8D6 5(3257,1* 2015 REPORTS GUIDE

Transcription

1 D 2015 REPORTS GUIDE

2 UDS Reporting Guide Overview Requirements Changes in Service Area Table 3a Universal Patients by Age and Gender Table 3b Patients By Race, Ethnicity and Language Table 4 Universal Selected Patient Characteristics Table 4 (continued) Table 5 Universal Staffing and Utilization TABLE 5 (Continued) Table 6a Universal Selected Diagnosis and Services Rendered TABLE 6A (Continued) Selected Services rendered TABLE 6A (Continued) Selected Services rendered Table 6b Quality of Care Indicators Lines 1 9 Prenatal Care Line 10 Childhood Immunization Line 11 Cervical Cancer Screening Line 12 Weight Assessment and Counseling for Children and Adolescents Line 13 Adult Weight Screening and Follow Up Line 16 Asthma Pharmacologic Therapy Line 19 Colorectal Cancer Screening Line 20 Newly Identified HIV Cases with Timely follow Up Line 21 Depression Screening and Follow Up Table 7 Health Outcomes and Disparities Universal Table 7 (continued) Table 7 (continued) Table 9 Patient Related Revenue How Table 9 is calculated in MicroMD PM: Table of Contents 1

3 UDS REPORTING GUIDE OVERVIEW This document contains a basic reference to assist users in understanding UDS Reporting. We have organized these tables by report and table. Users will also find directions for finding the appropriate location within MicroMD where the system actually pulls information to create the report. Requirements The information in this document is effective for MicroMD PM version or higher. Please contact MicroMD support staff to upgrade from an earlier version. CHANGES IN 2015 Please see the chapter for the specified table for more details. Table 4: Line 9a added for tracking patients who are insured by both Medicare and Medicaid. Table 6a: Line 1 2a (Newly Diagnosed HIV) removed. New Column added to show valid ICD 10 Codes. Table 7: Column removed from Diabetes section of the report. Populating Hypertension and Diabetes data from MicroMD EMR. Overview 1

4 SERVICE AREA Line # Description All Reporting Period: 1/1/2014 through 12/31/2014 Patients By ZIP CODE Zip Code (a) None / Uninsured (b) Medicaid/CHIP/ Other Public (c) Medicare (d) Private Insurance (e) Other Zip Codes Unknown Zip Code TOTAL This report is a listing of patients (and their primary insurance plans) by zip code. Insurance is pulled from the Active Primary Plan of the Primary Medical Plan Set (in Patient Profile Detail). ZIP Codes with ten (10) or fewer patients are reported in the Other Zip Codes line. The Service Date must be within the specified date range on the report. The total number of patients should match with the totals for Table 3a. 2 Service Area

5 TABLE 3A UNIVERSAL PATIENTS BY AGE AND GENDER Line # Description 1 38 Reporting Period: January 1, 2014 through December 31, 2014 TABLE 3A UNIVERSAL PATIENTS BY AGE AND GENDER Age Groups Male Patients (a) UDS Reporting Guide MicroMD Female Patients (b) Number of Patients 1 Under age Age Age Age Age Age Age Age Age Age Age Age Age Age Age Age Age Age Age Age Age Age Age Age Age Ages Ages Ages Ages Ages Aged Ages Ages Ages Ages Ages Table 3a Universal Patients by Age and Gender 3

6 37 Ages Age 85 and over TOTAL PATIENTS (Sum lines 1 38) Number of males and females in each age or age range. Un duplicated users. The Service Date must be within the specified date range on the report. Total patients on 3A must equal Total Patients on Table 3B Line 8 and Table 4 Line 6. Data comes from the Patient Demographics screen. For Patients where age < 1, report looks at patients born 7/1 of the previous year thru 12/ 31 of the reporting year.* *Age is calculated by the age of the patient as of the date entered into the Age computed as of field on the Report Options Screen. 4 Table 3a Universal Patients by Age and Gender

7 TABLE 3B PATIENTS BY RACE, ETHNICITY AND LANGUAGE Line # All (1 8) Description Reporting Period: January 1, 2014 through December 31, 2014 TABLE 3B UNIVERSAL PATIENTS BY RACE, ETHNICITY AND LANGUAGE PATIENTS BY RACE HISPANIC NON HISPANIC UNREPORTED / REFUSED TOTAL NUMBER OF PATIENTS 1. Asian a. Native Hawaiian b. Other Pacific Islander TOTAL HAWAIIAN/PACIFIC ISLANDER (SUM LINES 2a + 2b) Black or African American American Indian / Alaska Native (including Latino or Hispanic) White (including Latino or Hispanic Descent) More than one Race Unreported / Refused to report TOTAL PATIENTS (SUM LINES TO 7) USERS BY LANGUAGE NUMBER (A) NUMBER OF PATIENTS PATIENTS BEST SERVED IN A LANGUAGE OTHER THAN ENGLISH 15 Number of patients in each race and ethnicity. Un duplicated Users. The Service Date must be within the specified date range on the report. Race, Ethnicity and Language are all pulled from Patient Demographics. Table 3b Patients By Race, Ethnicity and Language 5

8 TABLE 4 UNIVERSAL SELECTED PATIENT CHARACTERISTICS Line # Description 1 6 Reporting Period: January 1, 2014 through December 31, 2014 TABLE 4 UNIVERSAL SELECTED PATIENT CHARACTERISTICS CHARACTERISTIC NUMBER OF PATIENTS (a) INCOME AS A PERCENT OF POVERTY LEVEL % and below % % 5 4. Over 200% Unknown TOTAL (SUM LINES 1 5) 240 Income as a percent of poverty level. Comes from Family Size/Income on Patient Profile Detail. Poverty amounts are set on the report options screen PRINCIPAL THIRD PARTY MEDICAL INSURANCE SOURCE 0 17 YEARS OLD (a) 18 AND OLDER (b) 7. None / Uninsured a. Regular Medicaid (Title XIX) 5 4 8b. CHIP Medicaid Total Medicaid (Line 8a+8b) Medicare (Title XVIII) 1 5 9a. Dually Eligible (Medicare + Medicaid) 1 2 (This is a subset of Line 9) 10a. Other Public Insurance Non CHIP (Specify:) b. Other Public Insurance CHIP Total Public Insurance (Line 10a+10b) Private Insurance TOTAL (Sum Lines ) Principal Third Party Medical Insurance Source Pulled from the Active Primary Plan of the Primary Medical Planset (in Patient Profile Detail). New this year: Line 9a tracks patients who have Primary Medicare and Secondary Medicaid. 6 Table 4 Universal Selected Patient Characteristics

9 TABLE 4 (CONTINUED) 13A 13C MANAGED CARE UTILIZATION Payor Category Medicaid (a) Medicare (b) UDS Reporting Guide MicroMD Other Public Including Non Medicaid S CHIP (c) Private (d) 13a. Capitated Member Months b. Fee for service Member Months c. TOTAL MEMBER MONTHS (13A + 13B) Managed Care Utilization. Pulled from the Primary Plans of the Primary Medical Planset (in Patient Profile Detail) with effective dates during the service period. Compares the plan s effective start date and effective end date and counts the range that occurs within the reporting period. This is used to determine the number of months CHARACTERISTICS SPECIAL POPULATIONS NUMBER OF PATIENTS (A) 14. MIGRANT (330g grantees only) SEASONAL (330g grantees only) PERMANENT (330g grantees only) TOTAL AGRICULTURAL WORKERS OR DEPENDENTS (All grantees report this line) Homeless Shelter (330h grantees only) Transitional (330h grantees only) Doubling Up (330h grantees only) Street (330h grantees only) Other (330h grantees only) Unknown (330h grantees only) TOTAL HOMELESS (All grantees report this line) TOTAL SCHOOL BASED HEALTH CENTER PATIENTS 2 (All grantees report this line) 25. TOTAL VETERANS (All grantees report this line) PUBLIC HOUSING PATIENTS (All grantees report this line) 1 Characteristics Special Populations. Pulled from the Patient Profile tab in the Social section. Total (e) Table 4 (continued) 7

10 TABLE 5 UNIVERSAL STAFFING AND UTILIZATION Line # Description All (1 34) Reporting Period: January 1, 2004 through December 31, 2004 TABLE 5 UNIVERSAL STAFFING AND UTILIZATION Personnel by Major Service Category FTEs (a) Clinic Visits (b) Patients (c) Family Practitioners General Practitioners Internists Obstetrician / Gynecologists Pediatricians Other Specialty Physicians Total Physicians (Lines 1 7) a Nurse Practitioners b Physician Assistants Certified Nurse Midwives a Total Mid Level Practitioners Nurses Other Medical Personnel Laboratory Personnel X Ray Personnel Total Medical (Lines 8+10a 14) Dentists d Hardware Staff Dental Hygienists Communication to the Mute Dental assistants, Aids, Techs Total Dental Services (Lines 16 18) a Psychiatrists a1 Licensed Clinical Psychologists a2 Licensed Clinical Social Workers b Other Licensed Mental Health Providers c Other Mental Health Staff Mental Health (Lines 20a c) Substance Abuse Services Other Professional Services (Specify ) 22a Ophthalmologists b Optometrists c Optometric Assistants d Total Vision Services (Lines 22a c) Pharmacy Personnel Case Managers Patient / Community Education Specialists Outreach workers Transportation Staff a Eligibility Assistance Workers Table 5 Universal Staffing and Utilization

11 TABLE 5 (Continued) 27b Interpretation Staff Other Enabling Services Total Enabling Services (Lines 24 28) a Other Programs / Services 0.00 (Specify ) 30a Management and Support Staff b Fiscal and Billing Staff c IT Staff Total Administration Staff (Lines 30a c) Facility Staff Patient Support Staff Total Admin & Facility (Lines 30 32) TOTAL (Lines d a+33) Must create service categories in Practice Setup under Aux > MicroMD CHC > Setup > Practice (Service Categories Tab). Must have Service Category linked to procedures in Aux > MicroMD CHC > Setup > Procedures if they are to be counted as an encounter/visit. Must have Provider Information completed in the provider section under Aux > MicroMD CHC > Setup > Provider indicating the major service category they are linked to for the report. Must not have duplicate count between major service categories. Un duplicated totals for patient column within each major service category. Client must calculate each provider s full time equivalency and link it to the provider detail under MicroMD CHC > Setup. TABLE 5 (Continued) 9

12 TABLE 6A UNIVERSAL SELECTED DIAGNOSIS AND SERVICES RENDERED Line # Description 1 20d Reporting Period: January 1, 2014 through December 31, 2014 TABLE 6A UNIVERSAL SELECTED DIAGNOSIS AND SERVICES RENDERED Diagnostic Category Selected Infections and Parasitic Diseases Applicable ICD 9 CM Code Applicable ICD 10 CM Code Visits with diagnosis Regardless of primacy (A) Total Patients with diagnosis Regardless of primacy (B) 1 2. Symptomatic and Asymptomatic HIV 042, , V08 B20, B97.35, O98.7, Z Tuberculosis 010.xx 018.xx A15 thru A Syphilis and other sexually transmitted diseases 090.xx 099.xx 4a. Hepatitis B , , , V b. Hepatitis C , , , , , , V02.62 Selected Diseases of the Respiratory System A50 thru A64 (Exclude A63.0), M02.3, N34.1 B16.0 B16.2, B16.9,B17.0, B18.0, B18.1, B19.10, B19.11, Z22.51 B17.10, B17.11, B18.2, B19.20, B19.21, Z Asthma 493.xx J Chronic Bronchitis and emphysema 490.xx 492.xx J40 thru J44, and J47 Selected Other Medical Conditions 7. Abnormal breast findings, female 174.xx, , 233.0x, 283.3, 793.8x 8. Abnormal cervical findings 180.xx, , 233.1x, 795.0x C50.01, C50.11, C50.21, C50.31, C50.41, C50.51, C50.61, C50.71, C50.81, C50.91, C79.81, D48.6, R92 C53, C79.82, D06, R87.61, R87.810, R Diabetes mellitus 250.xx, 648.0x E1 thru E13, O24 (Exclude O24.41) 10. Heart disease (selected) 391.xx 392.0x, 410.xx 429.xx I01, I02 (exclude I02.9), I20 thru I25, I 26 thru I28, I30 thru I Hypertension 401.xx 405.xx I10 thru I Contact dermatitis and other eczema 692.xx L23 thru L25, L30 (Exclude L30.1, L30.3, L30.5, L30.5), L55 thru L59 (Exclude L57.0 thru L57.4) Dehydration 276.5x E Exposure to heat or cold 991.xx 992.xx T33.XXXA, T34.XXXA, T67.XXXA, T68.XXXA, T69.XXXA a. Overweight and obesity ICD 9: or V85.xx excluding V85.0, V85.1, V85.51, V85.52 E66, Z68 (Excluding Z68.1, Z , Z68.51, Z68.52 Will count diagnosis codes referenced by a transaction line (regardless of whether or not the code is the primary diagnosis). Must have the service date in date range specified. New this year: This report will look at both ICD 9 and ICD 10 codes. The visit will be counted as long as long as the diagnosis code matches either the referenced ICD 9 OR ICD 10 codes. Also, Line 1 2a (First time diagnosis of HIV) has been removed Table 6a Universal Selected Diagnosis and Services Rendered

13 TABLE 6A (Continued) Line # Description Selected Childhood Conditions (limited to ages 0 thru 17) 15. Otitis media and eustachian tube disorders 381.xx 382.xx H65 thru H Selected perinatal medical conditions 17. Lack of expected normal physiological development (such as delayed milestone; failure to gain weight; failure to thrive); Nutritional deficiencies in children only. Does not include sexual or mental development, 770.xx; 771.xx; 773.xx; 774.xx 779.xx (excluding 779.3x) 260.xx 269.xx (excluding 268.2) 779.3x 783.3x 783.4x Selected Mental Health and Substance Abuse Conditions 18. Alcohol related disorders 291.xx; 303.xx; 305.0x; 357.5x 19. Other substance related disorders (excluding tobacco use disorders) 292.1x 292.8x, 292.9, 304.xx, 305.2x 305.9x; 357.6x, 648.3x A33, P20 thru P29 (excluding P22.0, P29.3); P35 thru P96 (excluding P50, P52, P54, P91.6, P92, P96.81), R78.81, R78.89 E40 E46, E50 thru E63 (excluding E64), P92, R62 (excluding R62.7), R63.2, R F10, G F11 thru F19 (excluding F17), G62.0, O a. Tobacco use disorder F a. Depression and other mood disorders 296.xx; 330.4, ; 311.xx 20b. Anxiety disorders including PTSD 300.0x; 300.2x; 300.3; 308.3; c. Attention deficit and disruptive behavior disorders 20d. Other mental disorders (includes mental retardation) 312.8x; 312.9x; ; 314.xx 290.xx, 293.xx 302.xx (excluding 296.xx, 300.0x, 300.2x, 300.3, 300.4, ) 306.xx 319.xx (excluding 307.xx, 308.3, , 311.xx, 312.8x, 312.9x, , 314.xx) F30 thru F F40 thru F42, F43.0, F F90 thru F F01 thru F09, F20 thru F29, F43 thru F48 (excluding F43.1), F50 thru F59 (excluding F55), F60 thru F99 (excluding F84.2, F90, F91, F98), R45.1, R45.2, R45.5, R45.6, R45.7, R45.81, R45.82, R Will count diagnosis codes referenced by a transaction line (regardless of whether or not the code is the primary diagnosis). Must have the service date in date range specified. New this year: This report will look at both ICD 9 and ICD 10 codes. The visit will be counted as long as the diagnosis code matches either the referenced ICD 9 OR ICD 10 codes. Table 6a Universal Selected Diagnosis and Services Rendered 11

14 TABLE 6A (CONTINUED) SELECTED SERVICES RENDERED Line # Description 21 26d. Service Category Applicable ICD 9 CM or CPT 4 Code Applicable ICD 10 CM or CPT 4 Code Number of Visits (A) Number of Patients (B) Selected Diagnostic Tests/Screening/Preventative Services 21. HIV test CPT 4:86698; ; a. Hepatitis B test CPT 4:86704, 86706, b. Hepatitis C test CPT 4: , Mammogram CPT 4: 77052, 77057; OR ICD 9: v76.11, v Pap test CPT 4: ; , OR ICD 9: V72.3; V72.31; V72.32; V Selected immunizations: Hepatitis A, Hemophilus, Influenza B (HiB), Influenza virus, Pneumococcal, Diphtheria, Tetanus, Pertussis (DTaP) (DTP) (DT), Mumps, Measles, Rubella, Poliovirus, Varicella, Hepatitis B (child) CPT 4: ; ; 90670; ; ; ; ; a. Seasonal Flu Vaccine CPT 4: , , CPT 4:86698; ; CPT 4:86704, 86706, CPT 4: , CPT 4: 77052, 77057; OR ICD 10: Z12.31 CPT 4: ; , OR ICD 10: Z01.41 Z01.42, Z12.4 CPT 4: ; ; 90670; ; ; ; ; CPT 4: , , Contraceptive management ICD 9: V25.xx ICD 10: Z Health supervision of an infant or child (ages 0 thru 11) 26a. Childhood lead test screening (9 to 72 months) 26b. Screening, Brief Intervention, and Referral (SBIRT) 26c. Smoke/tobacco counseling: Smoking cessation treatment 26d. Comprehensive and intermediate eye exams CPT 4: ; CPT 4: ; CPT 4: CPT 4: CPT 4: CPT 4: CPT 4: and 99407; HPCS: S9075 CPT II: 4000F, 4001F CPT 4: 92002, 92004, 92012, CPT 4: and 99407; HPCS: S9075 CPT II: 4000F, 4001F CPT 4: 92002, 92004, 92012, TABLE 6A (Continued) Selected Services rendered

15 TABLE 6A (CONTINUED) SELECTED SERVICES RENDERED Line # Description Service Category Applicable ICD 9 CM or CPT 4 Code Applicable ICD 10 CM or CPT 4 Code Number of Visits (A) Number of Patients (B) Selected Dental Services 27. I. Emergency Services ADA: D9110 ADA: D II. Oral Exams ADA: D0120, D0140, D0145, D0150, D0160, D0170, D0171, D0180 ADA: D0120, D0140, D0145, D0150, D0160, D0170, D0171, D Prophylaxis adult or child ADA: D1110, D1120 ADA: D1110, D Sealants ADA: D1351 ADA: D Fluoride treatment adult or child ADA: D1206, D1208 ADA: D1206, D III. Restorative Services ADA: D21xx D29xx ADA: D21xx D29xx IV. Oral Surgery (extractions only) ADA: D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, D7260, D7261, D7270, D72712, D7280, D7290 D V. Rehabilitative services (Endo, Perio, Prostho, Ortho) ADA: D3xxx, D4xxx, D5xxx, D6xxx, D8xxx ADA: D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, D7260, D7261, D7270, D72712, D7280, D7290 D7294 ADA: D3xxx, D4xxx, D5xxx, D6xxx, D8xxx Counts both procedure codes and diagnosis codes (for certain lines). Will count diagnosis codes referenced by a transaction line (regardless of whether or not the code is the primary diagnosis). Must have the service date in date range specified. New this year: This report will look at both ICD 9 and ICD 10 codes. The visit will be counted as long as long as the diagnosis code matches either the referenced ICD 9 OR ICD 10 codes. (on lines that are looking for diagnosis codes). TABLE 6A (Continued) Selected Services rendered 13

16 TABLE 6B QUALITY OF CARE INDICATORS Lines 1-9 Prenatal Care Line # Sec. A & B (lines 1 9) Description Pregnancy data is listed in the Pregnancy History section of the Patient Profile Detail tab of Patient Detail. This section will be hidden unless Prenatal User is checked. This section shows pregnancy information entered in PM, as well as those entered into Pregnancy History in the EMR. Entering a pregnancy into this section in the PM will create a new Pregnancy History record in the EMR. A 1 6 Reporting Period: January 1, 2014 through December 31, 2014 TABLE 6B QUALITY OF CARE INDICATORS UNIVERSAL Section A Age Categories for Prenatal Patients DEMOGRAPHIC CHARACTERISTICS OF PRENATAL CARE PATIENTS AGE NUMBER OF PATIENTS (a) 1. Less than 15 years 1 2. Ages Ages Ages Ages 45 and older 1 6. TOTAL PATIENTS (SUM LINES 1 5) 2 Prenatal User must be checked on the Patient Profile Detail tab of Patient Detail. A pregnancy must exist where EITHER the first care date OR the delivery date is within the service date range of the report. B 7 9 Section B Trimester of Entry into Prenatal Care Trimester of first known visit for women receiving prenatal care during reporting year Women having first visit with grantee (a) Women having first visit with another provider (b) 7. First trimester Second trimester Third trimester 0 0 Prenatal User must be checked on the Patient Profile Detail tab of Patient Detail. A pregnancy must exist where EITHER the first care date OR the delivery date is within the service date range of the report. 14 Table 6b Quality of Care Indicators

17 Clinical Data Instructions Table 6b (10 21) is different from the rest of the UDS tables. These lines closely resemble Clinical Quality Measures. In the PM, there is a window that shows whether or not a particular patient currently meets the criteria for these measures. NOTE For a patient to appear anywhere on the UDS report, they must have a qualifying visit. If a patient does not appear in Table 3a of the UDS reports, they will not appear anywhere else in the UDS reports. Figure 1 1 CHC UDS Clinical Data window To determine if a patient currently meets the criteria for these measures, follow the steps below. Procedure 1. Go to Maint > Patient and select a patient. 2. Double click the patient to open the Patient Detail window. Details Table 6b Quality of Care Indicators 15

18 3. Go to the Patient Profile Detail tab and click the Clinical Quality Measure Data at the bottom of the window. This opens the Patient CHC UDS Clinical Data window (shown below). If the practice is PM only (does not use the MicroMD EMR), each criteria in this window can be checked off if it applies to that patient for the selected year. If the practice also uses the MicroMD EMR, the checkboxes will not be available for manual updating. However, by selecting a year and clicking the Refresh from EMR button. This will refresh the patient s data from the EMR. An overnight process runs each day to update this data based on things that have changed in the EMR. However, if a practice feels that the numbers are not up to date, the UDS Clinical data can be manually refreshed for all patients. 4. Open Aux > MicroMD CHC > Utilities > Refresh Clinical Data 5. Click the Refresh All from EMR button. As noted on the window, this will refresh the Clinical Quality Measures data from the EMR, which will be displayed in table 6b. 16 Table 6b Quality of Care Indicators

19 Line 10 Childhood Immunization Procedure Description Denominator: Numerator: Details The performance measure is Percentage of children with their 3rd birthday during the measurement year or January 1st of the following year who are fully immunized before their third birthday. This is similar to NQF 0038, except there are differences in dates and which vaccinations are needed. Patients whose 3rd birthday occurs during the measurement year AND Who have had at least 1 Encounter of Office Visit or Face to Face Interaction or Preventive Care Established Office Visit, 0 to 17 or Preventive Care Initial Office Visit, 0 to 17 or Home Healthcare Services during the Measurement period (This encounter must occur before the Patient s 3rd birthday). Encounters with Encounter Level Specified (CPT codes) NOTE Reporting will also look at Encounter Plan Procedure Orders for Face to Face Interaction ( codes). (Must also fit criteria to be on the UDS report, if a patient is not listed in table 3a, they will not be counted in table 6a.) Number of children among those included in the denominator who were fully immunized before their 3rd birthday. A child is fully immunized if s/he has been vaccinated or there is documented evidence of contraindication for the vaccine or a history of illness for ALL of the following prior to their third birthday. (10a) 4 DTP/DTaP (10b) 3 IPV (10c) 1 MMR (10d) 3 Hib (10e) 3 HepB (10f) 1VZV (Varicella) (10g) 4 Pneumococcal conjugate How to meet each condition for this measure, found in the PM under Maint > Patient Details > Patient Profile Detail > Clinical Quality Measure Data Table 6b Quality of Care Indicators 17

20 10a [Used to calculate Numerator] An initial DTaP vaccination followed by at least three DTaP, DT or individual diphtheria and tetanus shots, on or before the child's third birthday. Vaccines administered prior to 42 days after birth cannot be counted. (Count as compliant anyone who is allergic to DTaP vaccine or who has encephalopathy or progressive neurological disorder.) *Patients who received 4 or more DTaP Immunizations (see code list) *Date Range > =42 days and < 36 months after patient s date of birth. Encounter Plan > Immunization Orders (CPT and codes of Vaccine Administered) MedInfo > Health Maintenance > Immunizations (CVX codes of Vaccine) OR *Patient has diagnosis of Encephalopathy or Anaphylactic Reaction to DTaP Vaccine (see code list for ICD and codes) * Date Range: Beginning date prior to end of the measurement period and end date (if exists) to be prior to end of the measurement period MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes) OR *Patient has a Medication Allergy of DTaP Vaccine MedInfo > Medical > Allergies (use allergy with a description that includes DTap or Dipht or Diphtheria ) 18 Table 6b Quality of Care Indicators

21 10b [Used to calculate Numerator] At least three polio vaccinations (IPV) with different dates of service on or before the child's third birthday. IPV administered prior to 42 days after birth cannot be counted. (Count as compliant anyone who is allergic to IPV vaccine, neomycin, streptomycin or polymyxin.) *Patients who received 3 or more Inactivated Polio Vaccine (IPV) Immunizations (see code list) *Date Range > =42 days and < 36 months after patient s date of birth. Encounter Plan > Immunization Orders (CPT and codes of Vaccine Administered) MedInfo > Health Maintenance > Immunizations CVX codes of Vaccine) OR *Patient has diagnosis of Anaphylactic Reaction to Inactivated Polio Vaccine (IPV) or Anaphylactic Reaction to Streptomycin or Anaphylactic Reaction to Polymyxin or Anaphylactic Reaction to Neomycin (see code list for codes) * Date Range: Beginning date prior to end of the measurement period and end date (if exists) prior to end of the measurement period MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes) OR *Patient has a Medication Allergy of IPV Vaccine or Polio or Streptomycin or Neomycin or Polymyxin MedInfo > Medical > Allergies (use allergy with a description that includes IPV or polio or Streptomycin or Polymyxin or Neomycin ) Table 6b Quality of Care Indicators 19

22 10c [Used to calculate Numerator] At least one measles, mumps and rubella (MMR) vaccination on or before the child's third birthday. (Count as compliant anyone who is allergic to MMR vaccine (or its individual vaccines) or who has ever had cancer of lymphoreticular or histiocytic tissue, or who currently has HIV disease, multiple myeloma, leukemia, or immunodeficiency). *Patients who received 1 or more Measles, Mumps and Rubella (MMR) Vaccine Immunizations (see code list) *Date Range < 36 months after patient s date of birth. Encounter Plan > Immunization Orders (CPT and codes of Vaccine Administered) MedInfo > Health Maintenance > Immunizations (CVX codes of Vaccine) OR *Patient has diagnosis of Disorders of the Immune System or HIV or Malignant Neoplasm of Lymphatic Tissue or Anaphylactic Reaction to Neomycin (see code list for ICD and codes) * Date Range: Beginning date prior to end of the measurement period and end date (if exists) prior to end of the measurement period. MedInfo > Medical > Problem List (Active, Inactive or Resolved) Medical Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes) OR *Patient has a Medication Allergy of M:MR Vaccine or Neomycin MedInfo > Medical > Allergies (use allergy with a description that includes MMR or measles or mumps or rubella or Neomycin ) OR **Patient met all of the following conditions: a) Patient had diagnosis of Measles (see code list for ICD and codes) *** Date Range: Beginning date prior to end of the measurement period and end date (if exists) prior to end of the measurement period MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) 20 Table 6b Quality of Care Indicators

23 MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes) OR ***Patient had Measles Antigen Test done with result As Seropositive' (see code list for LOINC codes) ***Date Range: Beginning date prior to end of the measurement period MedInfo > Medical > Lab Results AND b) Patient had diagnosis of Mumps (see code list for ICD and codes) *** Date Range: Beginning date prior to end of the measurement period and end date (if exists) prior to end of the measurement period MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes) OR ***Patient had Mumps Antigen Test done with result As 'Seropositive' (see code list for LOINC codes) ***Date Range: Beginning date prior to end of measurement period MedInfo > Medical > Lab Results AND c) Patient had diagnosis of Rubella (see code list for ICD and codes) *** Date Range: Beginning date prior to end of the measurement period and end date (if exists) prior to end of the measurement period. MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) Table 6b Quality of Care Indicators 21

24 MedInfo > Orders > Laboratory Orders (Diagnosis codes) OR ***Patient had Rubella Antigen Test done with result As 'Seropositive' (see code list for LOINC codes) ***Date Range: Beginning date prior to end of measurement period MedInfo > Medical > Lab Results 10d [Used to calculate Numerator] Two H influenza type B (HiB) vaccinations, with different dates of service on or before the child's third birthday. HiB administered prior to 42 days after birth cannot be counted. (Count as compliant anyone who is allergic to HiB vaccine). *Patients who received 3 or more Haemophilus Influenza B (HiB) Vaccine Immunizations (see code list) *Date Range >= 42 days and < 36 months after patient s date of birth. Encounter Plan > Immunization Orders (CPT and codes of Vaccine Administered) MedInfo > Health Maintenance > Immunizations (CVX codes of Vaccine) OR *Patient has diagnosis of Anaphylactic Reaction to Haemophilus Influenza B (HiB) Vaccine (see code list for codes) * Date Range: Beginning date prior to end of the measurement period and end date (if exists) prior to end of the measurement period MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes) OR *Patient has a Medication Allergy of Haemophilus Influenza B (HiB) Vaccine MedInfo > Medical > Allergies (use allergy with a description that includes Hemophilus or Haem ) 22 Table 6b Quality of Care Indicators

25 10e [Used to calculate Numerator] Three hepatitis B vaccinations, with different dates of service on or before the child's third birthday. (Count as compliant anyone who is allergic to the hepatitis B vaccine or Baker's Yeast.) *Patients who received 3 or more Hepatitis B Vaccine Immunizations (see code list) *Date Range: < 36 months after patient s date of birth. Encounter Plan > Immunization Orders (CPT and codes of Vaccine Administered) MedInfo > Health Maintenance > Immunizations (CVX codes of Vaccine) OR *Patient has diagnosis of Anaphylactic Reaction to Hepatitis B Vaccine or Anaphylactic Reaction to Common Baker's Yeast or Hepatitis B (see code list for ICD and codes) * Date Range: Beginning date prior to end of the measurement period and end date (if exists) prior to end of the measurement period MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes) OR *Patient has a Medication Allergy of Hepatitis B Vaccine or Yeast MedInfo > Medical > Allergies (use allergy with a description that includes hepatitis B or yeast ) OR *Patient had Hepatitis B Antigen Test done with result As 'Seropositive' (see code list for LOINC codes) *Date Range: Beginning date prior to end of the Measurement period MedInfo > Medical > Lab Results Table 6b Quality of Care Indicators 23

26 10f [Used to calculate Numerator] At least one chicken pox vaccination (VZV) on or after the child's first birthday and on or before the child's third birthday. (Count as compliant anyone who is allergic to the VZV vaccine, or who has ever had cancer of lymphoreticular or histiocytic tissue, or who currently has HIV disease, multiple myeloma, leukemia, or immunodeficiency). *Patients who received 1 or more Varicella Zoster Vaccine (VZV) Immunizations (see code list) *Date Range >= 12 months and < 36 months after patient s date of birth. Encounter Plan > Immunization Orders (CPT and codes of Vaccine Administered) MedInfo > Health Maintenance > Immunizations (CVX codes of Vaccine) OR *Patient has diagnosis of Disorders of the Immune System or HIV or Malignant Neoplasm of Lymphatic Tissue or Anaphylactic Reaction to Neomycin or Varicella Zoster (see code list for ICD and codes) * Date Range: Beginning date prior to end of the measurement period and end date (if exists) prior to end of the measurement period MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes) OR *Patient has a Medication Allergy of Varicella Zoster Vaccine or Neomycin MedInfo > Medical > Allergies (use allergy with a description that includes Varicella or VZV or zoster or Neomycin ) OR *Patient had Varicella Zoster Antigen Test done with result As 'Seropositive' (see code list for LOINC codes) *Date Range: Beginning date prior to end of the Measurement period MedInfo > Medical > Lab Results 24 Table 6b Quality of Care Indicators

27 10g [Used to calculate Numerator] At least four pneumococcal conjugate vaccinations on or before the child's third birthday. (Count as compliant anyone who is allergic to the pneumococcal conjugate vaccine). *Patients who received 4 or more Pneumococcal Conjugate Vaccine Immunizations (see code list) *Date Range < 36 months after patient s date of birth. Encounter Plan > Immunization Orders (CPT and codes of Vaccine Administered) MedInfo > Health Maintenance > Immunizations (CVX codes of Vaccine) OR *Patient has diagnosis of Anaphylactic Reaction to Pneumococcal Conjugate Vaccine (see code list for codes) *Date Range: Beginning date prior to end of the measurement period and end date (if exists) prior to end of the measurement period MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes) OR *Patient has a Medication Allergy of Pneumococcal Conjugate Vaccine MedInfo > Medical > Allergies (use allergy with a description that includes pneumoc ) Code Lists for Measure Diagnosis, Active: Anaphylactic Reaction to Common Baker's Yeast: Diagnosis, Active: Anaphylactic Reaction to DTaP Vaccine: , , , , Table 6b Quality of Care Indicators 25

28 Diagnosis, Active: Anaphylactic Reaction to Haemophilus Influenza B (HiB) Vaccine: Diagnosis, Active: Anaphylactic Reaction to Hepatitis B Vaccine: Diagnosis, Active: Anaphylactic Reaction to Inactivated Polio Vaccine (IPV): Diagnosis, Active: Anaphylactic Reaction to Neomycin: Diagnosis, Active: Anaphylactic Reaction to Pneumococcal Conjugate Vaccine: Diagnosis, Active: Anaphylactic Reaction to Polymyxin: Diagnosis, Active: Anaphylactic Reaction to Streptomycin: Diagnosis, Active: Disorders of the Immune System: ICD9 Diagnosis, Active: Disorders of the Immune System: ICD , , , , , , , , , , , , , 279.2, 279.3, , , , , , , 279.8, D80.0, D80.1, D80.2, D80.3, D80.4, D80.5, D80.6, D80.7, D80.8, D80.9, D81.0, D81.1, D81.2, D81.6, D81.7, D81.89, D81.9, D82.0, D82.1, D82.2, D82.3, D82.4, D82.8, D82.9, D83.0, D83.1, D83.2, D83.8, D83.9, D84.0, D84.1, D84.8, D84.9, D89.3, D89.810, D89.811, D89.812, D89.813, D89.82, D89.89, D89.9, M Table 6b Quality of Care Indicators

29 Diagnosis, Active: Disorders of the Immune System: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators 27

30 Diagnosis, Active, Resolved: Encephalopathy: ICD9 Diagnosis, Active, Resolved: Encephalopathy: ICD10 Diagnosis, Active, Resolved: Encephalopathy: Diagnosis, Active: HIV: ICD9 Diagnosis, Active: HIV: ICD10 Diagnosis, Active: HIV: Diagnosis, Active, Inactive: Hepatitis B: ICD9 Diagnosis, Active, Inactive: Hepatitis B: ICD10 Diagnosis, Active, Inactive: Hepatitis B: G04.01, G04.02, G , , , , , , , , , , , , , V08 B20, Z , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , V02.61 B16.0, B16.1, B16.2, B16.9, B17.0, Z , , , , , , , , , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators

31 Diagnosis, Active: Malignant Neoplasm of Lymphatic Tissue: ICD , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators 29

32 Diagnosis, Active: Malignant Neoplasm of Lymphatic Tissue: ICD10 C81.00, C81.01, C81.02, C81.03, C81.04, C81.05, C81.06, C81.07, C81.08, C81.09, C81.10, C81.11, C81.12, C81.13, C81.14, C81.15, C81.16, C81.17, C81.18, C81.19, C81.20, C81.21, C81.22, C81.23, C81.24, C81.25, C81.26, C81.27, C81.28, C81.29, C81.30, C81.31, C81.32, C81.33, C81.34, C81.35, C81.36, C81.37, C81.38, C81.39, C81.40, C81.41, C81.42, C81.43, C81.44, C81.45, C81.46, C81.47, C81.48, C81.49, C81.70, C81.71, C81.72, C81.73, C81.74, C81.75, C81.76, C81.77, C81.78, C81.79, C81.90, C81.91, C81.92, C81.93, C81.94, C81.95, C81.96, C81.97, C81.98, C81.99, C82.00, C82.01, C82.02, C82.03, C82.04, C82.05, C82.06, C82.07, C82.08, C82.09, C82.10, C82.11, C82.12, C82.13, C82.14, C82.15, C82.16, C82.17, C82.18, C82.19, C82.20, C82.21, C82.22, C82.23, C82.24, C82.25, C82.26, C82.27, C82.28, C82.29, C82.30, C82.31, C82.32, C82.33, C82.34, C82.35, C82.36, C82.37, C82.38, C82.39, C82.40, C82.41, C82.42, C82.43, C82.44, C82.45, C82.46, C82.47, C82.48, C82.49, C82.50, C82.51, C82.52, C82.53, C82.54, C82.55, C82.56, C82.57, C82.58, C82.59, C82.60, C82.61, C82.62, C82.63, C82.64, C82.65, C82.66, C82.67, C82.68, C82.69, C82.80, C82.81, C82.82, C82.83, C82.84, C82.85, C82.86, C82.87, C82.88, C82.89, C82.90, C82.91, C82.92, C82.93, C82.94, C82.95, C82.96, C82.97, C82.98, C82.99, C83.00, C83.01, C83.02, C83.03, C83.04, C83.05, C83.06, C83.07, C83.08, C83.09, C83.10, C83.11, C83.12, C83.13, C83.14, C83.15, C83.16, C83.17, C83.18, C83.19, C83.30, C83.31, C83.32, C83.33, C83.34, C83.35, C83.36, C83.37, C83.38, C83.39, C83.50, C83.51, C83.52, C83.53, C83.54, C83.55, C83.56, C83.57, C83.58, C83.59, C83.70, C83.71, C83.72, C83.73, C83.74, C83.75, C83.76, C83.77, C83.78, C83.79, C83.80, C83.81, C83.82, C83.83, C83.84, C83.85, C83.86, C83.87, C83.88, C83.89, C83.90, C83.91, C83.92, C83.93, C83.94, C83.95, C83.96, C83.97, C83.98, C83.99, C84.00, C84.01, C84.02, C84.03, C84.04, C84.05, C84.06, C84.07, C84.08, C84.09, C84.10, C84.11, C84.12, C84.13, C84.14, C84.15, C84.16, C84.17, C84.18, C84.19, C84.40, C84.41, C84.42, C84.43, C84.44, C84.45, C84.46, C84.47, C84.48, C84.49, C84.60, C84.61, C84.62, C84.63, C84.64, C84.65, C84.66, C84.67, C84.68, C84.69, C84.70, C84.71, C84.72, C84.73, C84.74, C84.75, C84.76, C84.77, C84.78, C84.79, C84.90, C84.91, C84.92, C84.93, C84.94, C84.95, C84.96, C84.97, C84.98, C84.99, C84.A0, C84.A1, C84.A2, C84.A3, C84.A4, C84.A5, C84.A6, C84.A7, C84.A8, C84.A9, C84.Z0, C84.Z1, C84.Z2, C84.Z3, C84.Z4, C84.Z5, C84.Z6, C84.Z7, C84.Z8, C84.Z9, C85.10, C85.11, C85.12, C85.13, C85.14, C85.15, C85.16, C85.17, C85.18, C85.19, C85.20, C85.21, C85.22, C85.23, C85.24, C85.25, C85.26, C85.27, C85.28, C85.29, C85.80, C85.81, C85.82, C85.83, C85.84, C85.85, C85.86, C85.87, C85.88, C85.89, C85.90, C85.91, C85.92, C85.93, C85.94, C85.95, C85.96, C85.97, C85.98, C85.99, C86.0, C86.1, C86.2, C86.3, C86.4, C86.5, C86.6, C88.4, C91.40, C91.41, C91.42, C96.0, C96.2, C96.4, C96.9, C96.A, C96.Z 30 Table 6b Quality of Care Indicators

33 Diagnosis, Active: Malignant Neoplasm of Lymphatic Tissue: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators 31

34 Diagnosis, Active: Malignant Neoplasm of Lymphatic Tissue: (con t) Diagnosis, Active, Resolved: Measles: ICD , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 055.1, 055.2, , , 055.8, Table 6b Quality of Care Indicators

35 Diagnosis, Active, Resolved: Measles: ICD10 Diagnosis, Active, Resolved: Measles: Diagnosis, Active, Resolved: Mumps: ICD9 Diagnosis, Active, Resolved: Mumps: ICD10 Diagnosis, Active, Resolved: Mumps: Diagnosis, Active, Resolved: Rubella: ICD9 Diagnosis, Active, Resolved: Rubella: ICD10 Diagnosis, Active, Resolved: Rubella: Diagnosis, Active, Inactive, Resolved: Varicella Zoster: ICD9 Diagnosis, Active, Inactive, Resolved: Varicella Zoster: ICD10 B05.0, B05.1, B05.2, B05.3, B05.4, B05.81, B05.89, B , , , , , , , , , , , , , , 072.1, 072.2, 072.3, , , , 072.8, B26.0, B26.1, B26.2, B26.3, B26.81, B26.82, B26.83, B26.84, B26.85, B26.89, B , , , , , , , , , , , , , , , , , , , , , , , , 056.8, B06.00, B06.01, B06.02, B06.09, B06.81, B06.82, B06.89, B , , , , , , , , , , , , , , , 052.1, 052.2, 052.7, 052.8, 052.9, 053.0, , , , , , , , , , , , , 053.8, B01.0, B01.11, B01.12, B01.2, B01.81, B01.89, B01.9, B02.0, B02.1, B02.21, B02.22, B02.23, B02.24, B02.29, B02.30, B02.31, B02.32, B02.33, B02.34, B02.39, B02.7, B02.8, B02.9 Table 6b Quality of Care Indicators 33

36 Diagnosis, Active, Inactive, Resolved: Varicella Zoster: Encounter, Performed: Face to Face Interaction: Encounter, Performed: Home Healthcare Services: CPT Encounter, Performed: Office Visit: CPT Encounter, Performed: Preventive Care Established Office Visit, 0 to 17: CPT Encounter, Performed: Preventive Care Initial Office Visit, 0 to 17: CPT Laboratory Test, Result: Hepatitis B Antigen Test: LOINC Laboratory Test, Result: Measles Antigen Test: LOINC Laboratory Test, Result: Mumps Antigen Test: LOINC Laboratory Test, Result: Rubella Antigen Test: LOINC , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 99342, 99343, 99344, 99345, 99347, 99348, 99349, , 99202, 99203, 99204, 99205, 99212, 99213, 99214, , 99392, 99393, , 99382, 99383, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators

37 Laboratory Test, Result: Varicella Zoster Antigen Test: LOINC Medication, Administered: DTaP Vaccine: CVX Medication, Administered: Haemophilus Influenza B (HiB) Vaccine: CVX Medication, Administered: Hepatitis B Vaccine: CVX Medication, Administered: Inactivated Polio Vaccine (IPV): CVX Medication, Administered: Measles, Mumps and Rubella (MMR) Vaccine: CVX Medication, Administered: Pneumococcal Conjugate Vaccine: CVX Medication, Administered: Varicella Zoster Vaccine (VZV): CVX Procedure, Performed: DTaP Vaccine Administered: CPT Procedure, Performed: DTaP Vaccine Administered: Procedure, Performed: Haemophilus Influenza B (HiB) Vaccine Administered: CPT Procedure, Performed: Haemophilus Influenza B (HiB) Vaccine Administered: , , , , , , , , , , , , , , , 110, 120, 130, 20, , 48, 49, 50, 51 08, 104, 110, 44, 51 10, 110, , , 133, 33 21, , 90700, 90721, , , , , , , , , 90646, 90647, 90648, 90721, , , , , , , , Table 6b Quality of Care Indicators 35

38 Procedure, Performed: Hepatitis B Vaccine Administered: CPT Procedure, Performed: Hepatitis B Vaccine Administered: Procedure, Performed: Inactivated Polio Vaccine (IPV) Administered: CPT Procedure, Performed: Inactivated Polio Vaccine (IPV) Administered: Procedure, Performed: Measles, Mumps and Rubella (MMR) Vaccine Administered: CPT Procedure, Performed: Measles, Mumps and Rubella (MMR) Vaccine Administered: Procedure, Performed: Pneumococcal Conjugate Vaccine Administered: CPT Procedure, Performed: Pneumococcal Conjugate Vaccine Administered: Procedure, Performed: Varicella Zoster Vaccine (VZV) Administered: CPT Procedure, Performed: Varicella Zoster Vaccine (VZV) Administered: 90723, 90740, 90744, 90747, , , , , , , , , , , , , , 90713, , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators

39 Attribute: Result: Seropositive: Table 6b Quality of Care Indicators 37

40 Line 11 Cervical Cancer Screening Name Description Denominator: Numerator: Exclusion Details The performance measure is Percentage of women years of age who received one or more Pap tests to screen for cervical cancer. (Note this is the same measure that had been previously called Women 24 through 64 for clarity purposes. No women aged 21, 22, or 23 should be included in the calculation of this measure.) This is partially related to Clinical Quality Measure NQF 0032 (but with some major differences) Number of all female patients age years of age during the measurement year who had at least one medical visit during the reporting year (Must also fit criteria to be on the UDS report, if a patient is not listed in table 3a, they will not be counted in table 6a.) (11a) Documentation exists that the patient received one or more documented Pap tests during the measurement year or during the two years prior to the measurement year. OR (11c) Documentation exists that the patient received at least one pap test accompanied by an HPV test during the measurement year (or in the four years prior to the measurement year) and was at least 30 at the time (11b) Documentation exists that the patient has had a hysterectomy and has no residual cervix How to meet each condition for this measure, found in the PM under Maint > Patient Details > Patient Profile Detail > Clinical Quality Measure Data 11a [Used to calculate Numerator] Documentation exists that the patient received one or more documented Pap tests during the measurement year or during the two years prior to the measurement year. * Patients who are female AND * Patients between 23 and 63 years old at the beginning of the measurement period. (Patients who turn during the measurement period) *Patients who had a Lab Test with results of Pap Test (see code list for LOINC codes) *Date Range: performed <= 3 year(s) before end of the measurement period MedInfo > Medical > Lab Result 38 Table 6b Quality of Care Indicators

41 11b [Used to calculate Numerator] 11c [Used to calculate Numerator] Documentation exists that the patient has had a hysterectomy and has no residual cervix. *Patients who have had a procedure performed of Hysterectomy with No Residual Cervix (see code list for CPT and codes ) *Date Range: performed before or during the Measurement Period. MedInfo > Orders > Procedure Order (Performed) MedInfo > Orders > Procedure Diagnostic Test (Performed) MedInfo > Histories > Hospitalization History MedInfo > Histories > Surgical Procedures MedInfo > Histories > Surgical History NOTE Reporting will look at Procedure names in Surgical History Documentation exists that the patient received at least one pap test accompanied by an HPV test during the measurement year (or in the four years prior to the measurement year) and was at least 30 at the time. * Patients between 29 and 63 years old at the beginning of the measurement period. (Patients who turn during the measurement period) AND *Patients who had a Lab Test with results of Pap Test (see code list for LOINC codes) *Date Range: performed <= 5 year(s) before end of the measurement period MedInfo > Medical > Lab Result AND *Patients who had an HPV test performed (see code list for CPT codes) *Date Range: performed <= 5 year(s) before end of the measurement period Encounter Plan that has been performed MedInfo > Medical > Lab Result MedInfo > Health Maintenance > Screening and Prevention Table 6b Quality of Care Indicators 39

42 Code Lists for Measure Laboratory Test, Result: Pap Test: LOINC Procedure, Performed: Hysterectomy with No Residual Cervix: CPT , , , , , , , , , , 51925, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58951, 58953, 58954, 58956, Table 6b Quality of Care Indicators

43 Procedure, Performed: Hysterectomy with No Residual Cervix: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Total hysterectomy with unilateral removal of tube (procedure), Radical vaginal hysterectomy (procedure), Ward Mayo operation for vaginal hysterectomy (procedure), Tuffier operation for vaginal hysterectomy (procedure), Mayo operation for vaginal hysterectomy (procedure), Heaney operation for vaginal hysterectomy (procedure), Wertheim Meigs abdominal hysterectomy (procedure), Wertheim operation (procedure), Vaginal hysterectomy with conservation of ovaries (procedure), Laparoscopic total abdominal hysterectomy and bilateral salpingo oophorectomy (procedure), Excision of cervical stump by vaginal approach (procedure), Vaginal hysterectomy with total colpectomy (procedure), Laparoscopy assisted vaginal hysterectomy with bilateral salpingo oophorectomy (procedure), Total abdominal hysterectomy and removal of vaginal cuff (procedure), Total laparoscopic excision of uterus by abdominal approach (procedure), Abdominal hysterectomy and excision of periuterine tissue (procedure), Vaginal hysterectomy and excision of periuterine tissue (procedure), Vaginal hysterectomy with repair of enterocele (procedure), Total hysterectomy with unilateral removal of tube and ovary (procedure), Vaginal hysterectomy with colpourethrocystopexy, Pereyra type (procedure), Laparoscopicassisted vaginal hysterectomy (procedure), Vaginal hysterectomy with partial colpectomy (procedure), Total hysterectomy with removal of both tubes and ovaries (procedure), Removal of ectopic interstitial uterine pregnancy requiring total hysterectomy (procedure) Procedure Performed: HPV Test CPT 87620, 87621, Table 6b Quality of Care Indicators 41

44 Line 12 Weight Assessment and Counseling for Children and Adolescents Name Description Denominator: Numerator: Exclusion: Details The performance measure is Percentage of patients aged 28 until 17 who had evidence of BMI percentile documentation AND who had documentation of counseling for nutrition AND who had documentation of counseling for physical activity during the measurement year. Note that, while this measure is titled 2 until 17, health centers should only review the charts of children who were at least 3 years old during the measurement year. This is related to Clinical Quality Measure NQF 0024 Patients who were 3 to 17 during the measurement year AND had at least one medical visit during the reporting year AND were seen for the first time prior to their 17th birthday. (Must also fit criteria to be on the UDS report, if a patient is not listed in table 3a, they will not be counted in table 6a.). (12a) Patient had their BMI percentile documented during the measurement year AND (12b) Documentation exists that patient received counseling on physical activity during the measurement year. AND (12c) Documentation exists that patient received counseling on nutrition during the measurement year. (12d) The patient was pregnant when the BMI Percentile was documented How to meet each condition for this measure, found in the PM under Maint > Patient Details > Patient Profile Detail > Clinical Quality Measure Data 12a [Used to calculate Numerator] Patient had their BMI percentile documented during the measurement year ** Vital Signs Recorded: Height and Weight to calculate BMI ** Date Range: During the Measurement Period MedInfo > Medical > Vital Signs 12b [Used to calculate Numerator] Documentation exists that patient received counseling on physical activity during the measurement year. Do not count charts that only show that a well child visit was provided unless there is specific documentation of physical activity counseling. ** Patients who had an Intervention Performed of Counseling for Physical Activity (see code list for codes) ** Date Range: During the Measurement Period MedInfo > Orders > Referral Orders MedInfo > Orders > Procedure Orders (Performed) MedInfo > Orders > Procedure Diagnostic Test (Performed) Encounter Plan Procedure Orders 42 Table 6b Quality of Care Indicators

45 Name 12c [Used to calculate Numerator] 12d [Determine Exclusion] Details Documentation exists that patient received counseling on nutrition during the measurement year. Do not count charts that only show that a well child visit was provided unless there is specific documentation of nutritional counseling. ** Patients who had an Intervention Performed of Counseling for Nutrition (see code list for CPT and codes) ** Date Range: during the Measurement Period MedInfo > Orders > Referral Orders MedInfo > Orders > Procedure Orders (Performed) MedInfo > Orders > Procedure Diagnostic Test (Performed) Encounter Plan Procedure Orders The patient was pregnant when the BMI Percentile was documented **Patients who have an active diagnosis of Pregnancy recorded in their chart (see code list for ICD 9 and codes) **Date Range: Beginning during the measurement period MedInfo > Medical > Problem List Entry Encounter with an Assessment Code Lists for Measure: Diagnosis, Active: Pregnancy: ICD , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators 43

46 654.83, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.49, V23.5, V23.7, V23.81, V23.82, V23.83, V23.84, V23.85, V23.86, V Table 6b Quality of Care Indicators

47 Diagnosis, Active: Pregnancy: ICD10 O00.1, O00.2, O00.8, O00.9, O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.211, O09.212, O09.213, O09.219, O09.291, O09.292, O09.293, O09.299, O09.30, O09.31, O09.32, O09.33, O09.40, O09.41, O09.42, O09.43, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.70, O09.71, O09.72, O09.73, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, O10.011, O10.012, O10.013, O10.019, O10.111, O10.112, O10.113, O10.119, O10.211, O10.212, O10.213, O10.219, O10.311, O10.312, O10.313, O10.319, O10.411, O10.412, O10.413, O10.419, O10.911, O10.912, O10.913, O10.919, O11.1, O11.2, O11.3, O11.9, O12.00, O12.01, O12.02, O12.03, O12.10, O12.11, O12.12, O12.13, O12.20, O12.21, O12.22, O12.23, O13.1, O13.2, O13.3, O13.9, O14.00, O14.02, O14.03, O14.10, O14.12, O14.13, O14.20, O14.22, O14.23, O14.90, O14.92, O14.93, O15.00, O15.02, O15.03, O16.1, O16.2, O16.3, O16.9, O20.0, O20.8, O20.9, O21.0, O21.1, O21.2, O21.8, O21.9, O22.00, O22.01, O22.02, O22.03, O22.10, O22.11, O22.12, O22.13, O22.20, O22.21, O22.22, O22.23, O22.30, O22.31, O22.32, O22.33, O22.40, O22.41, O22.42, O22.43, O22.50, O22.51, O22.52, O22.53, O22.8X1, O22.8X2, O22.8X3, O22.8X9, O22.90, O22.91, O22.92, O22.93, O23.00, O23.01, O23.02, O23.03, O23.10, O23.11, O23.12, O23.13, O23.20, O23.21, O23.22, O23.23, O23.30, O23.31, O23.32, O23.33, O23.40, O23.41, O23.42, O23.43, O23.511, O23.512, O23.513, O23.519, O23.521, O23.522, O23.523, O23.529, O23.591, O23.592, O23.593, O23.599, O23.90, O23.91, O23.92, O23.93, O24.011, O24.012, O24.013, O24.019, O24.111, O24.112, O24.113, O24.119, O24.311, O24.312, O24.313, O24.319, O24.410, O24.414, O24.419, O24.811, O24.812, O24.813, O24.819, O24.911, O24.912, O24.913, O24.919, O25.10, O25.11, O25.12, O25.13, O26.00, O26.01, O26.02, O26.03, O26.10, O26.11, O26.12, O26.13, O26.20, O26.21, O26.22, O26.23, O26.30, O26.31, O26.32, O26.33, O26.40, O26.41, O26.42, O26.43, O26.50, O26.51, O26.52, O26.53, O26.611, O26.612, O26.613, O26.619, O26.711, O26.712, O26.713, O26.719, O26.811, O26.812, O26.813, O26.819, O26.821, O26.822, O26.823, O26.829, O26.831, O26.832, O26.833, O26.839, O26.841, O26.842, O26.843, O26.849, O26.851, O26.852, O26.853, O26.859, O26.86, O26.872, O26.873, O26.879, O26.891, O26.892, O26.893, O26.899, O26.90, O26.91, O26.92, O26.93, O28.0, O28.1, O28.2, O28.3, O28.4, O28.5, O28.8, O28.9, O29.011, O29.012, O29.013, O29.019, O29.021, O29.022, O29.023, O29.029, O29.091, O29.092, O29.093, O29.099, O29.111, O29.112, O29.113, O29.119, O29.121, O29.122, O29.123, O29.129, O29.191, O29.192, O29.193, O29.199, O29.211, O29.212, O29.213, O29.219, O29.291, O29.292, O29.293, O29.299, O29.3X1, O29.3X2, O29.3X3, O29.3X9, O29.40, O29.41, O29.42, O29.43, O29.5X1, O29.5X2, O29.5X3, O29.5X9, O29.60, O29.61, O29.62, O29.63, O29.8X1, O29.8X2, O29.8X3, O29.8X9, O29.90, O29.91, O29.92, O29.93, O30.001, O30.002, O30.003, O30.009, O30.011, O30.012, O30.013, O30.019, O30.021, O30.022, O30.023, O30.029, O30.031, O30.032, O30.033, O30.039, O30.041, O30.042, O30.043, O30.049, O30.091, O30.092, O30.093, O30.099, O30.101, O30.102, O30.103, O30.109, O30.111, O30.112, O30.113, O30.119, O30.121, O30.122, O30.123, O30.129, O30.191, O30.192, O30.193, O30.199, O30.201, O30.202, O30.203, O30.209, O30.211, O30.212, O30.213, O30.219, O30.221, O30.222, O30.223, O30.229, O30.291, O30.292, O30.293, O30.299, O30.801, O30.802, O30.803, O30.809, O30.811, O30.812, O30.813, O30.819, O30.821, O30.822, O30.823, O30.829, O30.891, O30.892, O30.893, O30.899, O30.90, O30.91, O30.92, O30.93, O31.00X0, O31.00X1, O31.00X2, O31.00X3, O31.00X4, Table 6b Quality of Care Indicators 45

48 O31.00X5, O31.00X9, O31.01X0, O31.01X1, O31.01X2, O31.01X3, O31.01X4, O31.01X5, O31.01X9, O31.02X0, O31.02X1, O31.02X2, O31.02X3, O31.02X4, O31.02X5, O31.02X9, O31.03X0, O31.03X1, O31.03X2, O31.03X3, O31.03X4, O31.03X5, O31.03X9, O31.10X0, O31.10X1, O31.10X2, O31.10X3, O31.10X4, O31.10X5, O31.10X9, O31.11X0, O31.11X1, O31.11X2, O31.11X3, O31.11X4, O31.11X5, O31.11X9, O31.12X0, O31.12X1, O31.12X2, O31.12X3, O31.12X4, O31.12X5, O31.12X9, O31.13X0, O31.13X1, O31.13X2, O31.13X3, O31.13X4, O31.13X5, O31.13X9, O31.20X0, O31.20X1, O31.20X2, O31.20X3, O31.20X4, O31.20X5, O31.20X9, O31.21X0, O31.21X1, O31.21X2, O31.21X3, O31.21X4, O31.21X5, O31.21X9, O31.22X0, O31.22X1, O31.22X2, O31.22X3, O31.22X4, O31.22X5, O31.22X9, O31.23X0, O31.23X1, O31.23X2, O31.23X3, O31.23X4, O31.23X5, O31.23X9, O31.30X0, O31.30X1, O31.30X2, O31.30X3, O31.30X4, O31.30X5, O31.30X9, O31.31X0, O31.31X1, O31.31X2, O31.31X3, O31.31X4, O31.31X5, O31.31X9, O31.32X0, O31.32X1, O31.32X2, O31.32X3, O31.32X4, O31.32X5, O31.32X9, O31.33X0, O31.33X1, O31.33X2, O31.33X3, O31.33X4, O31.33X5, O31.33X9, O31.8X10, O31.8X11, O31.8X12, O31.8X13, O31.8X14, O31.8X15, O31.8X19, O31.8X20, O31.8X21, O31.8X22, O31.8X23, O31.8X24, O31.8X25, O31.8X29, O31.8X30, O31.8X31, O31.8X32, O31.8X33, O31.8X34, O31.8X35, O31.8X39, O31.8X90, O31.8X91, O31.8X92, O31.8X93, O31.8X94, O31.8X95, O31.8X99, O32.0XX0, O32.0XX1, O32.0XX2, O32.0XX3, O32.0XX4, O32.0XX5, O32.0XX9, O32.1XX0, O32.1XX1, O32.1XX2, O32.1XX3, O32.1XX4, O32.1XX5, O32.1XX9, O32.2XX0, O32.2XX1, O32.2XX2, O32.2XX3, O32.2XX4, O32.2XX5, O32.2XX9, O32.3XX0, O32.3XX1, O32.3XX2, O32.3XX3, O32.3XX4, O32.3XX5, O32.3XX9, O32.4XX0, O32.4XX1, O32.4XX2, O32.4XX3, O32.4XX4, O32.4XX5, O32.4XX9, O32.6XX0, O32.6XX1, O32.6XX2, O32.6XX3, O32.6XX4, O32.6XX5, O32.6XX9, O32.8XX0, O32.8XX1, O32.8XX2, O32.8XX3, O32.8XX4, O32.8XX5, O32.8XX9, O32.9XX0, O32.9XX1, O32.9XX2, O32.9XX3, O32.9XX4, O32.9XX5, O32.9XX9, O33.0, O33.1, O33.2, O33.3XX0, O33.3XX1, O33.3XX2, O33.3XX3, O33.3XX4, O33.3XX5, O33.3XX9, O33.4XX0, O33.4XX1, O33.4XX2, O33.4XX3, O33.4XX4, O33.4XX5, O33.4XX9, O33.5XX0, O33.5XX1, O33.5XX2, O33.5XX3, O33.5XX4, O33.5XX5, O33.5XX9, O33.6XX0, O33.6XX1, O33.6XX2, O33.6XX3, O33.6XX4, O33.6XX5, O33.6XX9, O33.7, O33.8, O33.9, O34.00, O34.01, O34.02, O34.03, O34.10, O34.11, O34.12, O34.13, O34.21, O34.29, O34.30, O34.31, O34.32, O34.33, O34.40, O34.41, O34.42, O34.43, O34.511, O34.512, O34.513, O34.519, O34.521, O34.522, O34.523, O34.529, O34.531, O34.532, O34.533, O34.539, O34.591, O34.592, O34.593, O34.599, O34.60, O34.61, O34.62, O34.63, O34.70, O34.71, O34.72, O34.73, O34.80, O34.81, O34.82, O34.83, O34.90, O34.91, O34.92, O34.93, O35.0XX0, O35.0XX1, O35.0XX2, O35.0XX3, O35.0XX4, O35.0XX5, O35.0XX9, O35.1XX0, O35.1XX1, O35.1XX2, O35.1XX3, O35.1XX4, O35.1XX5, O35.1XX9, O35.2XX0, O35.2XX1, O35.2XX2, O35.2XX3, O35.2XX4, O35.2XX5, O35.2XX9, O35.3XX0, O35.3XX1, O35.3XX2, O35.3XX3, O35.3XX4, O35.3XX5, O35.3XX9, O35.4XX0, O35.4XX1, O35.4XX2, O35.4XX3, O35.4XX4, O35.4XX5, O35.4XX9, O35.5XX0, O35.5XX1, O35.5XX2, O35.5XX3, O35.5XX4, O35.5XX5, O35.5XX9, O35.6XX0, O35.6XX1, O35.6XX2, O35.6XX3, O35.6XX4, O35.6XX5, O35.6XX9, O35.7XX0, O35.7XX1, O35.7XX2, O35.7XX3, O35.7XX4, O35.7XX5, O35.7XX9, O35.8XX0, O35.8XX1, O35.8XX2, O35.8XX3, O35.8XX4, O35.8XX5, O35.8XX9, O35.9XX0, O35.9XX1, O35.9XX2, O35.9XX3, O35.9XX4, O35.9XX5, O35.9XX9, O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , 46 Table 6b Quality of Care Indicators

49 O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O36.20X0, O36.20X1, O36.20X2, O36.20X3, O36.20X4, O36.20X5, O36.20X9, O36.21X0, O36.21X1, O36.21X2, O36.21X3, O36.21X4, O36.21X5, O36.21X9, O36.22X0, O36.22X1, O36.22X2, O36.22X3, O36.22X4, O36.22X5, O36.22X9, O36.23X0, O36.23X1, O36.23X2, O36.23X3, O36.23X4, O36.23X5, O36.23X9, O36.4XX0, O36.4XX1, O36.4XX2, O36.4XX3, O36.4XX4, O36.4XX5, O36.4XX9, O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O36.60X0, O36.60X1, O36.60X2, O36.60X3, O36.60X4, O36.60X5, O36.60X9, O36.61X0, O36.61X1, O36.61X2, O36.61X3, O36.61X4, O36.61X5, O36.61X9, O36.62X0, O36.62X1, O36.62X2, O36.62X3, O36.62X4, O36.62X5, O36.62X9, O36.63X0, O36.63X1, O36.63X2, O36.63X3, O36.63X4, O36.63X5, O36.63X9, O36.70X0, O36.70X1, O36.70X2, O36.70X3, O36.70X4, O36.70X5, O36.70X9, O36.71X0, O36.71X1, O36.71X2, O36.71X3, O36.71X4, O36.71X5, O36.71X9, O36.72X0, O36.72X1, O36.72X2, O36.72X3, O36.72X4, O36.72X5, O36.72X9, O36.73X0, O36.73X1, O36.73X2, O36.73X3, O36.73X4, O36.73X5, O36.73X9, O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O36.90X0, O36.90X1, O36.90X2, O36.90X3, O36.90X4, O36.90X5, O36.90X9, O36.91X0, O36.91X1, O36.91X2, O36.91X3, O36.91X4, O36.91X5, O36.91X9, O36.92X0, O36.92X1, O36.92X2, O36.92X3, O36.92X4, O36.92X5, O36.92X9, O36.93X0, O36.93X1, O36.93X2, O36.93X3, O36.93X4, O36.93X5, O36.93X9, O40.1XX0, O40.1XX1, O40.1XX2, O40.1XX3, O40.1XX4, O40.1XX5, O40.1XX9, O40.2XX0, O40.2XX1, O40.2XX2, O40.2XX3, O40.2XX4, O40.2XX5, O40.2XX9, O40.3XX0, O40.3XX1, O40.3XX2, O40.3XX3, O40.3XX4, O40.3XX5, O40.3XX9, O40.9XX0, O40.9XX1, O40.9XX2, O40.9XX3, O40.9XX4, O40.9XX5, O40.9XX9, O41.00X0, O41.00X1, Table 6b Quality of Care Indicators 47

50 O41.03X5, O41.03X9, O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O41.8X10, O41.8X11, O41.8X12, O41.8X13, O41.8X14, O41.8X15, O41.8X19, O41.8X20, O41.8X21, O41.8X22, O41.8X23, O41.8X24, O41.8X25, O41.8X29, O41.8X30, O41.8X31, O41.8X32, O41.8X33, O41.8X34, O41.8X35, O41.8X39, O41.8X90, O41.8X91, O41.8X92, O41.8X93, O41.8X94, O41.8X95, O41.8X99, O41.90X0, O41.90X1, O41.90X2, O41.90X3, O41.90X4, O41.90X5, O41.90X9, O41.91X0, O41.91X1, O41.91X2, O41.91X3, O41.91X4, O41.91X5, O41.91X9, O41.92X0, O41.92X1, O41.92X2, O41.92X3, O41.92X4, O41.92X5, O41.92X9, O41.93X0, O41.93X1, O41.93X2, O41.93X3, O41.93X4, O41.93X5, O41.93X9, O42.00, O42.011, O42.012, O42.013, O42.019, O42.02, O42.10, O42.111, O42.112, O42.113, O42.119, O42.12, O42.90, O42.911, O42.912, O42.913, O42.919, O42.92, O43.011, O43.012, O43.013, O43.019, O43.021, O43.022, O43.023, O43.029, O43.101, O43.102, O43.103, O43.109, O43.111, O43.112, O43.113, O43.119, O43.121, O43.122, O43.123, O43.129, O43.191, O43.192, O43.193, O43.199, O43.211, O43.212, O43.213, O43.219, O43.221, O43.222, O43.223, O43.229, O43.231, O43.232, O43.233, O43.239, O43.811, O43.812, O43.813, O43.819, O43.891, O43.892, O43.893, O43.899, O43.90, O43.91, O43.92, O43.93, O44.00, O44.01, O44.02, O44.03, O44.10, O44.11, O44.12, O44.13, O45.001, O45.002, O45.003, O45.009, O45.011, O45.012, O45.013, O45.019, O45.021, O45.022, O45.023, O45.029, O45.091, O45.092, O45.093, O45.099, O45.8X1, O45.8X2, O45.8X3, O45.8X9, O45.90, O45.91, O45.92, O45.93, O46.001, O46.002, O46.003, O46.009, O46.011, O46.012, O46.013, O46.019, O46.021, O46.022, O46.023, O46.029, O46.091, O46.092, O46.093, O46.099, O46.8X1, O46.8X2, O46.8X3, O46.8X9, O46.90, O46.91, O46.92, O46.93, O47.00, O47.02, O47.03, O47.1, O47.9, O48.0, O48.1, O60.00, O60.02, O60.03, O71.00, O71.02, O71.03, O88.011, O88.012, O88.013, O88.019, O88.111, O88.112, O88.113, O88.119, O88.211, O88.212, O88.213, O88.219, O88.311, O88.312, O88.313, O88.319, O88.811, O88.812, O88.813, O88.819, O90.3, O91.011, O91.012, O91.013, O91.019, O91.111, O91.112, O91.113, O91.119, O91.211, O91.212, O91.213, O91.219, O92.011, O92.012, O92.013, O92.019, O92.111, O92.112, O92.113, O92.119, O92.20, O92.29, O98.011, O98.012, O98.013, O98.019, O98.111, O98.112, O98.113, O98.119, O98.211, O98.212, O98.213, O98.219, O98.311, O98.312, O98.313, O98.319, O98.411, O98.412, O98.413, O98.419, O98.511, O98.512, O98.513, O98.519, O98.611, O98.612, O98.613, O98.619, O98.711, O98.712, O98.713, O98.719, O98.811, O98.812, O98.813, O98.819, O98.911, O98.912, O98.913, O98.919, O99.011, O99.012, O99.013, O99.019, O99.111, O99.112, O99.113, O99.119, O99.210, O99.211, O99.212, O99.213, O99.280, O99.281, O99.282, O99.283, O99.310, O99.311, O99.312, O99.313, O99.320, O99.321, O99.322, O99.323, O99.330, O99.331, O99.332, O99.333, O99.340, O99.341, O99.342, O99.343, O99.350, O99.351, O99.352, O99.353, O99.411, O99.412, O99.413, O99.419, O99.511, O99.512, O99.513, O99.519, O99.611, O99.612, O99.613, O99.619, O99.711, O99.712, O99.713, O99.719, O99.810, O99.820, O99.830, O99.840, O99.841, O99.842, O99.843, O99.89, O9A.111, O9A.112, O9A.113, O9A.119, O9A.211, O9A.212, 48 Table 6b Quality of Care Indicators

51 O9A.213, O9A.219, O9A.311, O9A.312, O9A.313, O9A.319, O9A.411, O9A.412, O9A.413, O9A.419, O9A.511, O9A.512, O9A.513, O9A.519, Z33.1, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z36 Diagnosis, Active: Pregnancy: Intervention, Performed: Counseling for Nutrition: CPT Intervention, Performed: Counseling for Nutrition: Intervention, Performed: Counseling for Physical Activity: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 97803, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators 49

52 Line 13 Adult Weight Screening and Follow-Up Name Description: Denominator: Numerator: Exclusion: Details The performance measure is Percentage of patients aged 18 and older who had documentation of a calculated BMI during the most recent visit or within the six months prior to that visit. This is related to Clinical Quality Measure NQF 0421 Number of patients who were 18 years of age or older during the measurement year, who had at least one medical visit during the reporting year (Must also fit criteria to be on the UDS report, if a patient is not listed in table 3a, they will not be counted in table 6a.) (13a) *BMI Charted at last visit (or within 6 months of last visit) AND ** Measured BMI is in desired BMI range [Patient DOESN T fit 13d] OR ***(13d) Measured BMI under or over desired BMI range AND ***(13b) Follow up Plan Documented (if under/overweight) (13c) Pregnant or Terminally Ill when BMI Measured How to meet each condition for this measure, found in the PM under Maint > Patient Details > Patient Profile Detail > Clinical Quality Measure Data 13a [Used to calculate Numerator] BMI Charted at last visit (or within 6 months of last visit). **Patients in Age Range: >= 18 years (by the end of the reporting period) AND ** Patients Who have had at least 1 Encounter of BMI Encounter Code Set ** Date Range: During the measurement period Encounters with Encounter Level Specified (CPT and HCPCS Codes) Encounter Plan > Procedure Orders (CPT, CDT, HCPCS and codes) AND ** Vital Signs Recorded: Height and Weight to calculate BMI ** Date Range: Beginning Date within 6 months before or on date of Encounter of BMI Encounter Code Set MedInfo > Medical > Vital Signs NOTE Reporting will look at most recent record of Vital signs 50 Table 6b Quality of Care Indicators

53 13b [Used to calculate Numerator] Follow up Plan Documented (if under/overweight). [Patients whose weight is Above Normal] * Patients whose most recent BMI is considered above normal (>=25 for those aged 18 64, >= 30 for those aged 65+) AND ** Patients who had an Intervention done for Above Normal Follow up ** Date Range: Beginning Date within 6 months before or on date of Encounter of BMI Encounter Code Set Encounter Plan > Procedure Orders (HCPCS, CPT and codes) OR ** Patients who had a Referral order created of Referrals where weight assessment may occur ** Date Range: Beginning Date within 6 months before or on date of Encounter of BMI Encounter Code Set MedInfo > Orders > Referral Orders ( codes) OR [Patients whose weight is Below Normal] * Patients whose most recent BMI is considered below normal (< 18.5 for those aged 18 64, < 22 for those aged 65+ ) AND ** Patients who had an Intervention done for Below Normal Follow up ** Date Range: Beginning Date within 6 months before or on date of Encounter of BMI Encounter Code Set. Encounter Plan > Procedure Orders (HCPCS and codes) OR **Patients who had a Referral order created of Referrals where weight assessment may occur. ** Date Range: Beginning Date within 6 months before or on date of Encounter of BMI Encounter Code Set. MedInfo > Orders > Referral Orders ( codes) Table 6b Quality of Care Indicators 51

54 13c [Determine Exclusion] 13d [Used to calculate Numerator] Pregnant or Terminally Ill when BMI Measured. **Patients who have an active diagnosis of Pregnancy in their chart (see code list for ICD 9 and codes) **Date Range: Beginning date prior to end of the measurement period and end date (if exists) to be after the start of the measurement period MedInfo > Medical > Problem List Entry Encounter with an Assessment OR ** Patients refused to get Physical Exam Performed (see code list of codes for Patient Reason Refused or Medical or Other Reason not done) [No criteria was given for determining patients that are terminally ill, so they can be recorded this way] ** Date Range: During Encounter of BMI Encounter Code Set Encounter Plan > Procedure Orders Measured BMI under or over desired BMI range. ** Vital Signs Recorded: Height and Weight to calculate BMI ** Date Range: Beginning Date within 6 months before or on date of Encounter of BMI Encounter Code Set MedInfo > Medical > Vital Signs NOTE Reporting will look at most recent record of Vital signs AND *** Patient is Between 18 and 64 AND *** BMI < 18.5 or >= 25 OR *** Patient is 65 or older AND *** BMI < 22 or >= Table 6b Quality of Care Indicators

55 Code Lists for Measure Diagnosis, Active: Pregnancy: ICD9 630, 631, 632, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 638.0, 638.1, 638.2, 638.3, 638.4, 638.5, 638.6, 638.7, 638.8, 638.9, 639.0, 639.1, 639.2, 639.3, 639.4, 639.5, 639.6, 639.8, 639.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 650, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators 53

56 653.10, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,674.02, , , , , , , , , 54 Table 6b Quality of Care Indicators

57 674.30, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.49, V23.5, V23.7, V23.81, V23.82, V23.83, V23.84, V23.85, V23.86, V23.9, V28.0, V28.1, V28.2, V28.3, V28.4, V28.5, V28.6, V28.81, V28.82, V28.89, V28.9 Table 6b Quality of Care Indicators 55

58 Diagnosis, Active: Pregnancy: ICD10 A34, O00.0, O00.1, O00.2, O00.8, O00.9, O01.9, O02.0, O02.1, O02.8, O03.0, O03.1, O03.2, O03.30, O03.31, O03.32, O03.33, O03.34, O03.37, O03.39, O03.4, O03.5, O03.6, O03.7, O03.80, O03.81, O03.82, O03.83, O03.84, O03.85, O03.86, O03.87, O03.88, O03.89, O03.9, O04.5, O04.6, O04.7, O04.80, O04.81, O04.82, O04.83, O04.84, O04.85, O04.86, O04.87, O04.88, O04.89, O07.0, O07.1, O07.2, O07.30, O07.31, O07.32, O07.33, O07.34, O07.35, O07.36, O07.37, O07.38, O07.39, O07.4, O08.0, O08.1, O08.2, O08.3, O08.4, O08.5, O08.6, O08.7, O08.81, O08.82, O08.83, O08.89, O08.9, O09.00, O09.10, O09.211, O09.291, O09.30, O09.40, O09.41, O09.42, O09.43, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.621, O09.819, O09.821, O09.822, O09.823, O09.829, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, O10.011, O10.012, O10.013, O10.019, O10.03, O10.111, O10.112, O10.113, O10.119, O10.12, O10.13, O10.211, O10.212, O10.213, O10.219, O10.22, O10.23, O10.311, O10.312, O10.313, O10.319, O10.32, O10.33, O10.411, O10.412, O10.413, O10.419, O10.42, O10.43, O10.911, O10.912, O10.913, O10.919, O10.92, O10.93, O11.1, O11.2, O11.3, O11.9, O12.00, O12.01, O12.02, O12.03, O12.20, O12.21, O12.22, O12.23, O13.1, O13.2, O13.3, O13.9, O14.00, O14.02, O14.03, O14.10, O14.12, O14.13, O14.20, O14.22, O14.23, O14.90, O14.92, O14.93, O15.02, O15.03, O15.1, O15.2, O16.1, O16.2, O16.3, O16.9, O20.0, O20.8, O20.9, O21.0, O21.2, O21.8, O21.9, O22.00, O22.01, O22.02, O22.03, O22.10, O22.11, O22.12, O22.13, O22.20, O22.21, O22.22, O22.23, O22.30, O22.31, O22.32, O22.33, O22.40, O22.41, O22.42, O22.43, O22.50, O22.51, O22.52, O22.53, O22.90, O22.91, O22.92, O22.93, O23.00, O23.10, O23.20, O23.30, O23.40, O23.41, O23.42, O23.43, O23.519, O23.529, O23.599, O23.90, O23.91, O23.92, O23.93, O24.319, O24.32, O24.419, O24.429, O24.439, O24.911, O24.912, O24.913, O24.92, O24.93, O25.10, O25.11, O25.12, O25.13, O25.2, O25.3, O26.00, O26.01, O26.02, O26.03, O26.11, O26.12, O26.13, O26.20, O26.21, O26.22, O26.23, O26.41, O26.42, O26.43, O26.50, O26.51, O26.52, O26.53, O26.611, O26.612, O26.613, O26.619, O26.62, O26.811, O26.812, O26.813, O26.819, O26.821, O26.822, O26.823, O26.829, O26.831, O26.832, O26.833, O26.839, O26.841, O26.842, O26.843, O26.849, O26.851, O26.852, O26.853, O26.859, O26.872, O26.873, O26.879, O26.891, O26.892, O26.893, O26.899, O26.90, O30.001, O30.002, O30.003, O30.009, O30.021, O30.022, O30.023, O30.029, O30.03, O30.101, O30.102, O30.103, O30.109, O30.201, O30.202, O30.203, O30.209, O30.801, O30.802, O30.803, O30.809, O30.90, O30.91, O30.92, O30.93, O33.0, O33.1, O33.2, O33.7, O33.8, O33.9, O34.00, O34.01, O34.02, O34.03, O34.10, O34.11, O34.12, O34.13, O34.21, O34.29, O34.30, O34.31, O34.32, O34.33, O34.40, O34.41, O34.42, O34.43, O34.511, O34.512, O34.513, O34.519, O34.521, O34.522, O34.523, O34.529, O34.531, O34.532, O34.533, O34.539, O34.591, O34.592, O34.593, O34.599, O34.60, O34.61, O34.62, O34.63, O34.70, O34.71, O34.72, O34.73, O34.80, O34.81, O34.82, O34.83, O34.90, O34.91, O34.92, O34.93, O35.7XX0, O35.7XX1, O35.7XX2, O35.7XX3, O35.7XX4, O35.7XX5, O35.7XX9, O35.8XX0, O35.8XX1, O35.8XX2, O35.8XX3, O35.8XX4, O35.8XX5, O35.8XX9, O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O , O42.00, O42.011, O42.012, O42.013, O42.02, O42.10, O42.111, O42.112, O42.113, O42.12, O43.011, O43.019, O43.101, O43.102, O43.103, O43.199, O43.211, O43.212, O43.213, O43.221, O43.222, O43.223, O43.231, O43.232, 56 Table 6b Quality of Care Indicators

59 O43.233, O43.239, O43.811, O43.812, O43.813, O43.819, O43.91, O43.92, O43.93, O44.00, O44.01, O44.02, O44.03, O44.10, O44.11, O44.12, O44.13, O45.001, O45.002, O45.003, O45.011, O45.012, O45.013, O45.021, O45.022, O45.023, O45.091, O45.092, O45.093, O45.91, O45.92, O45.93, O46.001, O46.002, O46.003, O46.009, O46.011, O46.012, O46.013, O46.019, O46.021, O46.022, O46.023, O46.029, O46.091, O46.092, O46.093, O46.099, O46.90, O46.91, O46.92, O46.93, O47.00, O47.02, O47.03, O47.1, O47.9, O48.0, O48.1, O60.00, O60.02, O60.03, O61.0, O61.1, O61.9, O62.0, O62.1, O62.2, O62.3, O62.4, O62.9, O63.0, O63.1, O63.2, O63.9, O65.4, O65.5, O65.9, O66.0, O66.1, O66.40, O66.5, O66.8, O66.9, O67.0, O67.8, O67.9, O68, O70.0, O70.1, O70.2, O70.3, O70.4, O70.9, O71.00, O71.02, O71.03, O71.1, O71.2, O71.3, O71.4, O71.5, O71.6, O71.7, O71.82, O71.89, O71.9, O72.0, O72.1, O72.2, O72.3, O73.0, O73.1, O74.1, O74.2, O74.3, O74.8, O74.9, O75.0, O75.1, O75.2, O75.3, O75.4, O75.5, O75.81, O75.89, O75.9, O76, O77.0, O80, O82, O85, O86.0, O86.11, O86.12, O86.13, O86.19, O86.20, O86.21, O86.22, O86.29, O86.4, O86.81, O86.89, O87.0, O87.1, O87.2, O87.3, O87.4, O87.8, O87.9, O88.011, O88.012, O88.013, O88.019, O88.02, O88.03, O88.111, O88.112, O88.113, O88.119, O88.12, O88.13, O88.211, O88.212, O88.213, O88.219, O88.22, O88.23, O88.311, O88.312, O88.313, O88.319, O88.32, O88.33, O88.811, O88.812, O88.813, O88.819, O88.82, O88.83, O89.09, O89.1, O89.2, O89.8, O89.9, O90.0, O90.1, O90.2, O90.3, O90.4, O90.5, O90.6, O90.81, O90.89, O90.9, O91.011, O91.012, O91.013, O91.019, O91.02, O91.111, O91.112, O91.113, O91.119, O91.12, O91.211, O91.212, O91.213, O91.219, O91.22, O91.23, O92.011, O92.012, O92.013, O92.019, O92.03, O92.111, O92.112, O92.113, O92.119, O92.13, O92.20, O92.29, O92.3, O92.5, O92.6, O92.70, O92.79, O94, O98.011, O98.012, O98.013, O98.019, O98.02, O98.03, O98.111, O98.112, O98.113, O98.119, O98.12, O98.13, O98.211, O98.212, O98.213, O98.219, O98.22, O98.23, O98.3, O98.311, O98.312, O98.313, O98.319, O98.32, O98.33, O98.42, O98.43, O98.511, O98.512, O98.513, O98.519, O98.52, O98.53, O98.611, O98.612, O98.613, O98.619, O98.62, O98.63, O98.811, O98.812, O98.813, O98.819, O98.82, O98.83, O98.911, O98.912, O98.913, O98.919, O98.92, O98.93, O99.011, O99.012, O99.013, O99.019, O99.02, O99.03, O99.111, O99.112, O99.113, O99.119, O99.12, O99.13, O99.210, O99.211, O99.212, O99.213, O99.214, O99.215, O99.280, O99.281, O99.282, O99.283, O99.284, O99.285, O99.320, O99.321, O99.322, O99.323, O99.324, O99.325, O99.330, O99.331, O99.332, O99.333, O99.334, O99.335, O99.340, O99.341, O99.342, O99.343, O99.344, O99.345, O99.350, O99.351, O99.352, O99.353, O99.354, O99.355, O99.411, O99.412, O99.413, O99.419, O99.42, O99.43, O99.810, O99.814, O99.815, O99.834, O99.835, O99.840, O99.841, O99.842, O99.843, O99.844, O99.845, O99.89, Z33.1, Z33.2, Z34.00, Z34.80, Z34.90, Z36 Diagnosis, Active: Pregnancy: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators 57

60 Encounter, Performed: BMI Encounter Code Set: HCPCS Encounter, Performed: BMI Encounter Code Set: CPT Encounter, Performed: BMI Encounter Code Set: Encounter, Performed: BMI Encounter Code Set: CDT Intervention, Order: Above Normal Follow up: ICD9 Intervention, Order: Above Normal Follow up: ICD10 Intervention, Order: Above Normal Follow up: G0101, G0108, G0270, G0271, G0402, G0438, G0439, G , 90792, 90832, 90834, 90837, 90839, 96150, 96151, 96152, 97001, 97003, 97802, 97803, 98960, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , D7140, D7210 V65.3, V65.41 Z , , , , , , , , , , , , , Table 6b Quality of Care Indicators

61 Intervention, Order: Above Normal Follow up: HCPCS Intervention, Order: Above Normal Follow up: CPT Intervention, Order: Below Normal Follow up: ICD9 Intervention, Order: Below Normal Follow up: ICD10 Intervention, Order: Below Normal Follow up: Intervention, Order: Below Normal Follow up: HCPCS Intervention, Order: Referrals where weight assessment may occur: G8417, S9449, S9451, S9452, S , 43645, 43770, 43771, 43772, 43773, 43774, 43842, 43843, 43845, 43846, 43847, 43848, 97804, 98960, V65.3 Z , , , , , , G8418, S9449, S9452, S , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators 59

62 Physical Exam, Finding: BMI LOINC Value: LOINC Physical Exam, Performed not done: Medical or Other reason not done: Physical Exam, Performed not done: Patient Reason Refused: Physical Exam, Performed: BMI LOINC Value Attribute: Reason: Overweight: Attribute: Reason: Underweight: , , , , , , , Table 6b Quality of Care Indicators

63 Line 14a Tobacco Use Screening and Cessation Name Description: Denominator: Numerator: Details Percentage of patients aged 18 years and older (seen after their 18 th birthday) who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. This is related to Clinical Quality Measure NQF 0028 but does have some differences (for example, the UDS version does not have exclusions) **Patients in Age Range > = 18 years (checked before the start of the measurement period) AND: ***Who have had at least 1 Encounter of Preventive Care Services Group Counseling or Preventive Care Services Other or Preventive Care Services Initial Office Visit, 18 and Up or Preventive Care Services Established Office Visit, 18 and Up or Preventive Care Services Individual Counseling or Face to Face Interaction or Annual Wellness Visit during the Measurement period OR ***Who have had At least 2 Encounters of Psych Visit Diagnostic Evaluation or Health and Behavior Assessment Initial or Health & Behavioral Assessment Individual or Occupational Therapy Evaluation or Office Visit or Psych Visit Psychotherapy or Psychoanalysis or Ophthalmological Services during the Measurement period Encounters with Encounter Level Specified (CPT codes and HCPCS codes) NOTE Reporting will look at Encounter Plan Procedure Orders for Face to Face Interaction ( codes). (Must also fit criteria to be on the UDS report, if a patient is not listed in table 3a, they will not be counted in table 6a.) (14a) Patient asked for Smoking status at last visit (or in last 2 years) AND * Patient has not been identified as a tobacco user in the past 2 years [Patient DOESN T Fit 15a] OR ** (15a) Patient identified as a tobacco user in the past 2 years AND ** (15b) Tobacco use intervention at last visit (or in last 2 years) How to meet each condition for this measure, found in the PM under Maint > Patient Details > Patient Profile Detail > Clinical Quality Measure Data Table 6b Quality of Care Indicators 61

64 14a [Used to calculate Numerator] 15a [Used to calculate Numerator] 15b [Used to calculate Numerator] The patient was queried about any and all forms of tobacco use at their most recent visit, or within the past 24 months. **Patients have had their Tobacco User or Tobacco Non User status documented (see code list for codes) **And it has been reviewed <= 24 months before end of the measurement period MedInfo > Histories > Habits The Patient has been identified as a tobacco user sometime in the past 24 months (including both smoked and smokeless tobacco). **Patients have had their Tobacco User status documented (see code list for codes) **Date Range: Has been reviewed <= 24 months before end of the measurement Period MedInfo > Histories > Habits There is documentation that within the past 24 months, the patient had received tobacco use cessation counseling OR received a prescription or recommendation to purchase a smoking cessation medication. This medication may be prescription or OTC. *** Patients who had an Intervention Performed of Tobacco Use Cessation Counseling (see code list for CPT and codes) ** Date Range: <= 24 months before end of the Measurement Period Encounter Plan Procedure Orders Encounter Plan Instructions OR ***who were prescribed Tobacco Use Cessation Pharmacotherapy medications (see medication names in code list) ** Date Range: <= 24 months before end of the Measurement Period MedInfo > Medical > Medications Code Lists for Measure Encounter, Performed: Annual Wellness Visit: HCPCS Encounter, Performed: Face to Face Interaction: Encounter, Performed: Health & Behavioral Assessment Individual: CPT G0438, G , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators

65 Encounter, Performed: Health and Behavioral Assessment Initial: CPT Encounter, Performed: Occupational Therapy Evaluation: CPT Encounter, Performed: Office Visit: CPT Encounter, Performed: Ophthalmological Services: CPT Encounter, Performed: Preventive Care Services Established Office Visit, 18 and Up: CPT Encounter, Performed: Preventive Care Services Group Counseling: CPT Encounter, Performed: Preventive Care Services Other: CPT Encounter, Performed: Preventive Care Services Individual Counseling: CPT Encounter, Performed: Preventive Care Services Initial Office Visit, 18 and Up: CPT Encounter, Performed: Psych Visit Diagnostic Evaluation: CPT Encounter, Performed: Psych Visit Psychotherapy: CPT , , 99202, 99203, 99204, 99205, 99212, 99213, 99214, , 92004, 92012, , 99396, , , , 99402, 99403, , 99386, , , 90834, Table 6b Quality of Care Indicators 63

66 Encounter, Performed: Psychoanalysis: CPT Intervention, Performed: Tobacco Use Cessation Counseling: CPT Intervention, Performed: Tobacco Use Cessation Counseling: Medication, Active: OR Medication, Order: Tobacco Use Cessation Pharmacotherapy: RXNORM , , , , , , , , , , , HR Nicotine MG/HR Transdermal Patch, 24 HR Nicotine MG/HR Transdermal Patch, topiramate 50 MG Oral Tablet, 24 HR Nicotine MG/HR Transdermal Patch, 24 HR Nicotine MG/HR Transdermal Patch, 24 HR Nicotine MG/HR Transdermal Patch, Nortriptyline 10 MG Oral Capsule, Nortriptyline 50 MG Oral Capsule, Nortriptyline 75 MG Oral Capsule, topiramate 25 MG Oral Tablet, topiramate 100 MG Oral Tablet, topiramate 200 MG Oral Tablet, topiramate 25 MG Oral Capsule, topiramate 15 MG Oral Capsule, Nicotine 4 MG/ACTUAT Inhalant Solution, 24 HR Nicotine MG/HR Transdermal Patch, 24 HR Nicotine MG/HR Transdermal Patch, Nicotine 4 MG Chewing Gum, Nortriptyline 2 MG/ML Oral Solution, Nicotine 2 MG Chewing Gum, Nortriptyline 25 MG Oral Capsule, Nicotine 2 MG Lozenge, Nicotine 4 MG Lozenge, 24 HR Nicotine MG/HR Transdermal Patch, varenicline 0.5 MG Oral Tablet, varenicline 1 MG Oral Tablet, {11 (varenicline 0.5 MG Oral Tablet) / 42 (varenicline 1 MG Oral Tablet) } Pack, {56 (varenicline 1 MG Oral Tablet) } Pack, {14 (24 HR Nicotine MG/ HR Transdermal Patch) / 14 (24 HR Nicotine MG/ HR Transdermal Patch) / 28 (24 HR Nicotine MG/ HR Transdermal Patch) } Pack, 200 ACTUAT Nicotine 0.5 MG/ACTUAT Nasal Inhaler, 12 HR Bupropion Hydrochloride 100 MG Extended Release Tablet, 12 HR Bupropion Hydrochloride 150 MG Extended Release Tablet, 12 HR Bupropion Hydrochloride 200 MG Extended Release Tablet, 24 HR Bupropion Hydrochloride 150 MG Extended Release Tablet, 24 HR Bupropion hydrobromide 174 MG Extended Release Tablet, 24 HR Bupropion Hydrochloride 300 MG Extended Release Tablet, 24 HR Bupropion hydrobromide 348 MG Extended Release Tablet, 24 HR Bupropion hydrobromide 522 MG Extended Release Tablet, 168 HR Clonidine MG/HR Transdermal Patch, 168 HR Clonidine MG/HR Transdermal Patch, 168 HR Clonidine MG/HR Transdermal Patch 64 Table 6b Quality of Care Indicators

67 Patient Characteristic: Tobacco Non User: Patient Characteristic: Tobacco User: Risk Category Assessment: Tobacco Use Screening: LOINC , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators 65

68 Line 16 Asthma Pharmacologic Therapy Name Description: Denominator: Numerator: Exclusion: Details The performance measure is Percentage of patients aged 5 through 40 with a diagnosis of mild, moderate, or severe persistent asthma who received or were prescribed accepted pharmacologic therapy. This is partially related to Clinical Quality Measure NQF 0036 (but with some major differences) Number of patients who were 5 through 40 years of age at some point during the measurement year, who have been seen at least twice in the practice and who had at least one medical visit during the reporting year. AND (16a) The patient was seen during the measurement year and had an active diagnosis of persistent asthma at the time of the visit. (Must also fit criteria to be on the UDS report, if a patient is not listed in table 3a, they will not be counted in table 6a.) (16b) There is documentation that the patient received, was prescribed, or used an inhaled corticosteroid or an acceptable pharmacological agent. (16c) Patient is allergic to asthma medications, or has had an adverse reaction to asthma medications How to meet each condition for this measure, found in the PM under Maint > Patient Details > Patient Profile Detail > Clinical Quality Measure Data 16a (used to determine denominator) The patient was seen during the measurement year and had an active diagnosis of persistent asthma at the time of the visit. **Patients in Age Range: >= 5 years and <= 41 years (checked on the last day of the measurement period) [everyone who turns 5 during the year to everyone who turns 41 during the year] AND ** Patient has diagnosis of Persistent Asthma (see code list for ICD and codes) ** Date Range: Beginning date between one year prior to start of the measurement period and end of the measurement period. MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes) 66 Table 6b Quality of Care Indicators

69 16b (used to determine numerator) 16c (used to determine exclusion) There is documentation that the patient received, was prescribed, or used an inhaled corticosteroid or an acceptable pharmacological agent. **Patients who were dispensed at least one prescription for a Preferred Asthma Therapy (see medication names in code list) **Date Range: during the measurement period. MedInfo > Medical > Medications Patient is allergic to asthma medications, or has had an adverse reaction to asthma medications. **Patients who were allergic to or had an adverse reaction to Preferred Asthma Therapy (see medication names in code list) **Date Range: prior to the end of the measurement period MedInfo > Medical > Allergies MedInfo > Medical > Medications (medication terminated because of adverse reaction) Code Lists for Measure Diagnosis, Active: Persistent Asthma: ICD 9 Diagnosis, Active: Persistent Asthma: , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators 67

70 Medication, Dispensed: Preferred Asthma Therapy: RXNORM 240 ACTUAT Triamcinolone Acetonide MG/ACTUAT Metered Dose Inhaler, Fluticasone propionate 0.22 MG/ ACTUAT Inhalant Powder, 60 ACTUAT flunisolide MG/ ACTUAT Metered Dose Inhaler, 120 ACTUAT flunisolide MG/ACTUAT Metered Dose Inhaler, 120 ACTUAT Budesonide 0.08 MG/ACTUAT / formoterol fumarate MG/ACTUAT Metered Dose Inhaler, 120 ACTUAT Budesonide 0.16 MG/ACTUAT / formoterol fumarate MG/ACTUAT Metered Dose Inhaler, 60 ACTUAT Budesonide 0.08 MG/ACTUAT / formoterol fumarate MG/ ACTUAT Metered Dose Inhaler, 60 ACTUAT Budesonide 0.16 MG/ACTUAT / formoterol fumarate MG/ACTUAT Metered Dose Inhaler, Aminophylline 250 MG Rectal Suppository, Dyphylline 200 MG Oral Tablet, Dyphylline 400 MG Oral Tablet, Dyphylline 200 MG / Guaifenesin 200 MG Oral Tablet, Theophylline 100 MG Oral Capsule, Theophylline 125 MG Extended Release Capsule, Theophylline 125 MG Oral Tablet, Theophylline 250 MG Oral Tablet, Theophylline 300 MG Oral Tablet, Theophylline 400 MG Extended Release Capsule, Guaifenesin 180 MG / Theophylline 300 MG Oral Capsule, Budesonide MG/ ACTUAT Inhalant Powder, Theophylline 50 MG Oral Tablet, zafirlukast 20 MG Oral Tablet, zileuton 600 MG Oral Tablet, montelukast 10 MG Oral Tablet, Theophylline 100 MG Extended Release Tablet, Dyphylline 6.67 MG/ML / Guaifenesin 6.67 MG/ML Oral Solution, montelukast 5 MG Chewable Tablet, Guaifenesin 6.67 MG/ML / Theophylline 20 MG/ML Oral Solution, Guaifenesin 20 MG/ML / Theophylline 20 MG/ML Oral Solution, Budesonide 0.2 MG/ ACTUAT Inhalant Powder, Dyphylline 6.67 MG/ML Oral Solution, Aminophylline 250 MG/ML Injectable Solution, Budesonide 0.5 MG/ML Inhalant Solution, Aminophylline 100 MG Enteric Coated Tablet, Aminophylline 21 MG/ML Oral Solution, Aminophylline 130 MG / Guaifenesin 100 MG / Phenobarbital 8 MG Oral Tablet, Aminophylline 130 MG / Potassium Iodide 195 MG Oral Tablet, Aminophylline 200 MG Enteric Coated Tablet, Aminophylline 225 MG Extended Release Tablet, Aminophylline 200 MG Oral Tablet, Aminophylline 25 MG/ML Injectable Solution, Dyphylline 20 MG/ML / Guaifenesin 20 MG/ML Oral Solution, Guaifenesin 6.67 MG/ML / Theophylline 6.67 MG/ML Oral Solution, Guaifenesin 100 MG / Theophylline 125 MG Oral Tablet, Guaifenesin 6 MG/ML / Theophylline 10 MG/ML Oral Solution, montelukast 4 MG Chewable Tablet, Theophylline 0.8 MG/ML Injectable Solution, Theophylline 1.6 MG/ML Injectable Solution, Theophylline 10.7 MG/ML Oral Solution, Theophylline 200 MG Extended Release Capsule, Theophylline 250 MG Oral Capsule, Theophylline 2 MG/ML Injectable Solution, Theophylline 3.2 MG/ML Injectable Solution,Theophylline 400 MG Extended Release Tablet, 68 Table 6b Quality of Care Indicators

71 Theophylline 4 MG/ML Injectable Solution, Theophylline 500 MG Extended Release Tablet, Theophylline 65 MG Extended Release Capsule, Theophylline 75 MG Extended Release Capsule, Theophylline 5.33 MG/ML Oral Solution, Theophylline 300 MG Extended Release Capsule, zafirlukast 10 MG Oral Tablet, Aminophylline 100 MG Oral Tablet, Theophylline 250 MG Extended Release Tablet, Theophylline 450 MG Extended Release Tablet, Guaifenesin 200 MG / Theophylline 250 MG Oral Tablet, Theophylline 300 MG Extended Release Tablet, Theophylline 130 MG Extended Release Capsule, Theophylline 200 MG Extended Release Tablet, Theophylline 600 MG Extended Release Tablet, Budesonide MG/ML Inhalant Solution, Dyphylline 200 MG / Guaifenesin 300 MG Oral Tablet, Budesonide 0.25 MG/ ML Inhalant Solution, montelukast 4 MG Granules, Dyphylline 200 MG / Guaifenesin 400 MG Oral Tablet, omalizumab 125 MG/ML Injectable Solution, Budesonide 0.08 MG/ACTUAT / formoterol MG/ACTUAT Inhalant Powder, Theophylline 50 MG Oral Capsule, Theophylline 20 MG/ML Oral Suspension, Aminophylline 60 MG/ML Enema, Theophylline 10 MG/ML Oral Solution, Aminophylline 130 MG / Guaifenesin 100 MG Oral Tablet, Guaifenesin 100 MG / Theophylline 137 MG Oral Tablet, Theophylline 330 MG Oral Tablet, Noscapine 30 MG / Theophylline 200 MG Extended Release Tablet, Aminophylline 300 MG Extended Release Tablet, 12 HR Aminophylline 225 MG Extended Release Tablet, Aminophylline 111 MG / Guaifenesin 100 MG Oral Tablet, Budesonide 0.16 MG/ACTUAT / formoterol MG/ACTUAT Inhalant Powder, mometasone furoate 0.2 MG/ACTUAT Inhalant Powder, Budesonide 0.18 MG/ ACTUAT Inhalant Powder, Budesonide 0.09 MG/ACTUAT Inhalant Powder, Theophylline 100 MG Extended Release Capsule, Theophylline 50 MG Extended Release Capsule, 12 HR zileuton 600 MG Extended Release Tablet, 120 ACTUAT mometasone furoate 0.2 MG/ACTUAT Dry Powder Inhaler, 14 ACTUAT mometasone furoate 0.2 MG/ACTUAT Dry Powder Inhaler, 30 ACTUAT mometasone furoate 0.2 MG/ ACTUAT Dry Powder Inhaler, 60 ACTUAT mometasone furoate 0.2 MG/ACTUAT Dry Powder Inhaler, 120 ACTUAT Budesonide MG/ACTUAT Nasal Inhaler, 200 ACTUAT Budesonide MG/ACTUAT Nasal Inhaler, 200 ACTUAT flunisolide MG/ACTUAT Nasal Inhaler, Dyphylline 20 MG/ML / Guaifenesin 10 MG/ML Oral Solution, Dyphylline 20 MG/ML / Guaifenesin 40 MG/ML Oral Solution, Dyphylline 40 MG/ML / Guaifenesin 20 MG/ML Oral Solution, Aminophylline 16.7 MG/ML Oral Solution, Guaifenesin 10 MG/ML / Pseudoephedrine 2 MG/ML / Theophylline 10 MG/ML Oral Solution, Theophylline 22 MG/ ML Oral Solution, Theophylline 7.5 MG/ML Oral Solution, Table 6b Quality of Care Indicators 69

72 ACTUAT mometasone furoate 0.1 MG/ACTUAT Dry Powder Inhaler, 30 ACTUAT mometasone furoate 0.1 MG/ACTUAT Dry Powder Inhaler, 100 ACTUAT flunisolide 0.25 MG/ ACTUAT Metered Dose Inhaler, Cromolyn Sodium 10 MG/ ML Inhalant Solution, Cromolyn Sodium 0.8 MG/ACTUAT Inhalant Powder, Cromolyn Sodium 20 MG/ML Oral Solution, Cromolyn Sodium 100 MG Oral Capsule, 120 ACTUAT Fluticasone propionate MG/ACTUAT Metered Dose Inhaler, 120 ACTUAT Fluticasone propionate 0.11 MG/ ACTUAT Metered Dose Inhaler, 120 ACTUAT Fluticasone propionate 0.22 MG/ACTUAT Metered Dose Inhaler, 60 ACTUAT Fluticasone propionate 0.05 MG/ACTUAT Dry Powder Inhaler, 60 ACTUAT Fluticasone propionate 0.1 MG/ ACTUAT Dry Powder Inhaler, 60 ACTUAT Fluticasone propionate 0.25 MG/ACTUAT Dry Powder Inhaler, 28 ACTUAT Fluticasone propionate 0.05 MG/ACTUAT Dry Powder Inhaler, 28 ACTUAT Fluticasone propionate 0.1 MG/ ACTUAT Dry Powder Inhaler, 14 ACTUAT Fluticasone propionate 0.1 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler, 60 ACTUAT Fluticasone propionate 0.1 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler, 14 ACTUAT Fluticasone propionate 0.25 MG/ ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler, 28 ACTUAT Fluticasone propionate 0.25 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler, 60 ACTUAT Fluticasone propionate 0.25 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler, 14 ACTUAT Fluticasone propionate 0.5 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler, 60 ACTUAT Fluticasone propionate 0.5 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler, 60 ACTUAT Fluticasone propionate MG/ACTUAT / salmeterol MG/ACTUAT Metered Dose Inhaler, 120 ACTUAT Fluticasone propionate MG/ACTUAT / salmeterol MG/ACTUAT Metered Dose Inhaler, 60 ACTUAT Fluticasone propionate MG/ACTUAT / salmeterol MG/ACTUAT Metered Dose Inhaler, 120 ACTUAT Fluticasone propionate MG/ACTUAT / salmeterol MG/ACTUAT Metered Dose Inhaler, 60 ACTUAT Fluticasone propionate 0.23 MG/ACTUAT / salmeterol MG/ACTUAT Metered Dose Inhaler, 120 ACTUAT Fluticasone propionate 0.23 MG/ACTUAT / salmeterol MG/ACTUAT Metered Dose Inhaler, Fluticasone propionate 0.25 MG/ML Inhalant Solution, 104 ACTUAT Nedocromil Sodium 1.75 MG/ACTUAT Metered Dose Inhaler, 120 ACTUAT Budesonide 0.16 MG/ACTUAT Dry Powder Inhaler, 200 ACTUAT Budesonide 0.16 MG/ ACTUAT Dry Powder Inhaler, 60 ACTUAT Budesonide 0.08 MG/ACTUAT Dry Powder Inhaler, 70 Table 6b Quality of Care Indicators

73 100 ACTUAT Beclomethasone Dipropionate 0.04 MG/ ACTUAT Metered Dose Inhaler, 100 ACTUAT Beclomethasone Dipropionate 0.08 MG/ACTUAT Metered Dose Inhaler, 200 ACTUAT Beclomethasone Dipropionate MG/ACTUAT Metered Dose Inhaler, 200 ACTUAT Beclomethasone Dipropionate MG/ACTUAT Metered Dose Inhaler, 80 ACTUAT Beclomethasone Dipropionate MG/ACTUAT Metered Dose Inhaler, 120 ACTUAT Beclomethasone Dipropionate MG/ACTUAT Metered Dose Inhaler. Line 17 Coronary Artery Disease: Lipid Lowering Therapy Name Description: Denominator: Details The performance measure is Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed a lipid lowering therapy. This is related to Pre 2014 Clinical Quality Measure NQF 0074 No equivalent measure exists in the 2014 CQMs Number of patients who were seen during the measurement year after their 18th birthday, who had at least one medical visit during the reporting year, with at least two medical visits ever. AND (17a) Patient has an active diagnosis of CAD (Coronary Artery Disease) including MI (Myocardial Infarction) or has had cardiac surgery (Must also fit criteria to be on the UDS report, if a patient is not listed in table 3a, they will not be counted in table 6a.) Numerator: (17b) Documentation exists that Patient was prescribed (or was already taking) a lipid lowering therapy during the measurement year. Exclusion: (17c) Patient is allergic to lipid lowering medications, or has had an adverse reaction to lipid lowering medications How to meet each condition for this measure, found in the PM under Maint > Patient Details > Patient Profile Detail > Clinical Quality Measure Data Table 6b Quality of Care Indicators 71

74 17a (used to determine denominator) 17b (used to determine numerator) Patient has an active diagnosis of CAD (Coronary Artery Disease) including MI (Myocardial Infarction) or has had cardiac surgery. **Patients in Age Range: >= 18 years (by the end of the measurement period) AND ***Who have had at least 1 Encounter with Encounter Levels Outpatient or Nursing Facility (see code list) **Date Range: During the measurement period Encounters with Encounter Level Specified (CPT codes and HCPCS codes) NOTE Reporting will look at Encounter Plan Procedure Orders for Face to Face Interaction ( codes) AND ***who have condition of Coronary Artery Disease includes MI recorded in their chart (see code list) ***Date Range: prior to the encounter date MedInfo > Medical > Problem List Entry Encounter Assessment OR ***who have had Cardiac Surgery (see code list) ***Date Range: Prior to the encounter Encounter Plan (performed) MedInfo > Histories > Surgical History MedInfo > Histories > Surgical Procedures MedInfo > Orders > Orders (completed) NOTE Reporting will look at the CPT codes or Procedure names related to the surgery. Documentation exists that Patient was prescribed (or was already taking) a lipid lowering therapy during the measurement year. **Patients who were prescribed Lipid Lowering Therapy (see code list) **Date Range: Prior to the end of the reporting period MedInfo > Medical > Medications 17c (used to determine exclusion) Patient is allergic to lipid lowering medications, or has had an adverse reaction to lipid lowering medications. **Patients who were allergic to or had an adverse reaction to Lipid Lowering Medications (see medication names in code list) MedInfo > Medical > Allergies MedInfo > Medical > Medications (medication terminated because of adverse reaction) 72 Table 6b Quality of Care Indicators

75 Code Lists for Measure Encounter, Performed: Outpatient: CPT Encounter, Performed: Nursing Facility: CPT Diagnosis, Active: Coronary Artery Disease includes MI ICD9 Procedure, Performed: Cardiac Surgery: CPT Procedure, Performed: Cardiac Surgery: Procedure Name Medication, Dispensed: Lipid Lowering Therapy: RXNORM 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, , 99305, 99306, 99307, 99308, 99309, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 411.0, 411.1, , , 412, 413.0, 413.1, 413.9, , , , , , , , , , 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536, 92980, 92981, 92982, 92984, 92995, Coronary Artery Bypass Graft (CABG) Advicor 1,000 mg 20 mg 24 hr Tab, Advicor 500 mg 20 mg 24 hr Tab, Advicor 750 mg 20 mg 24 hr Tab, Altocor 10 mg 24 hr Tab, Altocor 20 mg 24 hr Tab, Altocor 40 mg 24 hr Tab, Altocor 60 mg 24 hr Tab, Altoprev 10 mg 24 hr Tab, Altoprev 20 mg 24 hr Tab, Altoprev 40 mg 24 hr Tab, Altoprev 60 mg 24 hr Tab, amlodipine atorvastatin 10 mg 10 mg Tab, amlodipine atorvastatin 10 mg 20 mg Tab, amlodipineatorvastatin 10 mg 40 mg Tab, amlodipine atorvastatin 10 mg 80 mg Tab, amlodipine atorvastatin 2.5 mg 10 mg Tab, amlodipine atorvastatin 2.5 mg 20 mg Tab, amlodipineatorvastatin 2.5 mg 40 mg Tab, amlodipine atorvastatin 5 mg 10 mg Tab, amlodipine atorvastatin 5 mg 20 mg Tab, amlodipine atorvastatin 5 mg 40 mg Tab, amlodipineatorvastatin 5 mg 80 mg Tab, Antara 130 mg Cap, Antara 43 mg Cap, atorvastatin 10 mg Tab, atorvastatin 20 mg Tab, atorvastatin 40 mg Tab, atorvastatin 80 mg Tab, Atromid S 500 mg Cap, B 3 Niacin 100 mg Tab, B 3 Niacin ER 500 mg Tab, B mg Tab, B3 500 GR 500 mg Tab, Caduet 10 mg 10 mg Tab, Caduet 10 mg 20 mg Tab, Caduet 10 mg 40 mg Tab, Caduet 10 mg 80 mg Tab, Caduet 2.5 mg 10 mg Tab, Caduet 2.5 mg 20 mg Tab, Caduet 2.5 mg 40 mg Tab, Caduet 5 mg 10 mg Tab, Caduet 5 mg 20 mg Tab, Caduet 5 mg 40 mg Tab, Caduet 5 mg 80 mg Tab, Cholestyramine Light 4 gram Oral Powder, Cholestyramine Light 4 gram Packet, Table 6b Quality of Care Indicators 73

76 Cholestyramine Susp Light 4 gram Packet, cholestyramineaspartame 4 gram Oral Powder, cholestyramine aspartame 4 gram Packet, cholestyraminesucrose 4 gram Oral Powder, cholestyramine sucrose 4 gram Packet, clofibrate 500 mg Cap, colesevelam 625 mg Tab, Crestor 10 mg Tab, Crestor 20 mg Tab, Crestor 40 mg Tab, Crestor 5 mg Tab, Endur Acin 500 mg Tab, ezetimibe 10 mg Tab, ezetimibe simvastatin 10 mg 10 mg Tab, ezetimibesimvastatin 10 mg 20 mg Tab, ezetimibe simvastatin 10 mg 40 mg Tab, ezetimibe simvastatin 10 mg 80 mg Tab, fenofibrate 160 mg Tab, fenofibrate 54 mg Tab, fenofibrate micronized 130 mg Cap, fenofibrate micronized 134 mg Cap, fenofibrate micronized 160 mg Tab, fenofibrate micronized 200 mg Cap, fenofibrate micronized 43 mg Cap, fenofibrate micronized 67 mg Cap, fenofibrate nanocrystallized 145 mg Tab, fenofibrate nanocrystallized 160 mg Tab, fenofibrate nanocrystallized 48 mg Tab, fenofibrate nanocrystallized 50 mg Tab, fluvastatin 20 mg Cap, fluvastatin 40 mg Cap, fluvastatin ER 80 mg 24 hr Tab, Gemcor 600 mg Tab, gemfibrozil 600 mg Tab, inositol niacinate 500 mg Cap, Lescol 20 mg Cap, Lescol 40 mg Cap, Lescol XL 80 mg 24 hr Tab, Lipitor 10 mg Tab, Lipitor 20 mg Tab, Lipitor 40 mg Tab, Lipitor 80 mg Tab, LoCholest 4 gram Oral Packet, LoCholest 4 gram Oral Powder, LoCholest Light 4 gram Oral Packet, Lofibra 134 mg Cap, Lofibra 160 mg Tab, Lofibra 200 mg Cap, Lofibra 54 mg Tab, Lofibra 67 mg Cap, Lopid 600 mg Tab, lovastatin 10 mg Tab, lovastatin 20 mg Tab, lovastatin 40 mg Tab, lovastatin ER 10 mg 24 hr Tab, lovastatin ER 20 mg 24 hr Tab, lovastatin ER 40 mg 24 hr Tab, lovastatin ER 60 mg 24 hr Tab, Mevacor 10 mg Tab, Mevacor 20 mg Tab, Mevacor 40 mg Tab, Na mg Cap, Nb3 500 mg Tab, Nia Bid 400 mg Cap, Niac 400 mg Cap, Niacels 400 mg Cap, niacin 100 mg Tab, niacin 250 mg Tab, niacin 50 mg Tab, niacin 500 mg Tab, niacin ER 1,000 mg Tab, niacin ER 125 mg Cap, niacin ER 250 mg Cap, niacin ER 400 mg Cap, niacin ER 500 mg Cap, niacin ER 500 mg Tab, niacin ER 750 mg Tab, niacin lovastatin ER 1,000 mg 20 mg multiphase 24 hr Tab, niacin lovastatin ER 500 mg 20 mg multiphase 24 hr Tab, niacin lovastatin ER 750 mg 20 mg multiphase 24 hr Tab, Niacin Time 500 mg Tab, Niacinol 500 mg Cap, Niacor 500 mg Tab, Niacor B3 500 mg Tab, NiaDelay 500 mg Tab, Niaplus 400 mg Cap, Niatab 500 mg, Nico mg Cap, Nico Span 400 mg Cap, Nicobid 125 mg Cap, Nicobid 250 mg Cap, Nicobid 500 mg Cap, Nicocap 400 mg, Nicolar 500 mg Tab, Nicotinic Acid 100 mg Tab, Nicotinic Acid 250 mg Cap, Nicotinic Acid 500 mg Cap, Nicotym 400 mg Cap, Pravachol 10 mg Tab, Pravachol 20 mg Tab, Pravachol 40 mg Tab, Pravachol 80 mg Tab, pravastatin 10 mg Tab, pravastatin 20 mg Tab, pravastatin 40 mg Tab, pravastatin 80 mg Tab, Prevalite 4 gram Oral Packet, 74 Table 6b Quality of Care Indicators

77 Prevalite 4 gram Oral Powder, Questran 4 gram Oral Powder, Questran 4 gram Packet, Questran Light 4 gram Oral Powder, Questran Light 4 gram Packet, Ridicin 100 mg Tab, Ridicin 50 mg Tab, rosuvastatin 10 mg Tab, rosuvastatin 20 mg Tab, rosuvastatin 40 mg Tab, rosuvastatin 5 mg Tab, simvastatin 10 mg Tab, simvastatin 20 mg Tab, simvastatin 40 mg Tab, simvastatin 5 mg Tab, simvastatin 80 mg Tab, Slo Niacin 500 mg Tab, Slo Niacin 750 mg Tab, Tega Span mg Cap, Tega Span mg Cap, Tega Span mg Cap, Tega Span 400 mg Cap, Tricor 134 mg Cap, Tricor 145 mg Tab, Tricor 160 mg Tab, Tricor 200 mg Cap, Tricor 48 mg Tab, Tricor 67 mg Cap, Triglide 160 mg Tab, Triglide 50 mg Tab, Vytorin mg 10 mg Tab, Vytorin mg 20 mg Tab, Vytorin mg 40 mg Tab, Vytorin mg 80 mg Tab, WelChol 625 mg Tab, Zetia 10 mg Tab, Zocor 10 mg Tab, Zocor 20 mg Tab, Zocor 40 mg Tab, Zocor 5 mg Tab, Zocor 80 mg Tab. Line 18 Ischemic Vascular Disease (IVD): Aspirin or Antithrombotic Therapy Name Description: Denominator: Details Number of patients who were aged 18 and older at some point during the measurement year, who had at least one medical visit during the reporting year, who had an active diagnosis of ischemic vascular disease (IVD) during the current or prior year OR had been discharged alive after AMI, CABG or PTCA between January 1 and November 1 of the year prior to the measurement year, who had documentation of use of aspirin or another antithrombotic This is related to Clinical Quality Measure NQF 0068 **Patients in Age Range > = 18 years (by the end of the measurement period) AND ** (18a) Documentation exists that Patient was discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from Jan. 1 to Nov. 1 of the year prior to the measurement year OR patient had a diagnosis of ischemic vascular disease (IVD) during the measurement year or one year prior (Must also fit criteria to be on the UDS report, if a patient is not listed in table 3a, they will not be counted in table 6a.) Numerator: ** (18b) Documentation exists that Patient was prescribed (or was already taking) aspirin or another antithrombotic therapy during the measurement year. How to meet each condition for this measure, found in the PM under Maint > Patient Details > Patient Profile Detail > Clinical Quality Measure Data Table 6b Quality of Care Indicators 75

78 18a (used to determine denominator) 18b (used to determine numerator) Documentation exists that Patient was discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from Jan. 1 to Nov. 1 of the year prior to the measurement year OR patient had a diagnosis of ischemic vascular disease (IVD) during the measurement year or one year prior. **Patients in Age Range: >= 18 years (by the end of the measurement period) AND ***who have condition of Acute Myocardial Infarction recorded in their chart (see code list for ICD and codes) ***Date Range: Beginning date between 12 months and 2 months before the start of the measurement Period. MedInfo > Medical > Problem List Encounter Assessment MedInfo > Histories > Medical History OR ***who have condition of Ischemic Vascular Disease recorded in their chart (see code list for ICD and codes) ***Date Range: Beginning date after 12 months prior to the start Measurement period and prior to the end of the Measurement Period MedInfo > Medical > Problem List Encounter Assessment MedInfo > Histories > Medical History OR ***Patient has had Percutaneous Coronary Interventions or a Coronary Artery Bypass Graft (see code list for CPT, HCPCS and codes) ***Date Range: Between 12 months and 2 months before the start of the Measurement Period. MedInfo > Histories > Hospitalization History MedInfo > Histories > Surgical Procedures MedInfo > Histories > Surgical History NOTE Reporting will look at Procedure names in Surgical History Documentation exists that Patient was prescribed (or was already taking) aspirin or another antithrombotic therapy during the measurement year. **Patients who were prescribed Aspirin and Other Anti thrombotics medications (see medication names in code list) **Date Range: Beginning date prior to end of the measurement period and end date (if exists) after the start of the measurement period. MedInfo > Medical > Medications 76 Table 6b Quality of Care Indicators

79 Code Lists for Measure Diagnosis, Active: Acute Myocardial Infarction: ICD9 Diagnosis, Active: Acute Myocardial Infarction: ICD10 Diagnosis, Active: Acute Myocardial Infarction: Diagnosis, Active: Ischemic Vascular Disease: ICD , , , , , , , , , I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 411.1, , , 413.0, 413.1, 413.9, , , , , , , , , 414.2, 414.8, 414.9, 429.2, , , , , , , , , , , , , , , , , , , 440.1, , , , , , , 440.4, 444.0, 444.1, , , , , 444.9, , , , Table 6b Quality of Care Indicators 77

80 Diagnosis, Active: Ischemic Vascular Disease: ICD10 I20.0, I20.1, I20.8, I20.9, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750, I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.89, I25.9, I63.00, I63.011, I63.012, I63.019, I63.02, I63.031, I63.032, I63.039, I63.09, I63.10, I63.111, I63.112, I63.119, I63.12, I63.131, I63.132, I63.139, I63.19, I63.20, I63.211, I63.212, I63.219, I63.22, I63.231, I63.232, I63.239, I63.29, I63.30, I63.311, I63.312, I63.319, I63.321, I63.322, I63.329, I63.331, I63.332, I63.339, I63.341, I63.342, I63.349, I63.39, I63.40, I63.411, I63.412, I63.419, I63.421, I63.422, I63.429, I63.431, I63.432, I63.439, I63.441, I63.442, I63.449, I63.49, I63.50, I63.511, I63.512, I63.519, I63.521, I63.522, I63.529, I63.531, I63.532, I63.539, I63.541, I63.542, I63.549, I63.59, I63.6, I63.8, I63.9, I65.01, I65.02, I65.03, I65.09, I65.1, I65.21, I65.22, I65.23, I65.29, I65.8, I65.9, I66.01, I66.02, I66.03, I66.09, I66.11, I66.12, I66.13, I66.19, I66.21, I66.22, I66.23, I66.29, I66.3, I66.8, I66.9, I70.1, I70.201, I70.202, I70.203, I70.208, I70.209, I70.211, I70.212, I70.213, I70.218, I70.219, I70.221, I70.222, I70.223, I70.228, I70.229, I70.231, I70.232, I70.233, I70.234, I70.235, I70.238, I70.239, I70.241, I70.242, I70.243, I70.244, I70.245, I70.248, I70.249, I70.25, I70.261, I70.262, I70.263, I70.268, I70.269, I70.291, I70.292, I70.293, I70.298, I70.299, I70.92, I74.01, I74.09, I74.10, I74.11, I74.19, I74.2, I74.3, I74.4, I74.5, I74.8, I74.9, I75.011, I75.012, I75.013, I75.019, I75.021, I75.022, I75.023, I75.029, I75.81, I Table 6b Quality of Care Indicators

81 Diagnosis, Active: Ischemic Vascular Disease: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators 79

82 Medication, Active: Aspirin and Other Antithrombotics: RXNORM Procedure, Performed: Coronary Artery Bypass Graft: HCPCS Procedure, Performed: Coronary Artery Bypass Graft: CPT Aspirin 800 MG Extended Release Tablet, Aspirin 325 MG Oral Capsule, Aspirin 325 MG Enteric Coated Tablet, Aspirin 500 MG Oral Tablet, Aspirin 650 MG Oral Tablet, Aspirin 162 MG Enteric Coated Tablet, Aspirin 300 MG Oral Capsule, Aspirin 325 MG Oral Tablet, Aspirin 65 MG Oral Tablet, Aspirin 81 MG Oral Tablet, Aspirin 500 MG Oral Capsule, Aspirin 80 MG Enteric Coated Tablet, Aspirin 25 MG / Dipyridamole 200 MG Oral Capsule, Aspirin 500 MG Enteric Coated Tablet, Aspirin 650 MG Enteric Coated Tablet, Aspirin 75 MG Chewable Tablet, Aspirin 81 MG Enteric Coated Tablet, Aspirin 975 MG Enteric Coated Tablet, clopidogrel 75 MG Oral Tablet, Ticlopidine 250 MG Oral Tablet, Aspirin 81 MG Chewable Tablet, Aspirin 81 MG Enteric Coated Capsule, Aspirin 80 MG Oral Tablet, Aspirin 488 MG Oral Tablet, Aspirin 500 MG Enteric Coated Capsule, Aspirin 81 MG Disintegrating Tablet, clopidogrel 300 MG Oral Tablet, Aspirin 228 MG Chewing Gum, prasugrel 10 MG Oral Tablet, prasugrel 5 MG Oral Tablet S2205, S2206, S2207, S2208, S , 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, Table 6b Quality of Care Indicators

83 Procedure, Performed: Coronary Artery Bypass Graft: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Coronary artery bypass with autogenous graft, three grafts (procedure), Internal mammary coronary artery bypass graft (procedure), Coronary artery bypass graft, anastomosis of artery of thorax to coronary artery (procedure), Saphenous vein graft replacement of one coronary artery (procedure), Saphenous vein graft replacement of two coronary arteries (procedure), Saphenous vein graft replacement of three coronary arteries (procedure), Saphenous vein graft replacement of four or more coronary arteries (procedure), Allograft bypass of coronary artery (procedure), Allograft replacement of one coronary artery (procedure), Allograft replacement of two coronary arteries (procedure), Allograft replacement of three coronary arteries (procedure), Allograft replacement of four or more coronary arteries (procedure), Prosthetic bypass of coronary artery (procedure), Prosthetic replacement of one coronary artery (procedure), Prosthetic replacement of two coronary arteries (procedure), Prosthetic replacement of three coronary arteries (procedure), Prosthetic replacement of four or more coronary arteries (procedure), Connection of mammary artery to coronary artery (procedure), Double implantation of mammary arteries into coronary arteries (procedure), Single anastomosis of mammary artery to left anterior descending coronary artery (procedure), Single implantation of mammary artery into coronary artery (procedure), Coronary artery bypass grafting (procedure), Coronary artery bypass graft x 1 (procedure), Coronary artery bypass grafts x 2 (procedure), Coronary artery bypass grafts x 3 (procedure), Coronary artery bypass grafts x 4 (procedure), Coronary artery bypass grafts x 5 (procedure), Coronary artery bypass grafts greater than 5 (procedure), Double anastomosis of mammary arteries to coronary arteries (procedure), Left internal mammary artery single anastomosis (procedure), Right internal mammary artery single anastomosis (procedure), Table 6b Quality of Care Indicators 81

84 Left internal mammary artery sequential anastomosis (procedure), Right internal mammary artery sequential anastomosis (procedure), Anastomosis of thoracic artery to coronary artery, double (procedure), Aortocoronary bypass grafting (procedure), Aortocoronary artery bypass graft with saphenous vein graft (procedure), Single internal mammarycoronary artery bypass (procedure), Coronary artery bypass with autogenous graft of internal mammary artery, single graft (procedure), Coronary artery bypass with autogenous graft, four grafts (procedure), Anastomosis of internal mammary artery to coronary artery, double vessel (procedure), Emergency coronary artery bypass graft (procedure), Robot assisted coronary artery bypass (procedure), Minimally invasive direct coronary artery bypass (procedure), Anastomosis of thoracic artery to coronary artery, single (procedure), Coronary artery bypass with autogenous graft, two grafts (procedure), Coronary artery bypass with autogenous graft, five grafts (procedure) Procedure, Performed: Percutaneous Coronary Interventions: HCPCS Procedure, Performed: Percutaneous Coronary Interventions: CPT G , 92924, 92928, 92933, 92937, 92941, 92943, 92980, 92982, Table 6b Quality of Care Indicators

85 Procedure, Performed: Percutaneous Coronary Interventions: , , , , , , , , , , , , , , , , , , Percutaneous transluminal coronary angioplasty (procedure), Transmyocardial revascularization by laser technique (procedure), Percutaneous transluminal balloon angioplasty of bypass graft of coronary artery (procedure), Percutaneous directional coronary atherectomy (procedure), Percutaneous low speed rotational coronary atherectomy (procedure), Percutaneous high speed rotational coronary atherectomy (procedure), Percutaneous transluminal coronary angioplasty by rotoablation (procedure), Percutaneous transluminal coronary angioplasty with rotoablation, single vessel (procedure), Emergency percutaneous coronary intervention (procedure), Insertion of drug coated stent (procedure), Percutaneous coronary intervention (procedure), Placement of stent in anterior descending branch of left coronary artery (procedure), Placement of stent in circumflex branch of left coronary artery (procedure), Percutaneous transluminal balloon angioplasty with insertion of stent into coronary artery (procedure), Percutaneous transluminal atherectomy using fluoroscopic guidance (procedure), Infusion of intra arterial thrombolytic agent with percutaneous transluminal coronary angioplasty (procedure), Infusion of intraarterial thrombolytic agent with percutaneous transluminal coronary angioplasty, multiple vessels (procedure), Percutaneous transluminal coronary angioplasty, multiple vessels (procedure), Infusion of intra arterial thrombolytic agent with percutaneous transluminal coronary angioplasty, single vessel (procedure) Table 6b Quality of Care Indicators 83

86 Line 19 Colorectal Cancer Screening Name Description: Denominator: Numerator: Exclusion: Details The performance measure is Percentage of patients aged 50 to 75 who had appropriate screening for colorectal cancer. This closely related to Clinical Quality Measure NQF 0034 Adults 50 to 75 years of age (51 through 75 during the measurement year) A patient turning 50 has until a year after they turn 50 to become compliant, same for a patient turning 74, hence the at the end of the year) (Must also fit criteria to be on the UDS report, if a patient is not listed in table 3a, they will not be counted in table 6a.) (19a) There is documentation that the patient had a Colonoscopy performed during the reporting period or in the nine years prior to the reporting period. OR (19b) There is documentation that the patient had a Flexible sigmoidoscopy performed during the reporting period or in the four years prior to the reporting period. OR (19c) There is documentation that the patient had a Fecal Occult Blood Test (FOBT) performed During the reporting period. (19d) Patient has ever been diagnosed with Colorectal cancer How to meet each condition for this measure, found in the PM under Maint > Patient Details > Patient Profile Detail > Clinical Quality Measure Data 19a [Used to calculate Numerator] There is documentation that the patient had a Colonoscopy performed during the reporting period or in the nine years prior to the reporting period. ** Patient is between 51 and 75 years old (checked at the end of the measurement year) AND **Patient has had screening performed Colonoscopy (see code list for CPT, HCPCS and codes) **Date Range: up to 9 years prior to the end of the measurement period MedInfo > Orders > Procedure Order (Performed) MedInfo > Orders > Procedure Diagnostic Test (Performed) Encounter Plan > Procedure Orders MedInfo > Medical > Diagnostic Test MedInfo > Histories > Surgical Procedures MedInfo > Health Maintenance > Screening and Prevention MedInfo > Histories > Surgical History NOTE Reporting will look at Procedure names in Surgical History 84 Table 6b Quality of Care Indicators

87 19b [Used to calculate Numerator] 19c [Used to calculate Numerator] 19d [Determine Exclusion] There is documentation that the patient had a Flexible sigmoidoscopy performed during the reporting period, or in the four years prior to the reporting period. **Patient has had screening performed Flexible Sigmoidoscopy (see code list for CPT, HCPCS and codes ) **Date Range: up to 4 years prior to the end of the measurement period MedInfo > Orders > Procedure Order (Performed) MedInfo > Orders > Procedure Diagnostic Test (Performed) Encounter Plan > Procedure Orders MedInfo > Medical > Diagnostic Test MedInfo > Histories > Surgical Procedures MedInfo > Health Maintenance > Screening and Prevention MedInfo > Histories > Surgical History NOTE Reporting will look at Procedure names in Surgical History There is documentation that the patient had a Fecal Occult Blood Test (FOBT) performed During the reporting period. **Patient has had Fecal Occult Blood Testing (FOBT) (see code list for LOINC codes) **Date Range Within the measurement period MedInfo > Medical > Lab Results Patient has ever been diagnosed with Colorectal cancer **Patient has diagnosis of Malignant Neoplasm of Colon (see code list for ICD and codes) **Date Range: Prior to the end of the measurement period MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments Code Lists for Measure Diagnosis, Active: Malignant Neoplasm of Colon: ICD9 Diagnosis, Active: Malignant Neoplasm of Colon: 153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 154.0, 154.1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators 85

88 Diagnosis, Inactive: Malignant Neoplasm of Colon: ICD9 Diagnosis, Inactive: Malignant Neoplasm of Colon: Diagnosis, Resolved: Malignant Neoplasm of Colon: ICD9 Diagnosis, Resolved: Malignant Neoplasm of Colon: Laboratory Test, Result: Fecal Occult Blood Test (FOBT): LOINC Procedure, Performed: Colonoscopy: HCPCS Procedure, Performed: Colonoscopy: CPT 153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 154.0, 154.1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 154.0, 154.1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , G0105, G , 44389, 44390, 44391, 44392, 44393, 44394, 44397, 45355, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, 45387, 45391, Table 6b Quality of Care Indicators

89 Procedure, Performed: Colonoscopy: , , , , , , , , , , , , , , , , , , Colonoscopy with rigid sigmoidoscope through colotomy (procedure), Open colonoscopy (procedure), Diagnostic endoscopic examination on colon (procedure), Total colonoscopy (procedure), Limited colonoscopy (procedure), Fiberoptic colonoscopy with biopsy (procedure), Therapeutic colonoscopy (procedure), Check colonoscopy (procedure), Intraoperative colonoscopy (procedure), Fiberoptic colonoscopy (procedure), Virtual computed tomography colonoscopy (procedure), Diagnostic endoscopic examination of colonic pouch and biopsy of colonic pouch using colonoscope (procedure), Colonoscopy through colostomy with endoscopic biopsy of colon (procedure), Screening colonoscopy (procedure), Colonoscopy and excision of mucosa of colon (procedure), Colonoscopy and biopsy of colon (procedure), Colonoscopy and tattooing (procedure), Colonoscopy (procedure), Fiberoptic colonoscopy through colostomy (procedure) Procedure, Performed: Flexible Sigmoidoscopy: HCPCS Procedure, Performed: Flexible Sigmoidoscopy: CPT Procedure, Performed: Flexible Sigmoidoscopy: G , 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45339, 45340, 45341, 45342, , , , Flexible fiberoptic sigmoidoscopy for removal of foreign body (procedure), Flexible fiberoptic sigmoidoscopy with biopsy (procedure), Diagnostic endoscopic examination of lower bowel and sampling for bacterial overgrowth using fiberoptic sigmoidoscope (procedure), Flexible fiberoptic sigmoidoscopy (procedure) Table 6b Quality of Care Indicators 87

90 Line 20 Newly Identified HIV Cases with Timely follow-up Name Description: Denominator: Numerator: Details Patients whose first ever HIV diagnosis was made by health center staff between October 1 of the prior year and September 30 of the reporting year and who were seen for follow up within 90 days of that first ever diagnosis This is similar to NQF 0403 only in regards to what codes are used. There are no equivalent CQMs that check for first ever HIV diagnosis. (20a) The Patient s first ever HIV diagnosis was made by health center staff between October 1 st of the year prior to the reporting period and September 30 th of the reporting year. (Must also fit criteria to be on the UDS report, if a patient is not listed in table 3a, they will not be counted in table 6a.) (20b) The patient was seen for a follow up visit within 90 days of their first ever HIV diagnosis. How to meet each condition for this measure, found in the PM under Maint > Patient Details > Patient Profile Detail > Clinical Quality Measure Data 88 Table 6b Quality of Care Indicators

91 20a [Used to calculate Denominator] The Patient s first ever HIV diagnosis was made by health center staff between October 1 st of the prior year and September 30 th of the reporting year. ** Patient diagnosed with HIV (see code list) **Date Range: between October 1st of the prior year and September 30th of the reporting year MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes) AND **The patient has had NO prior diagnoses of HIV prior to October 1 st of the previous year MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes) 20b [Used to calculate Numerator] The patient was seen for a follow up visit within 90 days of their first ever HIV diagnosis. **Patients Who have had a follow up Encounter of HIV Visit (see code list) **Date Range: Between 1 day and 90 days after their first ever HIV diagnosis (as recorded in 20a) Encounters with Encounter Level Specified (CPT Codes) Encounter Plan > Procedure Orders ( codes) Code Lists for Measure Diagnosis, Active: HIV: ICD9 Diagnosis, Active: HIV: ICD10 042, V08 B20, Z21 Table 6b Quality of Care Indicators 89

92 Diagnosis, Active: HIV: Encounter, Performed: HIV Visit: CPT Encounter, Performed: HIV Visit: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, , , , , , , , , , , , , , , , Table 6b Quality of Care Indicators

93 Line 21 Depression Screening and Follow-Up Name Description: Denominator: Numerator: Exclusion: Details Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow up plan is documented on the date of the positive screen. This closely related to Clinical Quality Measure NQF 0418 Patients 12 or older during measurement year with an encounter during the reporting period. (Must also fit criteria to be on the UDS report, if a patient is not listed in table 3a, they will not be counted in table 6a.) (21a) Patient was screened by a normalized and validated depression screening tool developed for the patient population in which it is being utilized AND (21b does NOT apply to patient) The patient tested negative for depression on an age appropriate standardized screening tool OR * (21b) The patient tested positive for depression on an age appropriate standardized screening tool AND * (21c) Following a positive depression screening, there is documentation of follow up which include one or more of the following: additional evaluation for depression, suicide risk assessment, referral to a practitioner who is qualified to diagnose and treat depression, pharmacological interventions, other interventions or follow up for the diagnosis or treatment of depression. (21d) Patient has an active diagnosis of Depression or Bipolar Disorder that existed prior to the Depression Screening. OR (21e) Depression Screening was not done because the patient refused to participate, because of medical reasons, or because the patient's functional capacity or motivation to improve may impact the accuracy of results How to meet each condition for this measure, found in the PM under Maint > Patient Details > Patient Profile Detail > Clinical Quality Measure Data Table 6b Quality of Care Indicators 91

94 21a [Used to calculate Numerator] Patient was screened by a normalized and validated depression screening tool developed for the patient population in which it is being utilized **Patients Who have had at least 1 Depression Screening Encounter (See Codes for Encounter of Depression Screening Denominator Encounter Codes New) **Date Range: During the measurement period Encounters with Encounter Level Specified (CPT and HCPCS codes) Encounter Plan > Procedure Orders (CPT, HCPCS and codes) AND [ADOLESCENT PATIENTS] **Patients in Age Range: < 18 years (checked at Start of Risk Category Assessment of Adolescent Depression Screening) AND **Patients who had Risk Category Assessment of Adolescent Depression Screening (see LOINC codes for Assessment of Adolescent Depression Screening) ** Date Range: During the measurement period MedInfo > Medical > Diagnostic Test MedInfo > Health Maintenance > Screening and Prevention OR [ADULT PATIENTS] ** Patients in Age Range: >= 18 years (checked at Start of Risk Category Assessment of Adult Depression Screening) AND **Patients who had Risk Category Assessment of Adult Depression Screening (see LOINC codes for Assessment of Adult Depression Screening) ** Date Range: During the measurement period MedInfo > Medical > Diagnostic Test MedInfo > Health Maintenance > Screening and Prevention NOTE Most recent Screening result During the measurement period will be used 92 Table 6b Quality of Care Indicators

95 21b [Used to calculate Numerator] The patient tested positive for depression on an age appropriate standardized screening tool. [ADOLESCENT PATIENTS] ** Patients in Age Range: < 18 years (checked at Start of Risk Category Assessment of Adolescent Depression Screening) AND ** Patients who had Risk Category Assessment of Adolescent Depression Screening with Result Flag or Result Status as Positive (see LOINC codes for Assessment of Adolescent Depression Screening) **Date Range: During the measurement period MedInfo > Medical > Diagnostic Test (uses Result Flag) MedInfo > Health Maintenance > Screening and Prevention (uses Result Status) OR [ADULT PATIENTS] ** Patients in Age Range: >= 18 years (checked at Start of Risk Category Assessment of Adult Depression Screening) AND ** Patients who had Risk Category Assessment of Adult Depression Screening with Result Flag or Result Status as Positive (see LOINC codes for Assessment of Adult Depression Screening) **Date Range: During the measurement period MedInfo > Medical > Diagnostic Test (uses Result Flag) MedInfo > Health Maintenance > Screening and Prevention (uses Result Status) Table 6b Quality of Care Indicators 93

96 21c [Used to calculate Numerator] Following a positive depression screening, there is documentation of follow up which include one or more of the following: additional evaluation for depression, suicide risk assessment, referral to a practitioner who is qualified to diagnose and treat depression, pharmacological interventions, other interventions or follow up for the diagnosis or treatment of depression. [ADOLESCENT PATIENTS] ** Patients in Age Range: < 18 years (checked at Start of Risk Category Assessment of Adolescent Depression Screening) AND ****Patients who had Risk Category Assessment of Adolescent Depression Screening with Result Flag or Result Status as Positive (see LOINC codes for Assessment of Adolescent Depression Screening) **Date Range: During the measurement period MedInfo > Medical > Diagnostic Test (uses Result Flag) MedInfo > Health Maintenance > Screening and Prevention (uses Result Status) AND *** Patients who had an Intervention done for Additional evaluation for depression adolescent or Referral for Depression Adolescent or Follow up for depression adolescent ***Date Range: Within one day after the start of Risk Category Assessment of Adolescent Depression Screening with Result Flag or Result Status as Positive OR Encounter Plan > Procedure Orders ( codes) *** Patients who had a Referral order created of Referral for Depression Adolescent ***Date Range: Within one day after the start of Risk Category Assessment of Adolescent Depression Screening with Result Flag or Result Status as Positive OR MedInfo > Orders > Referral Orders 94 Table 6b Quality of Care Indicators

97 *** Patients who were prescribed Depression medications adolescent (see medication names in code list) ***Date Range: Within one day after the start of Risk Category Assessment of Adolescent Depression Screening with Result Flag or Result Status as Positive MedInfo > Medical > Medications OR ***Patient had a Suicide Risk Assessment Procedure performed (see code list for codes) ***Date Range: Within one day after the start of Risk Category Assessment of Adolescent Depression Screening with Result Flag or Result Status as Positive MedInfo > Medical > Diagnostic Test MedInfo > Orders > Procedure Orders (Performed) MedInfo > Orders > Procedure Diagnostic Test (Performed) Encounter Plan > Procedure Orders Encounter Plan > Nursing Orders MedInfo > Orders > Nursing Care Orders (Performed) MedInfo > Histories > Hospitalization History MedInfo > Histories > Surgical Procedures MedInfo > Histories > Surgical History NOTE Reporting will look at Procedure names in Surgical History OR [ADULT PATIENTS] **Patients in Age Range: >= 18 years (checked at Start of Risk Category Assessment of Adult Depression Screening with result value as 'Depression Screening Result' ) AND **Patients who had Risk Category Assessment of Adult Depression Screening with Result Flag or Result Status as Positive (see LOINC codes for Assessment of Adult Depression Screening) Table 6b Quality of Care Indicators 95

98 ** Date Range: During the measurement period AND MedInfo > Medical > Diagnostic Test (uses Result Flag) MedInfo > Health Maintenance > Screening and Prevention (uses Result Status) *** Patients who had an Intervention done for Additional evaluation for depression Adult or Referral for Depression Adult or Follow up for depression Adult ***Date Range: Within one day after the start of Risk Category Assessment of Adult Depression Screening with Result Flag or Result Status as Positive Encounter Plan > Procedure Orders ( codes) OR *** Patients who had a Referral order created of Referral for Depression Adult ***Date Range: Within one day after the start of Risk Category Assessment of Adult Depression Screening with Result Flag or Result Status as Positive MedInfo > Orders > Referral Orders OR *** Patients who were prescribed Depression medications Adult (see medication names in code list) *** Date Range: Within one day after the start of Risk Category Assessment of Adult Depression Screening with Result Flag or Result Status as Positive MedInfo > Medical > Medications OR ***Patient had a Suicide Risk Assessment Procedure performed (see code list for codes) ***Date Range: Within one day after the start of Risk Category Assessment of Adult Depression Screening with Result Flag or Result Status as Positive MedInfo > Medical > Diagnostic Test MedInfo > Orders > Procedure Orders (Performed) MedInfo > Orders > Procedure Diagnostic Test (Performed) Encounter Plan > Procedure Orders Encounter Plan > Nursing Orders MedInfo > Orders > Nursing Care Orders (Performed) MedInfo > Histories > Hospitalization History 96 Table 6b Quality of Care Indicators

99 MedInfo > Histories > Surgical Procedures MedInfo > Histories > Surgical History NOTE Reporting will look at Procedure names in Surgical History 21d [Exclusion Criteria] Patient has an active diagnosis for Depression of Bipolar Disorder that existed prior to the Depression Screening. [ADOLESCENT PATIENTS] ** Patients who had Risk Category Assessment of Adolescent Depression Screening (see LOINC codes for Assessment of Adolescent Depression Screening) **Date Range: During the measurement period MedInfo > Medical > Diagnostic Test MedInfo > Health Maintenance > Screening and Prevention NOTE Most recent Screening result During the measurement period will be used AND **With an Active diagnosis of Depression diagnosis OR Bipolar diagnosis recorded in their chart.(see code list for ICD and codes) **Date Range: Begin Date before the start of Risk Category Assessment of Adolescent Depression Screening and End Date (if exists) after the start of Risk Category Assessment of Adolescent Depression Screening MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories > Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes) OR [ADULT PATIENTS] ** Patients who had Risk Category Assessment of Adult Depression Screening (see LOINC codes for Assessment of Adult Depression Screening) **Date Range : During the measurement period MedInfo > Medical > Diagnostic Test MedInfo > Health Maintenance > Screening and Prevention NOTE Most recent Screening result During the measurement period will be used. Table 6b Quality of Care Indicators 97

100 AND **With an Active diagnosis of Depression diagnosis OR Bipolar Diagnosis recorded in their chart.(see code list for ICD and codes) **Date Range: Begin Date before the start of Risk Category Assessment of Adult Depression Screening and End Date (if exists) after the start of Risk Category Assessment of Adult Depression Screening MedInfo > Medical > Problem List (Active, Inactive or Resolved) Encounter Assessments MedInfo > Histories > Hospitalization History (Diagnosis codes) MedInfo > Histories > Medical History (Diagnosis codes) MedInfo > Histories>Surgical Procedures > Medical Details (Diagnosis codes in before or after operation fields) MedInfo > Orders > Laboratory Orders (Diagnosis codes 21e [Exclusion Criteria] Depression Screening was not done because the patient refused to participate, because of medical reasons, or because the patient's functional capacity or motivation to improve may impact the accuracy of results. ** Documentation of medical reasons for not doing Risk Category Assessment of Adolescent or Adult Depression Screening (see code list for LOINC codes for Assessment of Adolescent and Adult Depression Screening and codes of Medical Reason contraindicated and Patient Refusal Reasons) ** Date Range: During the measurement period MedInfo > Orders > Procedure Orders (Performed) MedInfo > Orders > Procedure Diagnostic Test (Performed) MedInfo > Health Maintenance > Screening and Prevention Code Lists for Measure Diagnosis, Active: Bipolar Diagnosis: ICD9 Diagnosis, Active: Bipolar Diagnosis: ICD , , , , , , , F31.1, F31.11, F31.12, F31.13, F31.2, F31.73, F31.74, F Table 6b Quality of Care Indicators

101 Diagnosis, Active: Bipolar Diagnosis: Diagnosis, Active: Depression diagnosis: ICD9 Diagnosis, Active: Depression diagnosis: ICD10 Diagnosis, Active: Depression diagnosis: Encounter, Performed: Depression Screening Denominator Encounter Codes New: HCPC Encounter, Performed: Depression Screening Denominator Encounter Codes New: CPT , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 296.2, , , , , , , 296.3, , , , , , , 298.0, 300.4, , 309.0, 309.1, , 311 F01.51, F03, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.8, F32.9, F33.0, F33.1, F33.2, F33.3, F33.42, F33.9, F34.1, F43.21, F , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , G0101, G0402, G0438, G0439, G , 90792, 90832, 90834, 90837, 90839, 92557, 92567, 92568, 92625, 92626, 96116, 96118, 96150, 96151, 97003, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, Table 6b Quality of Care Indicators 99

102 Encounter, Performed: Depression Screening Denominator Encounter Codes New: Intervention, Order: Referral for Depression Adolescent: Intervention, Order: Referral for Depression Adult: Intervention, Performed: Additional evaluation for depression adolescent: Intervention, Performed: Additional evaluation for depression adult: Intervention, Performed: Follow up for depression adolescent: Intervention, Performed: Follow up for depression adult: Medication, Order: Depression medications adolescent: RXNORM , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Fluoxetine 60 MG Oral Tablet, Fluoxetine 20 MG Oral Tablet, Fluoxetine 10 MG Oral Capsule, Fluoxetine 20 MG Oral Capsule, Fluoxetine 4 MG/ML Oral Solution, Fluoxetine 40 MG Oral Capsule, Fluoxetine 10 MG Oral Tablet, Fluoxetine 90 MG Enteric Coated Capsule, Fluoxetine 15 MG Oral Tablet. 100 Table 6b Quality of Care Indicators

103 Medication, Order: Depression medications adult: RXNORM Doxepin Hydrochloride 10 MG Oral Capsule, Doxepin Hydrochloride 10 MG/ML Oral Solution, Doxepin Hydrochloride 100 MG Oral Capsule, Doxepin Hydrochloride 150 MG Oral Capsule, Doxepin Hydrochloride 25 MG Oral Capsule, Doxepin Hydrochloride 50 MG Oral Capsule, Doxepin Hydrochloride 50 MG/ML Topical Cream, Doxepin Hydrochloride 75 MG Oral Capsule, Omega 3 Acid Ethyl Esters (USP) 1400 MG Oral Capsule, Folic Acid 0.4 MG Oral Capsule, vilazodone hydrochloride 10 MG Oral Tablet, vilazodone hydrochloride 20 MG Oral Tablet, vilazodone hydrochloride 40 MG Oral Tablet, {7 (vilazodone hydrochloride 10 MG Oral Tablet) / 7 (vilazodone hydrochloride 20 MG Oral Tablet) / 16 (vilazodone hydrochloride 40 MG Oral Tablet) } Pack, Omega 3 Acid Ethyl Esters (USP) 1000 MG Enteric Coated Capsule, Nefazodone hydrochloride 100 MG Oral Tablet, Nefazodone hydrochloride 150 MG Oral Tablet, Nefazodone hydrochloride 200 MG Oral Tablet, Nefazodone hydrochloride 250 MG Oral Tablet, Nefazodone hydrochloride 50 MG Oral Tablet, Nefazodone hydrochloride 300 MG Oral Tablet, Desipramine Hydrochloride 10 MG Oral Tablet, Desipramine Hydrochloride 100 MG Oral Tablet, Desipramine Hydrochloride 150 MG Oral Tablet, Desipramine Hydrochloride 25 MG Oral Tablet, Desipramine Hydrochloride 50 MG Oral Tablet, Desipramine Hydrochloride 75 MG Oral Tablet, Omega 3 Acid Ethyl Esters (USP) 875 MG Chewable Tablet, Omega 3 Acid Ethyl Esters (USP) 840 MG Enteric Coated Capsule, Fluoxetine 60 MG Oral Tablet, 24 HR Bupropion Hydrochloride 450 MG Extended Release Tablet, Omega 3 Acid Ethyl Esters (USP) 333 MG Enteric Coated Capsule, Omega 3 Acid Ethyl Esters (USP) 875 MG Oral Capsule, Maprotiline Hydrochloride 25 MG Oral Tablet, Maprotiline Hydrochloride 50 MG Oral Tablet, Maprotiline Hydrochloride 75 MG Oral Tablet, Omega 3 Acid Ethyl Esters (USP) 1400 MG Enteric Coated Capsule, Omega 3 Acid Ethyl Esters (USP) 600 MG Enteric Coated Capsule, Amoxapine 100 MG Oral Tablet, Amoxapine 150 MG Oral Tablet, Amoxapine 25 MG Oral Tablet, Amoxapine 50 MG Oral Tablet, Nortriptyline 10 MG Oral Capsule, Nortriptyline 50 MG Oral Capsule, Nortriptyline 75 MG Oral Capsule, Folic Acid 0.4 MG Oral Tablet, Folic Acid 0.8 MG Oral Tablet, Nortriptyline 10 MG Oral Tablet, Folic Acid 5 MG Oral Tablet, Folic Acid 0.5 MG Oral Tablet, Trimipramine 25 MG Oral Tablet, ST. JOHN'S WORT EXTRACT 300 MG Oral Capsule, ST. JOHN'S WORT EXTRACT 510 MG Oral Capsule, Citalopram 20 MG Oral Tablet, Folic Acid 5 MG/ML Injectable Solution, ST. JOHN'S WORT EXTRACT 225 MG Oral Capsule, ST. JOHN'S WORT EXTRACT 25 MG/ML Oral Solution, ST. JOHN'S WORT EXTRACT 600 MG Oral Capsule, Trimipramine 50 MG Oral Tablet, Folic Acid 25 MG Oral Tablet, Fluoxetine 20 MG Oral Tablet, Sertraline 200 MG Oral Tablet, Table 6b Quality of Care Indicators 101

104 Folic Acid 0.8 MG Oral Capsule, ST. JOHN'S WORT EXTRACT 150 MG Oral Tablet, ST. JOHN'S WORT EXTRACT 300 MG Oral Tablet, ST. JOHN'S WORT EXTRACT 450 MG Extended Release Tablet, ST. JOHN'S WORT EXTRACT 400 MG Oral Capsule, ST. JOHN'S WORT EXTRACT 375 MG Oral Capsule, ST. JOHN'S WORT EXTRACT 500 MG/ML Oral Solution, Folic Acid 5 MG Oral Capsule, Folic Acid 20 MG Oral Capsule, ST. JOHN'S WORT EXTRACT 250 MG Oral Capsule, Mirtazapine 15 MG Disintegrating Tablet, Mirtazapine 30 MG Disintegrating Tablet, Mirtazapine 45 MG Disintegrating Tablet, Citalopram 10 MG Oral Tablet, ST. JOHN'S WORT EXTRACT 1000 MG Oral Capsule, Citalopram 2 MG/ML Oral Solution, Citalopram 40 MG Oral Tablet, Desipramine 25 MG Oral Capsule, Desipramine 50 MG Oral Capsule, Fluoxetine 10 MG Oral Capsule, Fluoxetine 20 MG Oral Capsule, Fluoxetine 4 MG/ML Oral Solution, Folic Acid 1 MG Oral Tablet, Mirtazapine 15 MG Oral Tablet, Mirtazapine 45 MG Oral Tablet, Nortriptyline 2 MG/ML Oral Solution, Paroxetine 10 MG Oral Tablet, Paroxetine 2 MG/ML Oral Suspension, Paroxetine 30 MG Oral Tablet, Paroxetine 40 MG Oral Tablet, Phenelzine 15 MG Oral Tablet, Sertraline 100 MG Oral Tablet, Sertraline 25 MG Oral Tablet, Sertraline 50 MG Oral Tablet, Tranylcypromine 10 MG Oral Tablet, Trimipramine 100 MG Oral Capsule, Trimipramine 100 MG Oral Tablet, Trimipramine 25 MG Oral Capsule, Trimipramine 50 MG Oral Capsule, venlafaxine 100 MG Oral Tablet, 24 HR venlafaxine 150 MG Extended Release Capsule, venlafaxine 25 MG Oral Tablet, 24 HR venlafaxine 37.5 MG Extended Release Capsule, venlafaxine 37.5 MG Oral Tablet, 24 HR venlafaxine 75 MG Extended Release Capsule, venlafaxine 75 MG Oral Tablet, Fluoxetine 40 MG Oral Capsule, Fluoxetine 10 MG Oral Tablet, Fluoxetine 90 MG Enteric Coated Capsule, Mirtazapine 30 MG Oral Tablet, Paroxetine 20 MG Oral Tablet, venlafaxine 50 MG Oral Tablet, Nortriptyline 25 MG Oral Capsule, Escitalopram 10 MG Oral Tablet, atomoxetine 10 MG Oral Capsule, atomoxetine 18 MG Oral Capsule, atomoxetine 25 MG Oral Capsule, atomoxetine 40 MG Oral Capsule, atomoxetine 60 MG Oral Capsule, Escitalopram 5 MG Oral Tablet, Escitalopram 20 MG Oral Tablet, Escitalopram 1 MG/ML Oral Solution, atomoxetine 5 MG Oral Capsule, 5 Hydroxytryptophan 100 MG Oral Capsule, Folic Acid 15 MG Oral Tablet, Mirtazapine 7.5 MG Oral Tablet, 5 Hydroxytryptophan 50 MG Oral Capsule, Paroxetine 12.5 MG Extended Release Tablet, Paroxetine 25 MG Extended Release Tablet, Paroxetine 37.5 MG Extended Release Tablet, Omega 3 Acid Ethyl Esters (USP) 1000 MG Oral Capsule, duloxetine 20 MG Enteric Coated Capsule, duloxetine 30 MG Enteric Coated Capsule, duloxetine 60 MG Enteric Coated Capsule, atomoxetine 100 MG Oral Capsule, atomoxetine 80 MG Oral Capsule, Folic Acid 0.2 MG Oral Tablet, Citalopram 10 MG Oral Capsule, Citalopram 20 MG Oral Capsule, Citalopram 40 MG Oral Capsule, 24 HR Desvenlafaxine 100 MG Extended Release Tablet, 24 HR Desvenlafaxine 50 MG Extended Release Tablet, Sertraline 150 MG Oral Tablet, 102 Table 6b Quality of Care Indicators

105 Fluoxetine 15 MG Oral Tablet, 24 HR venlafaxine 150 MG Extended Release Tablet, 24 HR venlafaxine 225 MG Extended Release Tablet, 24 HR venlafaxine 37.5 MG Extended Release Tablet, 24 HR venlafaxine 75 MG Extended Release Tablet, Imipramine Hydrochloride 25 MG Oral Tablet, Imipramine Hydrochloride 50 MG Oral Tablet, Imipramine pamoate 75 MG Oral Capsule, Imipramine pamoate 150 MG Oral Capsule, Imipramine Hydrochloride 12.5 MG/ML Injectable Solution, Imipramine pamoate 125 MG Oral Capsule, Imipramine pamoate 100 MG Oral Capsule, Imipramine Hydrochloride 10 MG Oral Tablet, Trazodone Hydrochloride 150 MG Oral Tablet, Trazodone Hydrochloride 300 MG Oral Tablet, Trazodone Hydrochloride 100 MG Oral Tablet, Trazodone Hydrochloride 50 MG Oral Tablet, Amitriptyline Hydrochloride 10 MG / Perphenazine 2 MG Oral Tablet, Amitriptyline Hydrochloride 10 MG / Perphenazine 4 MG Oral Tablet, Amitriptyline Hydrochloride 100 MG Oral Tablet, Amitriptyline Hydrochloride 12.5 MG / Chlordiazepoxide 5 MG Oral Tablet, Amitriptyline Hydrochloride 150 MG Oral Tablet, Amitriptyline Hydrochloride 10 MG Oral Tablet, Amitriptyline Hydrochloride 25 MG / Chlordiazepoxide 10 MG Oral Tablet, Amitriptyline Hydrochloride 25 MG / Perphenazine 2 MG Oral Tablet, Amitriptyline Hydrochloride 25 MG / Perphenazine 4 MG Oral Tablet, Amitriptyline Hydrochloride 25 MG Oral Tablet, Amitriptyline Hydrochloride 50 MG / Perphenazine 4 MG Oral Tablet, Amitriptyline Hydrochloride 50 MG Oral Tablet, Amitriptyline Hydrochloride 75 MG Oral Tablet, Clomipramine Hydrochloride 10 MG Oral Tablet, Clomipramine Hydrochloride 25 MG Oral Tablet, Clomipramine Hydrochloride 25 MG Oral Capsule, Clomipramine Hydrochloride 50 MG Oral Capsule, Clomipramine Hydrochloride 75 MG Oral Capsule, Clomipramine Hydrochloride 50 MG Oral Tablet, selegiline hydrochloride 5 MG Oral Capsule, selegiline hydrochloride 1.25 MG Disintegrating Tablet, selegiline hydrochloride 5 MG Oral Tablet, Sertraline 20 MG/ML Oral Solution, 24 HR selegiline hydrochloride 0.25 MG/HR Transdermal Patch, 24 HR selegiline hydrochloride MG/HR Transdermal Patch, 24 HR selegiline hydrochloride 0.5 MG/HR Transdermal Patch, Omega 3 Acid Ethyl Esters (USP) 1050 MG Oral Capsule, Omega 3 Acid Ethyl Esters (USP) 725 MG Oral Capsule, Omega 3 Acid Ethyl Esters (USP) 952 MG Oral Capsule, Omega 3 Acid Ethyl Esters (USP) 340 MG Enteric Coated Capsule, {5 (atomoxetine 10 MG Oral Capsule) / 5 (atomoxetine 18 MG Oral Capsule) / 5 (atomoxetine 25 MG Oral Capsule) / 15 (atomoxetine 40 MG Oral Capsule) } Pack, {5 (atomoxetine 18 MG Oral Capsule) / 5 (atomoxetine 25 MG Oral Capsule) / 5 (atomoxetine 40 MG Oral Capsule) / 15 (atomoxetine 60 MG Oral Capsule) } Pack, {5 (atomoxetine 25 MG Oral Capsule) / 5 (atomoxetine 40 MG Oral Capsule) / 5 (atomoxetine 60 MG Oral Capsule) / 15 (atomoxetine 80 MG Oral Capsule)} Pack, 24 HR Trazodone Hydrochloride 150 MG Extended Release Tablet, 24 HR Trazodone Hydrochloride 300 MG Extended Release Tablet, Omega 3 Acid Ethyl Esters (USP) 880 MG Oral Capsule, 24 HR Fluvoxamine Maleate 100 MG Extended Release Capsule, 24 HR Fluvoxamine Maleate 150 MG Extended Release Capsule, Table 6b Quality of Care Indicators 103

106 Fluvoxamine Maleate 100 MG Oral Tablet, Fluvoxamine Maleate 25 MG Oral Tablet, Fluvoxamine Maleate 50 MG Oral Tablet, Protriptyline Hydrochloride 10 MG Oral Tablet, Protriptyline Hydrochloride 5 MG Oral Tablet, Doxepin 3 MG Oral Tablet, Doxepin 6 MG Oral Tablet, Folic Acid 7.5 MG Oral Tablet, 12 HR Bupropion Hydrochloride 100 MG Extended Release Tablet, 12 HR Bupropion Hydrochloride 150 MG Extended Release Tablet, 12 HR Bupropion Hydrochloride 200 MG Extended Release Tablet, 24 HR Bupropion Hydrochloride 150 MG Extended Release Tablet, 24 HR Bupropion hydrobromide 174 MG Extended Release Tablet, 24 HR Bupropion Hydrochloride 300 MG Extended Release Tablet, 24 HR Bupropion hydrobromide 348 MG Extended Release Tablet, 24 HR Bupropion hydrobromide 522 MG Extended Release Tablet, Bupropion Hydrochloride 100 MG Oral Tablet, Bupropion Hydrochloride 75 MG Oral Tablet, Omega 3 Acid Ethyl Esters (USP) 100 MG Chewable Tablet. Procedure, Performed: Suicide Risk Assessment: Risk Category Assessment not done: Medical reason contraindicated: Risk Category Assessment not done: Patient Reason refused: Risk Category Assessment: Adolescent Depression Screening: Risk Category Assessment: Adult Depression Screening: LOINC Attribute: Result: Depression Screening Result: Attribute: Result: Negative Depression Screening: Suicide risk assessment (procedure) , , , , , , , , Table 6b Quality of Care Indicators

107 Attribute: Result: Positive Depression Screening: Table 6b Quality of Care Indicators 105

108 TABLE 7 HEALTH OUTCOMES AND DISPARITIES UNIVERSAL Line # All (Sec A C) A 0 2i A 0 Description Race and ethnicity need to be populated on the Patient Detail screen, along with items from the Patient Profile Detail screen. Must be a qualified visit during the reporting period. Race and ethnicity are pulled from Patient Detail. If a Patient has multiple races selected, they will be counted as More than One Race A Patient is counted as Hispanic if ethnicity is set to Hispanic A Patient is counted as Non Hispanic if ethnicity is set to All others or Non Hispanic OR ethnicity is set to Declined to Specify and race is NOT set to Declined to Specify A Patient is only counted in the Declined to Specify section if BOTH race and ethnicity are set as Declined to Specify Must have a qualified visit in the reporting period. If a patient doesn t show up on table 3a, they won t be counted anywhere else in the UDS Reports TABLE 7 HEALTH OUTCOMES AND DISPARITIES UNIVERSAL Section A: Deliveries and Birth Weight by Race and Hispanic/Latino Ethnicity. Pregnancy data is listed in the Pregnancy History section of the Patient Profile Detail tab of Patient Detail. This section will be hidden unless Prenatal User is checked. This section shows pregnancy information entered in PM, as well as those entered into Pregnancy History in the EMR. Entering a pregnancy into this section in the PM will create a new Pregnancy History record in the EMR. A 2 HIV Positive Pregnant Women Prenatal User must be checked on the Patient Profile Detail tab of Patient Detail Patient is Pregnant and HIV Positive must be checked on a pregnancy where EITHER the first care date OR the delivery date is within the service date range of the report. Deliveries performed by Health Center s Providers Prenatal User must be checked on the Patient Profile Detail tab of Patient Detail A pregnancy must exist where EITHER the first care date OR the delivery date is within the service date range of the report. 106 Table 7 Health Outcomes and Disparities Universal

109 TABLE 7 (CONTINUED) A 1a 2i Line # Hispanic / Latino Race and Ethnicity Prenatal Care Patients Who Delivered During the Year (1a) UDS Reporting Guide MicroMD Live Births: <1500 grams (1b) Live Births: grams (1c) Live Births: =>2500 grams (1d) 1a Asian b1 Native Hawaiian b2 Pacific Islander c Black / African American d American Indian / Alaska Native e White f More than One Race g Unreported / Refused to Report Race Subtotal Hispanic/Latino Non Hispanic Latino 2a Asian b1 Native Hawaiian b2 Pacific Islander c Black / African American d American Indian / Alaska Native e White f More than One Race g Unreported / Refused to Report Race Subtotal Non Hispanic/Latino Unreported / Refused to Report Ethnicity h Unreported / Refused to Report Race and Ethnicity i Total Deliveries by Birth Weight and Race Prenatal User must be checked on the Patient Profile Detail tab of Patient Detail. Delivery date must be during the service date range of the report. The total count of columns 1b, 1c and 1d will NOT necessarily match the count in 1a because of these things: Columns 1b 1d only look at deliveries where the Pregnancy Description is set as Full term or Pre term while column 1a also includes those with a pregnancy description of Stillbirth. If birth weight is not filled in, the pregnancy will NOT be counted in 1b 1d, but will still be counted in 1a. If a patient has delivered multiple children from a single pregnancy they will only be counted once in 1a, but may be counted multiple times in columns 1b 1d. If a patient has delivered children from multiple pregnancies in a single year they will be counted multiple times in both 1a and 1b 1d. Table 7 (continued) 107

110 TABLE 7 (CONTINUED) New info for Hypertension and Diabetes sections (sections B and C of the report): New Functionality has been added to make populating this table easier for practices that are also using MicroMD EMR. Beginning in version a nightly database job will update the Patient information related to diabetes and hypertension. [Patient Profile Detail tab of Patient Detail] It will search encounters and problem list to find patients who have been diagnosed with diabetes during or before the measurement year and patients who have been diagnosed with hypertension before June 30th of the measurement year. Adequate blood pressure and blood pressure measured are updated based on the most recent (during the measurement year) blood pressure data from Vital Signs. HbA1c Level and HbA1c Measured are updated based on the most recent hba1c lab tests (during the measurement year) that include discrete results. If a practice does not have MicroMD EMR then they will need to continue selecting these checkboxes and drop down selectors for each relevant patient. 108 Table 7 (continued)