hedis 2015 measures - simply healthcare plans members ages 18-74 years of age • what makes them...

HEDIS 2015 MEASURES

Quality Management Department

• Members ages 18-74 years of age

• What makes them compliant?

• Documentation in the medical record must reflect office visit with documented weight and body mass index (BMI) calculated.

• Documentation of >99% or <1% meet criteria

ABA- Adult BMI Assessment ( M e d i c a i d & M e d i c a r e )

ICD-9-CM Diagnosis:

V85.0, V85.1, V85.21-V85.25, V85.30-V85.39, V85.41-V85.45, V85.51-V85.54

• Members ages 50-75 years of age

FOBT in 2014 or Flexible sigmoidoscopy (2011-2014) or Colonoscopy (2005-2014)

COL- Colorectal Cancer Screening ( M e d i c a r e )

CPT: 82270, 82274, 45330-45335, 45337-45342, 45345 , 44388-44394, 44397, 45355, 45378-45387, 45391, 45392

ICD-9:

45.24, 45.22, 45.23, 45.25, 45.42, 45.43

HCPCS:

G0328, G0104,G0105, G0121

LOINC:

2335-8, 12503-9, 12504-7, 14563-1, 14564-9, 14565-6, 27396-1, 27401-9, 27925-7, 27926-5, 29771-3, 56490-6, 56491-4, 57905-2,

58453-2

WCC – Weight Assessment and Counseling for Nutrition and Physical activity for Children and Adolescents

• Members 3–17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of the following during the measurement year.

• What makes the member compliant? 1. BMI: Documentation must include height, weight and BMI percentile during the

measurement year. The height, weight and BMI must be from the same data source. BMI Percentile BMI Percentile plotted on age-growth chart.

2. Counseling for Nutrition: Documentation of counseling for nutrition or referral for

nutrition education during the measurement year as identified by administrative data or medical record review. Discussion of current nutrition behaviors (eating habits, dieting behaviors) Checklist indicating nutrition was addressed. Counseling or referral for nutrition education. Member received educational materials on nutrition during a face-to-face visit. Anticipatory guidance for nutrition. Weight or obesity counseling.

( M e d i c a i d )

3. Counseling for Physical Activity: Documentation of counseling for physical activity or referral for physical activity during the measurement year as identified by administrative data or medical record review.

Discussion of current physical activity

behaviors (e.g., exercise routine, participation in sports activities, exam for sports participation.)

Checklist indicating physical activity was addressed.

Counseling or referral for physical activity.

Member received educational materials on physical activity during a face-to-face visit.

Anticipatory guidance for physical activity.

Weight or obesity counseling.

WCC – Weight Assessment and Counseling for Nutrition and Physical activity for Children and Adolescents

( M e d i c a i d )

CPT:

97802-97804

ICD-9-CM Diagnosis:

V65.3, V65.41, V85.0, V85.1, V85.21, V85.22, V85.23, V85.24, V85.25, V85.30, V85.31, V85.32, V85.33, V85.34, V85.35, V85.36, V85.37, V85.38, V85.39, V85.41, V85.42, V85.43, V85.44, V85.45, V85.51, V85.52, V85.53

HCPCS:

G0270, G0271, G0447, S9449, S9451, S9452, S9470

CIS – Childhood Immunization Status ( M e d i c a i d )

• Children who turn 2 years of age during the measurement year.

• What makes the member compliant?

4 DTaP 3 IPV 1 MMR 3 HiB 3 HepB 1 VZV 4 PCV 1 HepA 2 or 3 RV 2 Influenza (flu) vaccines by

their second birthday

CPT codes:

90633, 90645-90648, 90655, 90657, 90661, 90662, 90669, 90670, 90673, 90680, 90681, 90685, 90698, 90700, 90704-90708, 90710, 90713, 90716, 90721, 90723, 90740, 90744, 90747, 90748

HCPCS:

G0008, G0009, G0010

ICD-9-CM Diagnosis:

052.0, 052.1, 052.2, 052.7, 052.8, 052.9, 053.0, 053.10, 053.11, 053.12, 053.13, 053.14, 053.19, 053.20, 053.21, 053.22, 053.29, 053.71, 053.79, 053.8, 053.9, 055.0, 055.1, 055.2, 055.71, 055.79, 055.8, 055.9, 056.00, 056.01, 056.09, 056.71, 056.79, 056.8, 056.9, 070.0, 070.1, 070.20, 070.21, 070.22, 070.23, 070.30, 070.31, 070.32, 070.33, 072.0, 072.1, 072.2, 072.3, 072.71, 072.72, 072.79, 072.8, 072.9, V02.61

• Children 2 years of age

• What makes the member compliant? 1 or more capillary or venous

lead blood test for lead poisoning by their second birthday.

LSC – Lead Screening in Children

( M e d i c a i d )

CPT: 83655

LOINC:

10368-9, 10912-4, 14807-2, 17052-2, 25459-9, 27129-6, 32325-3, 5671-3, 5674-7

IMA – Immunizations for Adolescents

• Adolescents who turn 13 years of age during the measurement year.

• What makes the member compliant? 1 dose of meningococcal

vaccine 1 dose of Tdap or 1 Td by their

13th birthday.

( M e d i c a i d )

CPT:

90703, 90714, 90715, 90718, 90719, 90733, 90734

ICD-9:

999.4, 999.42

• Women 50-74 years of age


One or more mammograms between October 1, 2013 and December 31, 2015.

BCS- Breast Cancer Screening ( M e d i c a i d & M e d i c a r e )

CPT:

77055-77057

ICD-9:

87.36,87.37

HCPCS:

G0202, G0204, G0206

UB Revenue:

0401, 0403

CCS- Cervical Cancer Screening

• Women screened for cervical cancer using the following criteria:

Women 21-64 years of age who had cervical cytology performed.

Women 30-64 years of age who had cervical cytology/ human papillomavirus (HPV) co- testing performed.


• Documentation in the medical record must include both the following:

Note indicating date of cervical cytology and HPV test on the same day or within 4 days of first test

The results or findings

CPT:

88141-88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164-88167, 88174, 88175

LOINC:

10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5

HCPCS:

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

UB Revenue: 0923

( M e d i c a i d )

CHL – Chlamydia Screening in Women ( M e d i c a i d )

• Women 16–24 years of age who were identified as sexually active who had at least one test for chlamydia during the measurement year.

• What identifies the member as sexually active?

Claim/encounter data indicating sexual activity during the measurement year.

Pharmacy data. Members who were dispensed prescription contraceptives during the measurement year.


At least one chlamydia test during the measurement year.

CPT :

86631, 86632, 87110, 87270, 87320, 87490, 87491, 87492, 87810

LOINC:

14463-4, 14464-2, 14467-5, 14470-9, 14471-7, 14474-1, 14509-4, 14510-2, 14513-6, 16600-9, 16601-7, 21189-6, 21190-4, 21191-2, 21192-0, 21613-5, 23838-6, 31771-9, 31772-7, 31775-0, 31777-6, 36902-5, 36903-3, 42931-6, 43304-5, 43404-3, 43406-8, 45067-6, 45068-4, 45069-2, 45070-0, 45074-2, 45076-7, 45078-3, 45080-9, 45084-1, 45091-6, 45095-7, 45098-1, 45100-5, 47211-8, 47212-6, 49096-1, 4993-2, 50387-0, 53925-4, 53926-2, 557-9, 560-3, 6349-5, 6354-5, 6355-2, 6356-0, 6357-8

CWP- Appropriate testing for children with Pharyngitis

• Members 2-18 years of age • What makes the member compliant?

Episode date (ED) with dx of Pharyngitis.

A strep test in the 7 day period from 3 days prior to the IESD through 3 days after the IESD.

Dispensed an antibiotic at time of discharge

CPT:

87070, 87071, 87081, 87430, 87650, 87651, 87652, 87880

LOINC:

11268-0, 17656-0, 18481-2, 31971-5, 49610-9, 5036-9, 60489-2, 626-2, 6556-5, 6557-3, 6558-1, 6559-9, 68954

( M e d i c a i d )

ASM- Use of Appropriate Medications for People with Asthma

• What makes them compliant? A diagnosis of asthma during

the measurement year Have at least 4 medication dispensing events for an asthma-control medication during the measurement year

( M e d i c a i d )

• Members 5-64 years of age identified as having persistent asthma and appropriately prescribed medication during the measurement year

Prescriptions:

Dyphylline-guaifenesin, Guaifenesin-theophylline,

Potassium iodide-theophylline, Omalizumab,

Budesonide-formoterol, Fluticasone-salmeterol,

Mometasone-formoterol, Beclomethasone, Flunisolide,

Mometasone, Budesonide, Fluticasone CFC free,

Triamcinolone, Ciclesonide, Montelukast, Zafirlukast,

Zileuton, Cromolyn, Nedocromil, Aminophylline,

Oxtriphylline, Dyphylline, Theophylline

ADD – Follow-Up Care for Children Prescribed ADHD Medication

( M e d i c a i d )

• Members six years as of March 1 of the year prior to

the measurement year to 12 years as of February 28

of the measurement year.


Children newly prescribed ADHD medication who

had at least three f/u care visits within a 10-month

period, one of which was within 30 days of when

the first ADHD medication was dispensed.

Two rates are reported:

• Initiation Phase: An outpatient, intensive

outpatient or partial hospitalization follow-up

visit with a practitioner with prescribing

authority, within 30 days after the IPSD.

• Continuation and Maintenance (C&M) Phase: At

least two follow-up visits from 31–300 days (9

months) after the IPSD with any practitioner.

CPT:

90791, 90792, 90801, 90802, 90804 - 90819, 90821 - 90824, 90826 - 90829, 90832 - 90834, 90836 - 90840, 90845, 90847, 90849, 90853, 90857, 90862, 90875, 90876, 96150 - 96154, 98960 - 98962, 98966 - 98968, 99078, 99201 - 99205, 99211 - 99215, 99217 - 99223, 99231 - 99233, 99238, 99239, 99241 - 99245, 99251 - 99255, 99341 - 99345, 99347 - 99350, 99381 - 99384, 99391 - 99394, 99401 - 99404, 99411, 99412, 99441 - 99443, 99510

ADD – Follow-Up Care for Children Prescribed ADHD Medication

( M e d i c a i d )

HCPCS:

G0155, G0176, G0177, G0409, G0410, G0411, G0463, H0002, H0004, H0031, H0034, H0035, H0036, H0037, H0039, H0040, H2000, H2001, H2010 - H2020, M0064, S0201, S9480, S9484, S9485

UB Revenue:

0510, 0513, 0515 - 0517, 0519 -0523, 0526 - 0529, 0900, 0902 - 0905, 0907, 0911 - 0917, 0919, 0982, 0983

POS:

03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 33, 49, 50, 52, 52, 53, 53, 71, 72

AMM- Antidepressant Medication Management

• Members 18 years of age and older with one of the following:

Effective Acute Phase Treatment

Effective Continuation Phase Treatment


A diagnosis of Major Depression

Effective Acute Phase- At least 84 days of continuous treatment with antidepressant medication within the 114- day period, following the IPSD

Effective Continuation Phase- At least 180 days of continuous treatment with antidepressant medication within 231 days of the IPSD

( M e d i c a i d & M e d i c a r e )

Antidepressant Medications:

Miscellaneous antidepressants

Monoamine oxidase inhibitors

Phenlpiperazine antidepressants

Psychotherapeutic combinations

SSNRI antidepressants

SSRI antidepressants

Tetracyclic antidepressants

Tricyclic antidepressants

CPT:

90791, 90792, 90832 - 90834, 90836 - 90840, 90845, 90847, 90849, 90853, 90867 - 90870, 90875, 90876, 98960 - 98962, 99078, 99201 - 99205, 99211 - 99215, 99217 - 99223, 99231 - 99233, 99238, 99239, 99241 - 99245, 99251 - 99255, 99341 - 99345, 99347 - 99350, 99383 - 99387, 99393 - 99397, 99401 - 99404, 99411, 99412, 99495, 99496, 99510

HCPCS:

G0155, G0176, G0177, G0409, G0410, G0411, G0463, H0002, H0004, H0031, H0034 - H0037, H0039, H0040, H2000, H2001, H2010 - H2020, M0064, S0201, S9480, S9484, S9485

FUH – Follow-Up After Hospitalization for Mental Illness

**Mental Health related measure • Members six years and older as of the

date of discharge. • What makes the member compliant?

The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner.

Two rates are reported: 30 Day Follow-Up 7 Day Follow-Up


UB Revenue:

0510, 0513, 0515, 0516, 0517, 0519 - 0523, 0526 - 0529, 0900 - 0905, 0907, 0911 - 0917, 0919, 0982, 0983

POS:

03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 24, 33, 49, 50, 52, 52, 53, 53, 71, 72

FUH – Follow-Up After Hospitalization for Mental Illness


IET – Initiation and Engagement of Alcohol and other Drug Dependence Treatment

• The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) dependence who received the following between January 1–November 15 of the measurement year:

Initiation of AOD Treatment: The

percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.

Engagement of AOD Treatment: The

percentage of members who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit

CPT:

90633, 90645-90648, 90655, 90657, 90661, 90662, 90669, 90670, 90673, 90680, 90681, 90685, 90698, 90700, 90704-90708, 90710, 90713, 90716, 90721, 90723, 90740, 90744, 90747, 90748

HCPCS:

G0155, G0176, G0177, G0396, G0397, G0409, G0410, G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0008, H0009, H0010, H0011, H0012, H0013, H0014, H0015, H0016, H0020, H0022, H0031, H0034, H0035, H0036, H0037, H0039, H0040, H2000, H2001, H2010, H2011, H2012, H2013, H2014, H2015, H2016, H2017, H2018, H2019, H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012

ICD-9:

291.0, 291.1, 291.2, 291.3, 291.4, 291.5, 291.81, 291.82, 291.89, 291.9, 303.00, 303.01, 303.02, 303.90, 303.91, 303.92, 304.00, 304.01, 304.02, 304.10, 304.11, 304.12, 304.20, 304.21, 304.22, 304.30, 304.31, 304.32, 304.40, 304.41, 304.42, 304.50, 304.51, 304.52, 304.60, 304.61, 304.62, 304.70, 304.71, 304.72, 304.80, 304.81, 304.82, 304.90, 304.91, 304.92, 305.00, 305.01, 305.02, 305.20, 305.21, 305.22, 305.30, 305.31, 305.32, 305.40, 305.41, 305.42, 305.50, 305.51, 305.52, 305.60, 305.61, 305.62, 305.70, 305.71, 305.72, 305.80, 305.81, 305.82, 305.90, 305.91, 305.92, 535.30, 535.31, 571.1


• Members 20 years of age and older who had an ambulatory or preventive care visit during the measurement year


One or more ambulatory or preventive visits during the measurement year

AAP- Adults’ Access to Preventive/ Ambulatory Health Services


CPT:

92002, 92004, 92012, 92014, 99201 - 99205, 99211 - 99215, 99241 - 99245, 99304 - 99310, 99315, 99316, 99318, 99324 - 99328, 99334 - 99337, 99341 - 99345, 99347 - 99350, 99381 - 99387, 99391 - 99397, 99401 - 99404, 99411, 99412, 99420, 99429

ICD-9:

V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

HCPCS:

G0402, G0438, G0439, G0463, S0620, S0621

UB Revenue:

0510 - 0517, 0519 - 0529, 0982, 0983

CAP – Children and Adolescents’ Access to Primary Care Practitioners

• Members 12 months–19 years of age who had a visit with a PCP.

• What makes the member

compliant? For 12–24 months, 25 months–6

years: One or more visits with a PCP during the measurement year.

For 7–11 years, 12–19 years: One or more visits with a PCP during the measurement year or the year prior to the measurement year.

( M e d i c a i d )

CPT:

99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99385, 99391-99395, 99401-99404, 99411, 99412, 99420, 99429

ICD-9:

V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

HCPCS:

G0402, G0438, G0439, G0463

ADV – Annual Dental Visit

• Members 2-21 years old, as of December 31st of the measurement year.

• What makes the member

compliant? One or more dental visits

with a dental practitioner during the measurement year.

( M e d i c a i d )

CPT:

70300, 70310, 70320, 70350, 70355

HCPCS:

D0120-D0999, D1110-D2999, D3110-D3999, D4210-D4999, D5110-D5899, D6010-D6205, D7111-D7999, D8010-D8999, D9110-D9999

PCR – Plan All-Cause Readmissions ( M e d i c a r e - M e d i c a i d )

• Members 18 years and older

Number of acute inpatient stays during MY that were followed by an acute readmission for any Dx within 30 days.

CPT:

99221-99223, 99231-99233, 99238,

99239, 99251-99255, 99291

UB Revenue:

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

AWC – Adolescent Well-Care Visits ( M e d i c a i d )

• Members 12–21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.

• What makes the member compliant? Documentation in the medical record must include a

note indicating a visit to a PCP or OB/GYN practitioner, the date when the well-care visit occurred and evidence of all of the following: A health history.

A physical developmental history.

A mental developmental history.

A physical exam.

Health education/anticipatory guidance.

CPT:

99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395, 99461

ICD-9:

V20.2, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

HCPCS:

G0438, G0439

W15 – Well Child Visits in the First 15 Months of Life ( M e d i c a i d )

• Members who turned 15 months old during the measurement year and who had 0-6 well-child visits with a PCP during their first 15 months of life.


Documentation from the medical record must

include a note indicating a visit with a PCP, the date when the well-child visit occurred and evidence of all of the following:

A health history.

A physical developmental history.

A mental developmental history.

A physical exam.

Health education/anticipatory guidance.

CPT:

99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395, 99461

ICD-9:

V20.2, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

HCPCS:

G0438, G0439

W34 – Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life

• Members 3–6 years of age who had one or more well-child visits with a PCP during the measurement year.

• What makes the member compliant? Documentation must include a note indicating

a visit to a PCP, the date when the well-child visit occurred and evidence of all of the following: A health history. A physical developmental history. A mental developmental history. A physical exam. Health education/anticipatory guidance.

( M e d i c a i d )

CPT:

99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395, 99461

ICD-9:

V20.2, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

HCPCS:

G0438, G0439

• Women with live births between November 6, 2014-November 5, 2015

Timeliness of Prenatal Care – Women that received prenatal care in the first trimester or within 42 days of enrollment.

Postpartum Care- Women that had a postpartum visit within 21- 56 days after delivery.


Live births between November 6, 2014 and November 5, 2015

Prenatal-care visit to an OB/ GYN or other prenatal-care practitioner in the first trimester

Postpartum visit with an OB/ GYN within 21- 56 days of delivery

PPC- Prenatal and Postpartum Care ( M e d i c a i d )

(PPC)

CPT:

0500F-0502F, 59400, 59425, 59426, 59510, 59610, 59618, 76801, 76805, 76811, 76813, 76815-76821, 76825-76828, 80055, 86644, 86694-86696, 86762, 86777, 86900, 86901, 99201-99205, 99211-99215, 99241-99245, 99500

ICD-9: 88.78

HCPCS:

G0463, H1000, H1001, H1002, H1003, H1004, H1005

UB Revenue: 0514

CPT:

0503F, 57170, 58300, 59400, 59410, 59430, 59510, 59515, 59610, 59614, 59618, 59622, 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175, 99501

ICD-9:

V24.1, V24.2, V25.11, V25.12, V25.13, V72.31, V72.32, V76.2, 89.26

HCPCS:

G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091

LOINC:

10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5

UB Revenue: 0923

Prenatal Postpartum

• Women with live births between November 6, 2014-November 5, 2015 with the following number of expected prenatal visits:

<21% of expected visits

21%- 40% of expected visits



> 81% of expected visits


Live birth between November 6, 2014 and November 5, 2015

Prenatal visits done in the first, second, and third trimesters.

FPC- Frequency of Ongoing Prenatal Care ( M e d i c a i d )

• Members 18-85 years of age who had a dx of hypertension (HTN) on or before June 30 of the measurement year.


Members 18-59 years of age whose last BP of the measurement year was <140/90

Members 60-85 years of age with a diagnosis of Diabetes whose last BP of the measurement year was <140/90 mm Hg

Members 60-85 years of age without a diagnosis of Diabetes whose BP was <150/90mm Hg

CBP- Controlling High Blood Pressure ( M e d i c a i d & M e d i c a r e )

CPT:

99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99420, 99429, 99455, 99456, 3074F, 3075F, 3078F, 3079F

ICD-9:

401, 401.0, 401.1, 401.9

• Members 18-75 years of age, discharged alive from AMI, CABG or PCI

LDL-C screening.

LDL-C control (<100 mg/dL).

CMC- Cholesterol Management for Patients with Cardiovascular Conditions


CPT:

80061, 83700, 83701, 83704, 83721, 3048F, 3049F, 3050F

LOINC:

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

• Members 18 years of age and older that were hospitalized and discharged from July 1, 2014 to June 30, 2015


Hospitalized with a dx of AMI from July 1, 2014- June 30, 2015

Discharged with a persistent Beta- Blocker

Beta- Blocker treatment for 6 months after discharge

PBH- Persistence of Beta- Blocker Treatment After a Heart Attack


Prescriptions: • Carteolol • Nadolol • Propranolol • Carvedilol • Penbutolol • Timolol • Labetalol • Pindolol • Sotalol • Acebutolol • Betaxolol • Metoprolol • Atenolol • Bisoprolol • Nebivolol • Atenolol-chlorthalidone •Hydrochlorothiazide-metoprolol • Bendroflumethiazide-nadolol •Hydrochlorothiazide-propranolol • Bisoprolol-hydrochlorothiazide

• Members 40 years of age and older who had an acute inpatient discharge or ED visit

on or between January 1–November 30 of the measurement year and who were dispensed appropriate medications:

PCE- Pharmocotherapy Management of COPD Exacerbation

( M e d i c a r e a n d M e d i c a i d )

ICD-9:

493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.81, 493.82, 493.90, 493.91, 493.92, 496

Prescriptions:

Betamethasone, Dexamethasone, Hydrocortisone, Prednisolone, Prednisone, Triamcinolone, Methylprednisolone, Ipratropium, Tiotropium, Albuteral-ipratropium, Aclidinium-bromide, Albuterol, Arformoterol, Formoterol, Indacaterol, Levalbuterol, Metaproterenol, Pirbuterol, Salmeterol, Mometasone-formoterol, Budesonide-formoterol, Fluticasone-salmeterol, Aminophylline, Dyphilline, Theophylline, Dyphylline-guaifenesin, Guaifenesin-theophylline

• Members 66 years of age and older


Advance care planning

Medication Review

Functional status assessment

Pain assessment

COA- Care for Older Adults ( M e d i c a r e )

CPT:

90863, 99605, 99606, 1125F, 1126F, 1160F, 1170F

• Female members 67 years of age and older who have suffered a fracture who either had

• a bone mineral density (BMD) test or

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

OMW- Osteoporosis Management ( M e d i c a r e )

CPT-HCPCS:

76977, 77078, 77080, 77081, 77082, G0130, J0630, J0897, J1000, J1740, J3110, J3487, J3488, J3489

ICD-9-CM Procedure:

88.98

Prescriptions:

Alendronate, Alendronate-cholecalciferol, Calcium

carbonate-risedronate, Ibandronate, Risedronate,

Zoledronic acid, Conjugated estrogens, Conugated

estrogens synthetic, Esterifed estrogens, Estradiol,

Estradiol acetate,

Estradiol cypionate, Estradiol valerate, Estropipate,

Calcitonin, Denosumab, Raloxifene, Teriparatide,

Conjugated- estrogens- medroxy progesterone, Estradiol-

levonorgestrel, Estradiol-norethindrone, Estradiol-

norgestimate, Ethinyl estradiol-norethindrone

• Members 18 years of age and older

• a prescription for DMARD during 2014

ART- Rheumatoid Arthritis Management ( M e d i c a r e a n d M e d i c a i d )

HCPCS:

J0129, J0135, J0717, J0718, J1438,

J1600, J1602, J1745, J3262, J7502,

J7515, J7516, J7517, J7518, J9250,

J9260, J9310

Prescriptions:

Sulfasalazine, Cyclophosphamide,

Hydrochloroquine, Auranofin, Gold sodium

thiomalate, Leflunomide, Penicillamine,

Methotrexate, Abatacept, Adalimumab,

Anakinra, Certolizumab, Certolizumab pegol,

Etanercept, Golimumab, Infliximab,

Rituximab, Tocilizumab, Azathioprine,

Cyclosporine, Mycophenolate, Minocycline

• Members 18-75 years of age with Diabetes (type 1 or type 2) who had each of the following during the measurement year:

HbA1c testing

HbA1c control <7%

HbA1c control <8%

HbA1c poor control >9%

Medical attention for Nephropathy

BP control <140/90 mm Hg

Retinal Eye Exam

CDC- Comprehensive Diabetes Care ( M e d i c a i d & M e d i c a r e )


Lab results from the measurement year

Documentation in the medical record must include a note indicating date HbA1C was performed and the result

Documentation in the medical record must include a note indicating date of microalbumin test and the result

Evidence of ACE/ ARB therapy in the measurement year

A retinal eye exam by an eye care professional in the measurement year or a negative retinal exam by an eye care professional in the year prior to the measurement year.



Kidney Disease Monitoring (CDC)

CPT:

82042, 82043, 82044, 84156, 3060F, 3061F

LOINC:

11218-5, 12842-1, 12842-1, 13705-9, 13801-6, 14585-4, 14956-7, 14957-5, 14958-3, 14959-1, 1753-3, 1754-1, 1755-8, 1757-4, 18373-1, 20621-9, 21059-1, 21482-5, 26801-1, 27298-9, 2887-8, 2888-6, 2889-4, 2890-2, 30000-4, 30001-2, 30003-8, 32209-9, 32294-1, 32551-4, 34366-5, 35663-4, 40486-3, 40662-9, 40663-7, 43605-5, 43606-3, 43607-1, 44292-1, 47558-2, 49023-5, 50949-7, 53121-0, 53530-2, 53531-0, 53532-8, 56553-1, 57369-1, 58448-2, 58992-9, 59159-4, 60678-0, 63474-1, 9318-7

CPT:

2022F, 2024F, 2026F, 3072F, 67028, 67030, 67031, 67036, 67039, 67040, 67041, 67042, 67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225, 92226, 92227, 92228, 92230, 92235, 92240, 92250, 92260, 99203, 99204, 99205, 99213, 99214, 99215, 99242, 99243, 99244, 99245

HCPCS:

S0620, S0621, S0625, S3000

Eye Exam (CDC)


Cholesterol (CDC)

Screening:

CPT: 83036, 83037, 3044F, 3045F, 3046F

LOINC: 4548-4, 4549-2, 17856-6, 59261-8, 62388-4

Controlled:

CPT: 80061, 8370, 83701, 83704, 83721, 3048F, 3049F, 3050F

LOINC: 2089-1, 12773-8, 13457-7, 18261-8, 18262-6, 22748-8, 39469-2, 49132-4, 55440-2, 69419-0

Blood Sugar Controlled (CDC)

CPT:

83036, 83037, 3044F, 3045F, 3046F

LOINC:

4548-4, 4549-2, 17856-6

• The frequency of HIV disease monitoring lab tests performed in the calendar year.

• Eligible population are members of any age with HIV/AIDS as identified by at least one encounter with an ICD-9-CM diagnosis code listed below, during the first 6 months of the measurement year.

Frequency of HIV Disease Monitoring: Lab Test CD4

( M e d i c a i d )

ICD-9-CM:

042, 079.53, 795.71, V08

CPT:

86359, 86360, 86361, 88184, 88185,

88187, 88188, 88189

• Frequency of Viral Load tests performed.


Frequency of HIV Disease Monitoring: Lab Test, Viral Load

( M e d i c a i d )

ICD-9-CM:

042, 079.53, 795.71, V08

CPT:

87534, 87535, 87536

• The percentage of members with an AIDS diagnosis that have been prescribed Highly Active Anti-Retroviral Treatment.

• Eligible population are members of any age with AIDS as identified by at least one encounter with an ICD-9-CM diagnosis code listed below, during the first 6 months of the measurement year.

Highly Active Anti-Retroviral Treatment (HAART)

( M e d i c a i d )

ICD-9-CM: 042

HAART Regimen:

A) 3 single-agent antiretroviral medications

B) One 2-agent combination medication with one other antiretroviral medication (from “a” or “b”

C) One 3-agent combination medication

Note: Combinations of AZT & d4T with either a PI or NNRTI are not considered HAART.

• The percentage of members who were seen on an outpatient basis with HIV/AIDS as the primary diagnosis by a Physician, Physician assistant or Advanced Registered Nurse Practitioner for an HIV-related medical visit within the measurement year.


HIV- Related Outpatient Medical Visits (HIVV)

( M e d i c a i d )

ICD-9-CM:

042, 079.53, 795.71 or V08

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