior, Allowable Gap: no more than 45 days

1 2 3 4 5

<43 >43 to <64 >64 to <74 >74 to <83 >83

Weighted Value- 1

CPT HCPCS ICD-9 CM Procedure

77055 – 77057 G0202, G0204, G0206

87.36, 87.37

TEST REQUIRED FOR COMPLIANCE: Mammogram NOTE: The Purpose of this measure is to evaluate primary screening. Do not count biopsies, breast ultrasounds or MRIs for this measure because they are not appropriate methods for primary breast cancer screening.

Colorectal Cancer Screening (COL) (Administrative/Hybrid)

STAR RATING: Percentage of plan members aged 50-75 who had appropriate screening for colon cancer. Test Performed by: Jan 01- Dec 31 of CY or Colonoscopy during past 10 years

HEDIS: Percentage of members 51-75 years of age who had appropriate screening for colorectal cancer. Exclusions: Members with a diagnosis of colorectal cancer or total colectomy. Continuous Enrollment: Measurement year and year prior, Allowable Gap: no more than 45 days

1 2 3 4 5

<35 >35 to 51 ≥51 to <58 ≥58 to <67 ≥67

Weighted Value- 1

Description

CPT ICD 9-CM Diagnosis

HCPCS ICD 9-CM Procedure

FOBT 82270,82274 G0328,

Flexible Sigmoidoscopy

45330-45335, 45337-45342, 45345

G0104

45.24

Colonoscopy 44388-44394,44397,45355, 45378-45387, 45391, 45392

G0105, G0121

45.22, 45.23, 45.25, 45.42, 45.43

TEST REQUIRED FOR COMPLIANCE: 1 of 3 depending of the FOBT test used. 1. Fecal occult blood test (FOBT) during the measurement year. Regardless of FOBT type, guaiac (gFOBT) or immunochemical (iFOBT), assume that the required number of samples was returned. 2. Flexible Sigmoidoscopy during the measurement year or the four years prior to the measurement year 3. Colonoscopy during the measurement year or the nine years prior to the measurement year

TEST REQUIRED FOR COMPLIANCE:

Documentation must be provided of previously performed colorectal screening test including result and date of service.

Preferred billing code for this measure


Revised 1/9/2013

Cholesterol Management for Patients with Cardiovascular Conditions (CMC) (Administrative/Hybrid)

STAR RATING: Percentage of plan members age 18-75 with ischemic vascular disease, AMI, coronary bypass Graft (CABG) or percutaneous trans luminal coronary angioplasty (PTCA) who had LDL-C test performed during the measurement year. Test Performed by: Jan 01- Dec 31 of CY

HEDIS: Percentage of members 18-75 years of age who were discharge alive for AMI, coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) from January 1-November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year. Continuous Enrollment: Measurement year and year prior, Allowable Gap: no more than 45 days

1 2 3 4 5

<66 ≥66 to <80 ≥80 to <85 ≥85 to <89 ≥89

Weighted Value- 1

CPT CPT Category II LOINC

80061, 83700, 83701, 83704, 83721

3048F, 3049F, 3050F 2089-1, 12773-8, 13457-7, 18261-8, 18262-6, 22748-8, 39469-2, 49132-4, 55440-2

Outpatient / Acute Inpatient Visits

CPT 99201-99205, 99211-99215,99217-99220,99241-99245,99341-99345,99347-99350,99384-99387, 99394-99397,99401-99404, 99411, 99412, 99420, 99429, 99455,99456, 99221-99223, 98231-99233, 99238, 99239, 99251-99255

UB Revenue 051x, 0520-0523, 0526-0529, 057x-059x, 0982, 0983

CABG (include only inpatient claims)

CPT 33510-33514, 33516-33519, 33521-33523, 33533-33536

ICD 9 – CM Procedure 36.1, 36.2

AM I (include only inpatient claims)

ICD 9- Diagnosis 410.x1

PCI CPT 92980, 92982, 92995

ICD 9 – CM Procedure 00.66, 36.06, 36.07

IVD ICD 9- Diagnosis 411, 413, 414.0, 414.2, 414.8,414.9, 429.2, 433-434, 440.1, 440.2, 440.4, 444, 445


LDL – C Screening test performed during the measurement year, as identified by claim/encounter or automated laboratory data <100mg/DL

Glaucoma Testing in Older Adults (GSO) (Administrative- Claims Data Only)

STAR RATING: Percent of senior plan members who got a glaucoma eye exam for early detection Test Performed by: Jan 01- Dec 31 of current or previous year

HEDIS: The percentage of Medicare members 65 years and older, without a prior diagnosis of glaucoma or glaucoma suspect, who received a glaucoma eye exam by an eye care professional for early identification of glaucomatous conditions. Exclusions: Members who had a prior diagnosis of glaucoma or glaucoma suspect. Continuous Enrollment: Measurement year and year prior, Allowable Gap: no more than 45 days

1 2 3 4 5

<54 ≥54 to <62 ≥62 to <70 ≥70 to <74 ≥74

Weighted Value- 1

CPT HCPCS ICD 9-CM Diagnosis

ICD 9-CM Procedure

92002, 92004, 92012, 92014, 92081-92083, 92140, 99202-99205, 99213-99215, 99242-99245

G0117, G0118, S0620, S0621


Optometrist and/or Ophthalmologist referral in order to conduct eye exams for glaucoma during the measurement year.

Preferred billing code for this measure


Revised 1/9/2013

Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) (Administrative –Claim/Encounter)

STAR RATING: Percent of plan members with Rheumatoid Arthritis who got 1 or more prescription(s) for an anti-rheumatic drug. Prescribed once in: Jan 01- Dec 31 of CY

HEDIS: The percentage of members who were diagnosed with rheumatoid arthritis and were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD). Exclusions: Members diagnosed with HIV or who are pregnant Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days

1 2 3 4 5

<49 ≥49 to <66 ≥66 to <78 ≥78 to <86 ≥86

Weighted Value- 1

Description ICD -9-CM Diagnosis

Rheumatoid arthritis 714.0, 714.1, 714.2, 714.81

Visit Type CPT

Outpatient

99201- 99205,99211-99215, 99241-99245,99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99411,99412, 99420, 99429, 99455, 99456

TEST REQUIRED FOR COMPLIANCE: NONE NOTE: In order to be compliant for this measure the member has to have at least one prescription, during the year, for any of the following anti-rheumatic drugs: First Line Therapy Medications -Azathioprine -Cyclophosphamide -Gold Sodium Thiomalate -Hydroxychloroquine -Leflunomide -Methotrexate -Minocycline -Sulfasalazine. -Cyclosporine


Revised 1/9/2013

Comprehensive Diabetes Care (CDC) – Cholesterol Screening (Administrative/Hybrid)

STAR RATING: Percentage of plan members with diabetes who had a test for “bad” (LDL) cholesterol. Test Performed by: Jan 01- Dec 31 of CY

HEDIS: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had LDL – C Screening during the measurement year, as identified by claim/encounter or automated laboratory data. Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days

1 2 3 4 5

<69 ≥69 to <81 ≥81 to <85 ≥85 to <90 ≥90

Weighted Value- 1

CPT CPT Category II LOINC

80061, 83700, 83701, 83704, 83721

3048F, 3049F, 3050F 2089-1, 12773-8, 13457-7, 18261-8, 18262-6, 22748-8, 39469-2, 49132-4, 55440-2


LDL – C Screening test performed during the measurement year, as identified by claim/encounter or automated laboratory data.

Comprehensive Diabetes Care (CDC) – Cholesterol Controlled / LDL control < 100 mg/dL (Administrative/Hybrid)

STAR RATING: Percentage of plan members with diabetes who had a cholesterol test during the year that showed an acceptable level of “bad” (LDL) cholesterol. Test Performed by: Jan 01- Dec 31 of CY

HEDIS: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had the most recent LDL-C test during the measurement year and the level is < 100mg/dL. Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days

1 2 3 4 5

<34 ≥34 to <48 ≥48 to 53 ≥53 to <60 ≥60

Weighted Value- 3

Description CPT Category II

Numerator compliant (LDL-C < 100mg/dL 3048F

Not numerator compliant (LDL-C ≥ 100 mg/dL) 3049F, 3050F


LDL – C Screening test performed during the measurement year with level outcome of <100mg/dL , as identified by claim/encounter or automated laboratory data

Comprehensive Diabetes Care (CDC) –Blood Sugar Controlled / HbA1c Controlled (Administrative/Hybrid)

STAR RATING: Percentage of plan members with diabetes who had an A1c lab test during the year that showed their average blood sugar is under control (<9%). Test Performed by: Jan 01- Dec 31 of CY

HEDIS: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had a Hemoglobin A1c screening and the most recent A1c test during the measurement year is < 8%. Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days

1 2 3 4 5

<41 ≥41 to <68 ≥68 to <80 ≥80 to <88 ≥88

Weighted Value- 3

Description CPT / CPT Category II

LOINC

HbA1c Test 83036, 83037 / 3044F, 3045F, 3046F

4548-4, 4549-2, 17856-6, 59261-8, 62388-4 Numerator compliant (HbA1c < 8%) 3044F

Not numerator compliant (HbA1c ≥ 8%) 3045F, 3046F

Numerator complaint (HbA1c >9%) 3046F


Hemoglobin A1c Screening Test performed during the measurement year, as identified by claim/encounter or automated laboratory data

A copy of all lab results should be kept in the members Medical Records.


Revised 1/9/2013

Comprehensive Diabetes Care (CDC)– Kidney Disease Monitoring/ Medical attention to Nephropathy (Administrative/Hybrid)

STAR RATING: Percentage of plan members with diabetes who had a kidney function test during the year Test Performed by: Jan 01- Dec 31 of CY

HEDIS: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had a urine micro albumin test during the measurement year or who had received medical attention for nephropathy during the measurement year. Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days

1 2 3 4 5

<78 ≥78 to <82 ≥82 to <85 ≥85 to <90 ≥90

Weighted Value- 1

Description CPT CPT Category II

Nephropathy screening test 82042, 82043, 82044, 84156 3060 F, 3061F

Urine macroalbumin test 81000-81003, 81005 3062F

Evidence of treatment for nephropathy

36147, 36800, 36810, 36815, 36818, 36819-

36821,36831,-36833, 50300, 50320,50340,

50360, 50365, 50370,50380, 90935, 90937,

90940, 90945, 90947, 90957,-90962, 90965,

90966, 90969, 90970, 90989, 90993, 90997,

90999, 99512


Micro albumin, Random Urine w/Createnine or Micro albumin, 24 hour Urine, w/o Createnine test performed during the measurement year, as identified by claim/encounter or automated laboratory data

Documented evidence of nephropathy with: o Any positive urine macro albumin test for protein o Medical attention for nephropathy o Nephrology consult in current year (include if primary care physician also is a nephrologist)


Revised 1/9/2013

Comprehensive Diabetes Care (CDC)– Diabetes Care – Eye Exam (Administrative/Hybrid)

STAR RATING: Percentage of plan members with diabetes who had an eye exam to check for damage from diabetes during the year Test Performed by: Jan 01- Dec 31 of current or previous year.

HEDIS: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or a negative retinal exam (no evidence of retinopathy) in the year prior to the measurement year. Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days

1 2 3 4 5

<47 ≥47 to <54 ≥54 to <64 ≥64 to <81 ≥81

Weighted Value- 1

CPT CPT Category II HCPCS

67028, 67030, 67031, 67036, 67038-67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92018, 92019, 92225, 92226, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245, 92134, 92227, 92228

2022F, 2024F, 2026F, 3072F

S0620, S0621, S0625, S3000


Referral to an eye care specialist (optometrist or ophthalmologist) for a retinal or dilated eye exam during the measurement year. For eye exam performed in the year prior to the measurement year, a result must be available and documented as part of the medical record indicating a positive or negative result.


Revised 1/9/2013

Osteoporosis Management in Women who had a Fracture (OMW) (Administrative –Claim/Encounter)

STAR RATING: Percentage of female plan members who broke a bone and got screening or treatment for osteoporosis within 6 months Fracture Date Range: July 01/CY-2 though Jun 30/ CY-1 Test Performed or prescription by: Jan 01- Dec 31 of CY-1

HEDIS: The Percentage of women 67 years of age and older who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after the fracture. This measure has an intake period which means that data is captured for 12 months beginning on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year. The intake period is used to capture the first fracture. Continuous Enrollment: 1 year before fracture diagnosis through 6 months after, Allowable Gap: no more than 45 days

1 2 3 4 5

<24 ≥24 to <38 ≥38 to <60 ≥60 to <67 ≥67

Weighted Value- 1


BMD (Bone Mineral Density) Exam

Osteoporosis Therapies identified through pharmacy data which includes prescription for the following medications:

- Alendronate, - Ibandronate, - Risedronate, - Conjugated estrogens , - Conjugated estrogens synthetic, - Esterified estrogens, - Estradiol, - Estradiol acetate, - Estradiol cypionate, - Estradiol valerate, - Estropipate, - Calcitonin, - Raloxifene, - Teriparatide, - Conjugated estrogens- medroxy-

progesterone, - Estradiol-levonorgestrel,

- Estradiol-norethindrone, - Estradiolnorgestimate, - Ethinyl estradiol-norethindrone

HEDIS BILLING CODES TO IDENTIFY A FRACTURE ICD 9-CM Procedure

J CODES TO IDENTIFY OSTEOPOROSIS THERAPIES

79.01-79.03, 79.05-79.07, 79.11-79.13, 79.15-79.17, 79.21-79.23, 79.25-79.27, 79.31-79.33, 79.35-79.37, 79.61-79.63, 79.65-79.67, 81.65, 91.66

J1740, J3488, J3487, J1000, J0630, J3110, J0897

HEDIS BILLING CODES TO IDENTIFY BONE MINERAL DENSITY TEST

CPT HCPCS ICD 9-CM Diagnosis

ICD 9-CM Procedure

76977, 77078- 77081, 77083, 78350, 78351 G0130 88.98


Revised 1/9/2013

Controlling High Blood Pressure (CBP) (Hybrid – 100% Medical Record Review)

STAR RATING: Percent of plan members with high blood pressure who got treatment and were able to maintain a healthy pressure. BP controlled during: Jan 01- Dec 31 of CY

HEDIS: The percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90) during the measurement year. Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days

1 2 3 4 5

<43 ≥43 to <53 ≥53 to 63 ≥63 to <70 ≥70

Weighted Value- 3


Blood Pressure to be performed at every visit, and controlled during measurement year HEDIS looks at the most recent blood pressure

*Note in order to have a positive hit, the blood pressure must be below 140/90.

Adult BMI (Body Mass Index) Assessment (ABA) (Administrative/Hybrid)

STAR RATING: Percentage of members 18-74 years of age who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior to the measurement year. Test Performed by: Jan 01- Dec 31 of CY or (CY-1)

HEDIS: Percentage of members 18-74 years of age who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior to the measurement year. Exclusions: Members who have a diagnosis of pregnancy during the measurement year or the year prior to the measurement year. Continuous Enrollment: Measurement year and year prior, Allowable Gap: no more than 45 days

1 2 3 4 5

<25 ≥25 to <50 ≥50 to <61 ≥61 to <80 ≥80

Weighted Value- 1

In order to ensure compliance the following must be included: Date of service, weight, height, and BMI calculations.

Description CPT ICD -9 CM Diagnosis

Body Mass Index

99201-99205, 99211-99215, 99217-99220, 99241-99345, 99347-99350, 99385-99387, 99395-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456

V85.0-V85.5


Revised 1/9/2013

Plan All-Cause Readmissions (Administrative – Claims/Encounter)

STAR RATING: Percentage of members 65 years and older discharged from a hospital stay who were readmitted to a hospital within 30 days, either for the same condition as their recent hospital stay or for a different reason. Discharge during: Jan 01- Dec 31 of CY Readmission: within 30 days of discharge

1 2 3 4 5

>17 >13 to ≤ 17 >11 to ≤13 >3 to ≤11 ≤3

Weighted Value- 3

HEDIS: The percentage of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days, for members 18 years of age and older, in the following categories:

1. Count of Index Hospital Stays (HS denominator) 2. Count of 30-Day Readmission (numerator) 3. Average Adjusted Probability of Readmission

Exclusions: Hospital stays where the admission day is the same as the discharge date. Exclusions: Any acute inpatient stays with a discharge date in the 30 days prior to the admission date. Exclusions: Inpatient stays with discharges for death; acute inpatient stays for pregnancy. Continuous Enrollment: 365 days prior to discharge through 30 days after, Allowable Gap: no more than 45 days during 365 day period, no gap during 30 days post discharge.

Description CPT HCPCS ICD -9 CM Diagnosis

Pregnancy 630-679, V22, V23, V28

Office or other outpatient Services

99201-99205, 99211-99215, 99241-99245, 99217-99220, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99411-99412, 99420, 99429, 99455, 99456, 92002, 92004, 92012, 92014, 98925-98929, 98940-98942

Non-acute inpatient 99304-99310, 99315, 99316, 9931899324-99328,99334-99337

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

Emergency Dept. 99281-99285


Revised 1/9/2013

Care for Older Adults (COA)- Medication Review (SNP only) (Administrative/Hybrid)

STAR RATING: Medication Review Percentage of plan members whose doctor or clinical pharmacist has reviewed a list of everything they take at least once a year. Medication Review once during: Jan 01- Dec 31 of CY

1 2 3 4 5

<44 ≥44 to <63 ≥63 to <81 ≥81 to <92 ≥92

Weighted Value- 1

In order to ensure compliance the following must be included: Medication Review and Medication listing, or documentation of no medications must be documented in the Medical Record.

HEDIS: Medication Review Documentation of at least one dated medication review conducted by a prescribing practitioner or clinical pharmacist with in the current year along with a medication list present in the same medical record. If patient is not taking any medication, dated notation should be documented in the chart with in the current year. A review of side effects for a single medication at the time of prescription alone is not sufficient. Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days

Description CPT CPT Category II

Medication Review 90862, 99605, 99606 1160F


Medication List 1159F

Care for Older Adults (COA)- Functional Status Assessment (SNP only) (Administrative/Hybrid)

STAR RATING: Functional Status Assessment (Comprehensive) Percent of plan members whose doctor has done a “functional status assessment” to see how well member is doing “activities of daily living” etc. Functional Status Assessment once during: Jan 01- Dec 31 of CY

1 2 3 4 5

<29 ≥29 to <54 ≥54 to <75 ≥75 to <89 ≥89

Weighted Value- 1

In order to ensure compliance the following must be included: Evidence of functional assessment and date of service.

HEDIS: Functional Status Assessment Documentation in the medical record of at least complete functional status assessment in current year including the date performed. Notations for a complete functional status assessment may include:

Assessment of instrumental activities of daily living (IADL) such as shopping for groceries, driving, using public transportation, using the telephone, meal preparation, housework, home repair, laundry, taking medications or handling finances of

Assessment of activities of daily living (ADL) such as bathing, dressing, eating, transferring (i.e., getting in and out of chairs), using the toilet and walking or

Results using a standardized functional status assessment tool or

Assessment of three of the following four components: - Cognitive status - Ambulation status - Sensory ability ( hearing, vision, speech) - Other functional independence (e.g., exercise, ability to perform job)

A functional status assessment limited to an acute or single condition, event, or body system (e.g., lower back, leg) NOT meet criteria for a comprehensive functional status assessment.

Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days

Description CPT Category II ICD 9-CM Procedure

Functional Status Assessment 1170F


Revised 1/9/2013

Care for Older Adults (COA)- Pain Screening (SNP only) (Administrative/Hybrid) STAR RATING: Pain Screening Percent of plan members who had a pain screening or pain management plan at least once during the measurement year. Pain screening during: Jan 01- Dec 31 of CY

1 2 3 4 5

<27 ≥27 to <41 ≥41 to <56 ≥56 to <78 ≥78

Weighted Value- 1

In order to ensure compliance the following must be included: Evidence of pain management or evidence of pain screening along with date of service.

HEDIS: Pain Screening Documentation in the medical record of at least one pain screening or pain management in the current year, including the date it was performed. Notations can include:

Notation of a comprehensive pain assessment or results of a screening using a standardized pain screening tool

Evidence of a pain management plan such as notation of no pain intervention and the rationale, notation of a plan for treatment (pain meds, psychological support and patient/family education) or notation of plan for reassessment of pain including time interval.

A pain assessment or management plan limited to an acute or single condition, event or body system does NOT meet criteria. Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days


Pain Screening 0521F, 1125F, 1126F

Care for Older Adults (COA)- Advance Care Planning (SNP only) (Administrative/Hybrid)

THIS IS NOT A STAR RATINGS MEASURE No Thresholds applicable*

HEDIS: Advance Care Planning Evidence of advance care planning must include:

An advance care plan in the medical record or

Advance care planning discussion with the provider documented and dated or

Notation that the member has previously executed an advanced care plan that meets criteria Percent of adults 66 years old and older who have active advance care planning such as

Advanced directive

Living will

Power of attorney

Health care proxy

Actionable medical decision maker or surrogate decision maker

Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days

Description CPT Category II HPCPS

Advance Care Planning 1157F, 1158F S0257


Revised 1/9/2013

High Risk Medications (Prescription Drug Event (PDE) Data)

STAR RATING: The percent of plan members who got prescriptions for certain drugs with a high risk of serious side effects, when there may be safer drug choices. METRIC: This measure calculates the percentage of Medicare Part D beneficiaries 65 years or older who received at least two prescriptions of the same drug with a high risk of serious side effects in the elderly. Measurement Period: Jan 01- Dec 31 of CY Continuous Enrollment Period: Begins on date of first fill and ends on last day of enrollment period (Fill should occur at least 91 days prior to end of enrollment period). Allowable Gap: no more than 1 month

1 2 3 4 5

> 10.2 to ≤ 28.1 > 8.7 to ≤ 10.2 > 7.0 to ≤ 8.7 > 5.0 to ≤ 7.0 ≤ 5.0

Weighted Value- 3

High Risk Medication Alternative

Oral Estrogen

Carisoprodol, Cyclobenzaprine, Metaxolone, Methocarbamol, Orphenadrine

Chlorpropamide

Cyproheptadine, Diphenhydramine, Hydroxyzine

Dicyclomine

Diphenoxylate/Atropine

Meprobamate

Nifedipine (Short Acting Only)

Estrogen patches or creams.

Baclofen

Glimeperide, Glipizide

Cetirizine (OTC Benefit), Loratadine (OTC Benefit)

Cholestyramine, Loperamide, Metamucil (OTC Benefit), Docusate (OTC Benefit),

Loperamide

Sleep: Temazepam, Zolpidem

Anxiety: Alprazolam, Buspirone

Nifedipine ER, Amlodipine

NOTE:


Revised 1/9/2013

Blood Pressure Medication for People with Diabetes (Prescription Drug Event (PDE) Data)

STAR RATING: When people with diabetes also have high blood pressure, there are two types of blood pressure medication recommended. This tells what percent got one of the recommended types of blood pressure medicine. METRIC: This is defined as the percentage of Medicare Part D beneficiaries who were dispensed a medication for diabetes and a medication for hypertension who were receiving an angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or renin inhibitor medication which are recommended for people with diabetes. Measurement Period: Jan 01- Dec 31 of CY) Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days

1 2 3 4 5

≥ 56.5 to < 82.0

≥ 82.0 to < 83.2 ≥ 83.2 to < 86.0 ≥ 86.0 to < 87.8 ≥ 87.8

Weighted Value- 3

Targeted Population Recommended Hypertension Medication

Members taking a medication for diabetes and a medication for hypertension

Preferred Formulary ACE-Inhibitor: benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril (Prinivil, Zestril), moexipril (Univasc), perindopril (Aceon), quinapril (Accupril), ramipril (Altace), trandolapril (Mavik) Preferred Formulary ARB: losartan (Cozaar)

Or Preferred Formulary Renin Inhibitor: Tekturna

NOTE:

Medication Adherence for Oral Diabetes Medications (Prescription Drug Event (PDE) Data)

STAR RATING: Percent of plan members with a prescription for oral diabetes medication who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication. (―Oral diabetes medication‖ means a biguanide drug, a sulfonylurea drug, a thiazolidinedione drug, or a DPP-IV inhibitor. Plan members who take insulin are not included.). METRIC: This measure is defined as the percent of Medicare Part D beneficiaries 18 years or older who adhere to their prescribed drug therapy across four classes of oral diabetes medications: biguanides, sulfonylureas, thiazolidinediones, and DiPeptidyl Peptidase (DPP)-IV Inhibitors. Measurement Period: Jan 01- Dec 31 of CY) Continuous Enrollment Period: Begins on date of first fill and ends on last day of enrollment period (Fill should occur at least 91 days prior to end of enrollment period). Allowable Gap: no more than 1 month

1 2 3 4 5

≥ 52.4 to < 68.3

≥ 68.3 to < 72.0 ≥ 72.0 to < 76 ≥ 76 to < 79.0 ≥ 79.0

Weighted Value- 3

Targeted Population Recommended Adherence Monitoring

Members taking oral diabetes medications in the following therapeutic classes: biguanides, sulfonylureas, thiazolidinediones, and DiPeptidyl Peptidase (DPP)-IV Inhibitors

Ensure Members are taking their medication as directed and order their refills on a monthly basis

Services Required:

Proactively assess whether the patient is taking medication as required

If you identify barriers to adherence, resolve those barriers and find ways to help the member take his or her medication as directed


Revised 1/9/2013

Medication Adherence for Hypertension (ACEI & ARBs) (Prescription Drug Event (PDE) Data)

STAR RATING: Percent of plan members with a prescription for a blood pressure medication who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication. (―Blood pressure medication‖ means an ACE (angiotensin converting enzyme) inhibitor or an ARB (angiotensin receptor blocker) drug.) METRIC: This measure is defined as the percent of Medicare Part D beneficiaries 18 years or older who adhere to their prescribed drug therapy for angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) medications. Measurement Period: Jan 01- Dec 31 of CY) Continuous Enrollment Period: Begins on date of first fill and ends on last day of enrollment period (Fill should occur at least 91 days prior to end of enrollment period). Allowable Gap: no more than 1 month

1 2 3 4 5

≥ 52.4 to < 67.8

≥ 67.8 to < 72.6

≥ 72.6 to < 77 ≥ 77 to < 79.7 ≥ 79.7

Weighted Value- 3


Members taking hypertension medications in the following therapeutic classes: ACE (Angiotensin Converting Enzyme) or ARB (Angiotensin Receptor Blocker)


Services Required:



Medication Adherence for Cholesterol (Statins) (Prescription Drug Event (PDE) Data)

STAR RATING: Percent of plan members with a prescription for a cholesterol medication (a statin drug) who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication.. METRIC: This measure is defined as the percent of Medicare Part D beneficiaries 18 years or older that adhere to their prescribed drug therapy for statin cholesterol medications. Measurement Period: Jan 01- Dec 31 of CY) Continuous Enrollment Period: Begins on date of first fill and ends on last day of enrollment period (Fill should occur at least 91 days prior to end of enrollment period). Allowable Gap: no more than 1 month

1 2 3 4 5

32.9 to < 63.0

≥ 63.0 to < 67.3 ≥ 67.3 to < 72 ≥ 72 to < 75.4 ≥ 75.4

Weighted Value- 3


Members taking a cholesterol medication in the following therapeutic class: Statin


Services Required:




Revised 1/9/2013

DISPLAY MEASURES

Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) (Administrative –Claim/Encounter)

STAR RATING: Percentage of senior plan members with active Chronic Obstructive Pulmonary Disease (COPD) who got appropriate Spirometry testing to confirm the diagnosis. Test Performed by: Jan 01- Dec 31 of CY

HEDIS: The percentage of members 40 years and older with a new diagnosis of newly active COPD who received appropriate Spirometry testing to confirm the diagnosis. Continuous Enrollment Period: 2 years prior to diagnosis date through 6 months after diagnosis date Allowable Gap: no more than 45 days per 12 month period

1 2 3 4 5

<20 >=20 & <35 >=35 & <60 >=60 & <83 >=83

**2011 Thresholds

Identifying Test

CPT IDC-9 CM Diagnosis

Spirometry 94010, 94014-94016, 94060, 94070, 94375, 94620 493.2, 496

TEST REQUIRED FOR COMPLIANCE: Spirometry Test


Revised 1/9/2013

Annual Monitoring for Patients on Persistent Medications (MPM) (Administrative –Claim/Encounter)

STAR RATING: Percentage of Plan members who got a 6 month (or longer) prescription for a drug known to have a possibly harmful side effects among seniors if used long-term, and who had at least one appropriate follow-up visit during the year to monitor these medications. Provider visit during: Jan 01- Dec 31 of CY

1 2 3 4 5

<70 >=70 & <78 >=78 & <90 >=90 & <92 >=92

**2011 Thresholds

HEDIS: The Percentage of members 18 years and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring vent for the therapeutic agent in the measurement year. For each of the following:

Annual monitoring for members on Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB)

Annual monitoring for members on digoxin

Annual monitoring for members on diuretics

Annual monitoring for members on anticonvulsants Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days

Physiologic- Monitoring Test CPT

Serum Potassium (K+) 80051, 84132

Serum Creatinine (SCr) 82565, 82575

Blood Urea Nitrogen (BUN) 84520, 84525

Description CPT

Drug serum concentration for phenobarbital 80184

Drug serum concentration for phenytoin 80185, 80186

Drug serum concentration for valproic acid or divalproex sodium 80164

Drug serum concentrations for carbamazepine 80156, 80157

CPT Lab Panel

80051, 84132

80047, 80048, 80050, 80053, 80069

82565, 82575

84520, 84525

CPT

80184

80185, 80186

80164

80156, 80157


Rate 1: Members on ACE Inhibitors or ARBs – Must order at least one serum potassium and serum createnine during the year or a serum potassium and blood urea nitrogen

Rate 2: Member on Digoxin – Must order a serum potassium and serum creatinine or a serum potassium and blood urea nitrogen

Rate 3: Members on Anticonvulsants – Must order serum phenobarbital, or serum phenytoin, or serum valproic acid or serum divalproex, or serum carbamazepine (depending which medication the members is on).

Rate 4: Members on Diuretics – Must order serum potassium and serum creatinine or serum potassium and blood urea nitrogen.


Revised 1/9/2013

Adults’ Access to Preventive/Ambulatory Health Services (AAP) (Administrative –Claim/Encounter)

STAR RATING: Percent of all plan members who saw their primary care doctor during the year. Doctor’s visit during: Jan 01- Dec 31 of CY

HEDIS: The percentage of members 20 years and older who had an ambulatory or preventive care visit. Continuous Enrollment: Measurement year, Allowable Gap: no more than 45 days

1 2 3 4 5

<73 ≥73 to <79 ≥79 to <85 ≥85 to <96 ≥96

**2012 Thresholds

Preventive Ambulatory Health Services

CPT HCPCS ICD-9- CM Diagnosis

Office or other outpatient Services

99201-99205, 99211-99215, 99241-99245

Home Services 99341-99345, 99347-99350

Nursing Facility Care 99304-99310, 99315, 99316, 99318

Domiciliary, rest home or custodial care services

99324-99328, 99334-99337

Preventive Medicine

99385-99387, 99395-99397, 99401-99404, 99411, 99412, 99420, 99429

G0344, G0402, G0438, G0439

Ophthalmology and Optometry

92002, 92004, 92012, 92014

S0620, S0621

General Medical Examination V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

hedis 2013 & cms star ratings- quick reference guide 1 · micro albumin, random urine...

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