Gaps in Care Technical Specifications and Billing Guide Provider Billing Guide

Transcription

1 Gaps in Care Technical Specifications and Billing Guide Provider Billing Guide Working with our Providers to enhance the Quality of Care provided to our Members

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3 Disclaimer This material serves as a tool to assist providers, their clinical team, and billing staff with information to improve HEDIS performance. HEDIS 2017 Volume 2 Technical Specifications for Health Plans was used to generate this Provider Billing Guide. The Technical Specifications were current at the time of publication (November 2016). HEDIS indicators have been designed by NCQA to standardize performance measurement and do not necessarily represent the ideal standard of care. ICD-9 codes listed in this guide are for services prior to October 2015 and will count for services such as mammograms or certain colon cancer screenings that have more than a one year look back period in order for the care to count as compliant. Information contained in this report is based on claims data only. What is HEDIS? HEDIS is a registered trademark of the National Quality Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) NCQA defines HEDIS as a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of health care plans. HEDIS is a registered trademark of the National Committee for Quality Assurance HEDIS is a performance measurement tool that is coordinated and administered by NCQA and used by the Centers for Medicare & Medicaid Services (CMS) for monitoring the performance of managed care organizations Results from HEDIS data collection serve as measurements for quality improvement processes, educational initiatives, and preventive care programs All managed care companies who are NCQA accredited perform HEDIS reviews the same time each year HEDIS consists of 91 measures across seven domains of care that address important health issues HEDIS is a retrospective review of services and performance of care from the prior calendar year There are two types of HEDIS data collected: Administrative data comes from submitted claims and encounters Hybrid data comes from chart collection/review

4 Annual HEDIS Timeline Feb - Early May Quality department staff collect and review HEDIS data (on-site provider office chart collecting occurs) June HEDIS results are certified and reported to NCQA October Remember that HEDIS is a retrospective process HEDIS 2017 = Calendar Year 2016 Data NCQA releases Quality Compass results nationwide for Medicaid HEDIS Medical Record Review Process: Data collection methods include: fax, mail, onsite visits for larger requests, and remote electronic medical record (EMR) system access if available Medical record fax requests will include a member list identifying their assigned measure(s) and the minimum necessary information needed sent to the health plan Due to the shortened data collection timeframe, a turnaround time of 3-5 days is appreciated For on-site chart collections, the office will be contacted to schedule a time the abstractor can come to the office for chart review. A list of members charts being reviewed will be provided ahead of time

5 Tips and Best Practices General tips and information that can be applied to most HEDIS measures: 1. Use your member roster to contact patients who are due for an exam or are new to your practice 2. Take advantage of this guide, coding information, and the on-line resources that can assist the practice with HEDIS measure understanding, compliance, and requirements 3. Use your Gaps in Care member list to outreach to patients in need of services/procedures. 4. You can provide evidence of completed HEDIS services and attach the supporting chart documentation by contacting the Quality Management department. 5. Schedule the members' next well-visit at the end of the current appointment 6. Assign a staff member at the office knowledgeable about HEDIS to perform internal reviews and serve as a point of contact with plans and their respective Quality Management staff. 7. Set up your Electronic Health Records (EHRs) so that the HEDIS alerts and flags to alert office personnel of patients in need of HEDIS services. HIPAA Under the Health Information Portability and Accountability Act (HIPAA) Privacy Rule, data collection for HEDIS is permitted, and the release of this information requires no special patient consent or authorization. Please be assured our members personal health information is maintained in accordance with all federal and state laws. HEDIS results are reported collectively without individual identifiers or outcomes. All of the health plans contracted providers records are protected by these laws. 1. HEDIS data collection and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities 2. The records you provide us during this process helps us to validate the quality of care our members received 5

6 Importance of Documentation Principles of the medical record and proper documentation: 1. Enable physician and other healthcare professionals to evaluate a patient s healthcare needs and assess the efficacy of the treatment plan 2. Serves as the legal document to verify the care rendered and date of service 3. Ensure date of care rendered is present and all documents are legible 4. Serves as communication tool among providers and other healthcare professionals involved in the patient s care for improved continuity of care 5. Facilitates timely claim adjudication and payment 7. Appropriately documented medical record can reduce many of the hassles associated with claims processing and HEDIS chart requests 8. ICD-10 and codes reported on billing statements should be supported by the documentation in the medical record Common reasons members with PCP visits continue to need recommended services/procedures: 1. Missing or lack of all required documentation components 2. Service provided without claim/encounter data submitted 3. Lack of referral to obtain the recommended service (i.e. diabetic member eye exam to check for retinopathy) 4. Service provided but outside of the required time frame or anchor date (i.e. Lead screening performed after age 2) 5. Incomplete services (i.e.no documentation of anticipatory guidnace during a well visit for the adolescent well child measure) 6. Failure to document or code exclusion criteria for a measure Look for the 'Common Chart Deficiencies and Tips' sections for guidance with some of the more challenging HEDIS measure s

7 ABA Adult BMI Assessment The percentage of members years of age who had an outpatient visit and whose body mass index (BMI) was documented in 2015 or For members 20 years of age or older on the date of service, BMI in 2015 or 2016 For members younger than 20 years of age on the date of service, BMI percentile in 2015 or Chart documentation should include height, weight and BMI percentile (as a value e.g. 85th or plotted on a growth cahrt). Documnetation of ranges or thresholds do not meet criteria for this indicator. Common Chart Deficiencies and Tips: 1. Common deficiency: Height and weight documented but no documentation of the BMI 2. ICD-10 Z68 codes can be used to make a member compliant without chart review. 3. ICD-9 codes should not be used for services in 2016 HCPCS ICD-9-CM ICD-10 UB Revenue BMI V85.0, V85.1, V85.21-V85.25, V85.30-V85.39, V85.41-V85.45 Z68.1, Z Z68.29, Z Z68.39, Z Z68.45 BMI Percentile V85.51-V85.54 Z68.51-Z68.54 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

8 AMR Asthma Medication Ratio The percentage of members 5-85 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the year. Four age bands and a total rate are reported: 5 11 years years years years Total Common Chart Deficiencies and Tips: 1. Perform a thorough review of medications at each visit to ensure that prescribed controller medicaiton is being utilized 2. Provide medication complaince education ICD-9 CM ICD-10 CM Asthma J45.20-J45.22, J45.30-J45.32, J J45.42, J45.50-J45.52, J J45.902, J45.909, J J45.991, J Codes to Identify Exclusions (anytime in history) ICD-9 CM ICD-10 CM Acute Respiratory Failure J96.00-J96.02, J96.20-J96.22 Chronic Respiratory Conditions Due to Fumes/Vapors COPD Cystic Fibrosis , , J44.0, J44.1, J44.9 E84.0, E84.11, E84.19, E84.8, E84.9 Emphysema 492.0, J43.0-J43.2, J43.8-J43.9 Obstructive Chronic Other Emphysema 518.1, J98.2, J98.3 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA). J68.4

9 ART Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis The percentage of members who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD) in ICD-9 CM ICD-10 CM Rheumatoid Arthritis 5-Aminosalicylates Alkylating agents Aminoquinolines Anti-rheumatics Immunomodulators Immunosuppressive agents Janus kinase (JAK) Inhibitor Tetracyclines Measure Exclusion Criteria: DMARD Medications Prescriptions Sulfasalazine Cyclophosphamide Hydroxychloroquine Auranofin Gold sodium thiomalate Leflunomide Abatacept Adalimumab Anakinra Certolizumab Certolizumab pegol Azathioprine Cyclosporine Tofacitinib Minocycline Methotrexate Penicillamine Etanercept Golimumab Infliximab Rituximab Tocilizumab Mycophenolate Codes to Identify Exclusions ICD-9 CM M05.00-M06.9 J Codes J1600, J9250, J9260 J0129, J0135, J0717, J1438, J1602, J1745, J3262, J9310 J7502, J7515, J7516, J7517, J7518 A diagnosis of HIV any time during the member s history through December 31, 2016 OR A diagnosis of pregnancy in ICD-10 CM HIV V08, 042 B20, Z21 HIV Type B97.35 Pregnancy , V22, V23, V28 O00.0-O9A53, Z03.71-Z36 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

10 AWC Adolescent Well-Care Visits The percentage of enrolled members years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during The comprehensive well care must visit include: Health and developmental history (physical and mental) Complete physical exam Health education/anticipatory guidance (documented and age appropriate) Common Chart Deficiencies and Tips: 1. Missing or undocumented anticipatory guidance 2. Sick visit in calendar year without well-child visit 3. Turn a sick visit into a well-child visit 4. Schedule next visit at end of each appointment HCPCS ICD-10 CM Office Visit , G0438, G0439 Z00.00-Z00.129, Z00.5, Z00.8, Z02.0- Z02.9 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

11 BCS Breast Cancer Screening Measure Exclusion Criteria: Bilateral Mastectomy History of Bilateral Mastectomy Unilateral Mastectomy Bilateral Modifier The percentage of women years of age who had a mammogram to screen for breast cancer from October 2014 through December 31, Unilateral Mastectomy Breast Cancer Screening Unilateral Mastectomy Exclusion Unilateral Mastectomy with Bilateral Modifier 19180, 19200, 85.41, 85.43, 85.45, 19220, 19240, WITH 50, 9950 Two Unilateral Mastectomy More Than 14 days Apart 19180, 19200, 19220, 19240, HCPCS G0202, G0204, G , 85.44, 85.46, , 85.43, 85.45, ICD-9 PCS Z90.13 Unilateral Mastectomy with Right/Left Side Modifier 19180, 19200, 85.41, 85.43, 85.45, 19220, 19240, WITH Left Modifier LT OR Right Modifer Both of the following (on the same or a different dates of service) ICD-10 CM UB Revenue A female who had the following: Bilateral mastectomy, unilateral mastectomy with bilateral modifier, two unilateral mastectomies, or unilateral mastectomy with right/left side modifier on or before December 31, Exclusion ICD-9 CM 87.36, , 0403 ICD-10 CM ICD-10 PCS 0HTV0ZZ Unilateral Mastectomy Left 0HTU0ZZ Right 0HTT0ZZ Absence of Breast Left Z90.12 Right Z90.11 RT HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

12 CBP Controlling High Blood Pressure* The percentage of members years of age who had a diagnosis of hypertension (HTN) in the first six months of 2016 and whose BP was adequately controlled based on the following criteria: Members years of age whose BP was <140/90 mm Hg. Members years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg. Members years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg. *NOTE: This measure was selected for informational purposes only. The goal is to provide you with a list of members diagnosed with hypertension. Since blood pressure values can only be obtained from the medical record, your rate for this measure will always be zero. Common Chart Deficiencies and Tips: 1. Retake the blood pressure if elevated - HEDIS accepts lowest BP 2. Ensure that the BP cuff is the correct size for patient's arm Hypertension ICD-9 CM ICD-10 CM Measure Exclusion Criteria: Exclusion Evidence of ESRD Exclude from the eligible population all members with evidence of end-stage renal disease (ESRD) or kidney transplant on or prior to December 31, 2016 or a diagnosis of pregnancy in , 36800, 36810, 36815, , , 90935, 90837, 90940, 90945, 90947, , 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, ICD-9 PCS 38.95, 39.27, 39.42, 39.43, 39.53, 39.93, 39.94, 39.95, ICD-9 CM 585.5, 585.6, V45.11, V45.12, ICD-10 PCS 3E1M39Z, 5A1D00Z, 5A1D60Z ICD-10 CM N18.5, N18.6, Z91.15, Z99.2 I10 UB Revenue , 0809, , , , , 0859, , 0889 UB Type of Bill 072X HCPCS S9339, G0257 POS 65 Exclusion ICD-9 PCS ICD-10 PCS UB Revenue HCPCS

13 Kidney Transplant Pregnancy 50300, 50320, 50340, 50360, 50365, 50370, TY00Z , TY00Z2, 0TY10Z0-367 S2065 0TY10Z2 ICD-9 CM V42.0 ICD-10 CM Z94.0 ICD-9 CM ICD-10 CM , V22, V23, V28 O00.0-O9A53, Z03.71-Z36 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

14 CCS Cervical Cancer Screening The percentage of women years of age who were screened for cervical cancer using either of the following criteria: Women age who had cervical cytology performed in 2014, 2015, or Women age who had cervical cytology/human papillomavirus (HPV) co-testing performed between 2012 and Common Chart Deficiencies and Tips: 1. Documentation of hysterectomy must include words such as 'complete', 'total', or 'radical' 2. Documentation of hysterectomy alone does not meet guidelines because it does Cervical Cancer Screening HPV Tests Exclusion Absence of Cervix , 88147, 88148, 88150, , , 88174, , Measure Exclusion Criteria: HCSPCS A female who had a hysterectomy with no residual cervix on or before December 31, G0123, G0124, G0141, G0143- G0145, G0147, G0148, P3000, P3001, Q0091 G , 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, , 58548, 58550, , , 58951, 58953, 58954, 58956, ICD-9 PCS 68.41, 68.49, 68.51, 68.59, 68.61, 68.69, 68.71, 68.79, 68.8 LOINC , , , , , , , , , , , , , , , , , , , , , , , ICD-9 CM 618.5, , V88.01, V88.03 ICD-10 PCS 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA). UB 0923 ICD-10 CM Q51.5, Z90.710, Z90.712

15 CDC Comprehensive Diabetes Care - HbA1c Testing Members 18 to 75 years of age with diabetes (type 1 and type 2) who had an HbA1c test in Common Chart Deficiencies and Tips: 1. Failure to order lab tests or lab results not documented in chart 2. Lab values show poor control Diabetes Diabetes Without Complications HbA1c Screening ICD-9 CM 250, 357.2, 362.0, , , ICD-10 CM E10.10-E13.9, O O24.33, O O24.83 E10.9, E11.9, E13.9 LOINC , , HbA1c Result Measure Exclusion Criteria: Lab Result <7% 7.0% - 9.0% II 3044F 3045F >9.0% 3046F Identify members who do not have a diagnosis of diabetes, in any setting, during 2015 or 2016 and who meet either of the following criteria: Exclusion Diabetes Exclusions A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during 2015 or 2016, with no encounters in any setting with a diagnosis of diabetes. ICD-9 CM 249, 251.8, 962, 648.8, , 962 ICD-10 CM E08.00-E09.9, O O24.439, O O24.93 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

16 CDC Comprehensive Diabetes Care - Monitor for Nephropathy Members 18 to 75 years of age with diabetes (type 1 and type 2) who received medical attention for nephropathy in 2016 through one of the following: A screening or monitoring test (urine protein test) Evidence of treatment for nephropathy or ACE/ARB therapy Evidence of stage 4 chronic kidney disease, ESRD or kidney transplant Visit with a nephrologist Diabetes Diabetes Without Complications Monitoring for Nephropathy E10.9, E11.9, E13.9 II LOINC Urine Protein Tests Common Chart Deficiencies and Tips: 1. Failure to order lab tests for Nephropathy screening 2. Failure to document monitoring for nephropathy 3. Incomplete or missing information from specialists who may be monitoring nephropathy ICD-9 CM ICD-10 CM 250, 357.2, 362.0, , , 81005, , F, 3061F, 3062F E10.10-E13.9, O O24.33, O O , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ll ICD-9 CM ICD-10 CM Treatment for Nephropathy 3066F, 4010-F E08.21-E08.29, E09.21-E09.29, E10.21-E10.29, E11.21-E11.29, E13.21-E13.29, I12.0-I13.2, I15.0- I15.1, N00.0-N08, N14.0-N14.4, N17.0-N19, N25.0- N26.9, Q60.0-Q61.9, R80.0-R80.9

17 ICD-9 CM ICD-9 PCS ICD-10 CM 585.5, 585.6, V45.12, V , 39.27, 39.42, 39.43, 39.53, , N18.5, N18.6, Z91.15, Z99.2 ICD-10 PCS 3E1M39Z, 5A1D00Z, 5A1D60Z ESRD Kidney Transplant 36147, 36800, 36810, 36815, , , 90935, 90937, 90940, 90945, 90947, , 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, , 50320, 50340, 50360, 50365, 50370, POS 65 ICD-9 CM V42.0 HCPCS S9339, G0257 ICD-9 PCS 55.61, ICD-10 CM Z94.0 UB Rev , 809, , 829, , , , 859, , 889 ICD-10 PCS 0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY10Z2 UB Rev ICD-9 CM ICD-10 CM Stage 4 Chronic Kidney Disease N18.4 UB Type of Bill , 0727, 0728, 072A- 072K, 072M, 072O, 072X- 072Z HCPCS 367 S2065 Angiotensin converting enzyme inhibitors Angiotensin II inhibitors Benazepril Captopril Enalapril Fosinopril Lisinopril Azilsartan Candesartan Eprosartan Irbesartan Aliskiren-valsartan Amlodipine-benazepril 16 ACE Inhibitors/ARBs Moexipril Perindopril Quinapril Ramipril Trandolapril Losartan Olmesartan Telmisartan Valsartan Eprosartan-hydrochlorothiazide Fosinopril-hydrochlorothiazide

18 Anti- Hypertensive Combinations Amlodipine-hydrochlorothiazidevalsartan Amlodipine-hydrochlorothiazideolmesartan Amlodipine-olmesartan Amlodipine-telmisartan Amlodipine-valsartan Azilsartan-chlorthalidone Benazepril-hydrochlorothiazide Candesartan-hydrochlorothiazide Captopril-hydrochlorothiazide Enalapril-hydrochlorothiazide Measure Exclusion Criteria: Hydrochlorothiazide-irbesartan Hydrochlorothiazide-lisinopril Hydrochlorothiazide-losartan Hydrochlorothiazide-moexipril Hydrochlorothiazide-olmesartan Hydrochlorothiazide-quinapril Hydrochlorothiazide-telmisartan Hydrochlorothiazide-valsartan Trandolapril-verapamil Identify members who do not have a diagnosis of diabetes, in any setting, during 2015 or 2016 and who meet either of the following criteria: A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during 2015 or 2016 with no encounters in any setting with a diagnosis of diabetes Exclusion Diabetes Exclusions ICD-9 CM ICD-10 CM 249, 251.8, 962, , 962 E08.00-E09.9, O O24.439, O O24.93 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

19 CDC Comprehensive Diabetes Care - Blood Pressure Less Than 140/90 Diabetes Diabetes Without Complications Systolic > or = 140 Diastolic Diastolic <80 Diastolic > or = 90 Members 18 to 75 years of age with diabetes (type 1 and type 2) whose last blood pressure in 2016 was less than 140/90. ICD-9 CM ICD-10 CM 250, 357.2, 362.0, , F 3079F 3078F 3080F A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during 2015 or 2016, with no encounters in any setting with a diagnosis of diabetes. Diabetes Exclusions 249, 251.8, 962, 648.8, , 962 E10.10-E13.9, O O24.33, O O24.83 E10.9, E11.9, E13.9 II Codes to Identify Systolic and Diastolic BP Levels <140/90 II Systolic <140 Measure Exclusion Criteria: 3074F, 3075F Identify members who do not have a diagnosis of diabetes, in any setting, during 2015 or 2016 and who meet either of the following criteria: Exclusion Tips: 1. II codes for BP values are accepted for this measure 2. Retake blood pressue during the visit if it is intially elevated 3. Ensure that the BP cuff is the correct size for the patient's arm ICD-9 CM ICD-10 CM E08.00-E09.9, O O24.439, O O24.93 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

20 CHL Chlamydia Screening in Women The percentage of women years of age who were identified as sexually active and who had at least one test for chlamydia in LOINC Chlamydia Test Measure Exclusion Criteria: Pregnancy 81025, 84702, Exclusion Diagnostic Radiology Exclusion: Exclude female members who qualified for the denominator based on a pregnancy test alone and who meet either of the following: A pregnancy test in 2016 followed within seven days (inclusive) by a prescription for isotretinoin. A pregnancy test in 2016 followed within seven days (inclusive) by an x-ray. Exclusion Retinoid 87110, 87270, 87320, , , , , , , , , , , , ,, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 557-9, 560-3, , , , , , , , , , , UB Revenue 925 WITH UB Revenue OR Isotretinoin Prescription LOINC , , , , , , , , , , , , , , , , , , , , , LOINC HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

21 CIS Childhood Immunization Status The percentage of children turning 2 years of age in 2016 who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (Hep B), one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates. Common Chart Deficiencies and Tips: 1. Vaccinations for DTaP, IPV, HiB, or PCV given before 42 days after birthday do not count towards vaccine compliance 2. Participate in State Immunization registries, where available 3. Devote time during each visit to review immunization record and look for opportunities to catch-up on missing immunizations 4. Document date of first hepatitis B vaccination if given at hospital and note the hospital # in Series HCPCS ICD-9 CM ICD-10 CM DTaP , 90700, 90721, IPV MMR , 90713, , Any Combination of the following to satisfy recommendation of 1 MMR , Measles Only , , Mumps Only Rubella Only Hib Hepatitis B 1 1 Measles and Rubella # in Series HCPCS ICD-9 CM ICD-10 CM , 90698, 90721, , 90740, 90744, 3 G , , , , , , 072.8, , , , , , 056.8, , , V02.61 B05.0-B05.4, B05.81, B05.89, B05.9 B26.0-B26.3, B B26.85, B B26.9 B06.00-B06.02, B06.09, B B06.82, B06.89, B06.9 B16.0-B16.2, B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, Z22.51 CVX 20, 50, 106, 110, , 110, , CVX 46-51, 120, , 44, 51, 110

22 VZV , , 053 B01.0, B01.11-B01.2, B01.81-B01.9, B02.0, B02.1, B B02.29, B B02.39, B02.7-B , 94 Pneumococcal Conjugate , G , 133 Hepatitis A , B15.0, B Rotavirus 2-dose or 3-dose vaccinations satisfy Rotavirus recommendations. Rotavirus 2- dose Rotavirus 3- dose Influenza , 90657, 90661, 135, 140, 141, 453, 90662, 90673, 90685, G , 158, Measure Exclusion Criteria: Exclusion: Exclude children who had a contraindication for a specific vaccine. Exclusion HCPCS ICD-9 CM ICD-10 CM Any particular vaccine - Anaphylactic Reaction T80.52XA, T80.52XD, T80.52XS G04.32 DTaP - Encephalopathy with WITH Adverse-Effect E948.4, E948.5, E948.6 T50.A15A, T50.A15D, T50.A15S MRR, VZV and Influenza - Immunodeficiency, Lymphoreticular cancer, multiple myeloma or leukemia, or HIV , 279, V08, 042 D80.0-D80.9, D81.0-D81.2, D81.4, D81.6, D81.7, D81.84, D81.6- D81.9, D82.0-D82.4, D82.8- D83.2, D83.8-D84.1, D84.8-D84.9, D89.3, D D89.813, D89.82, D89.89, D89.9, B20, Z21, C C86.6, C88.2-C94.32, C94.80-C96.Z Rotavirus - Severe combined immunodeficiency or a history of intussusception Exclusion MRR, VZV and Influenza IPV Hepatitis B 279.2, D81.0-D81.2, D81.9, K56.1 General Exclusion Criteria Anaphylactic reaction to neomycin Anaphylactic reaction to streptomycin, polymyxin B, or neomycin Anaphylactic reaction to common baker's yeast HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

23 COA Care for Older Adults The percentage of adults 66 years and older who had each of the following in 2016: Advance care planning. Medication review. Functional status assessment. Pain assessment. Common Chart Deficiencies and Tips Advance Care Planning - document discussion and/or presence of advance directive or living will in chart Medication Review - Medication list in chart and medication review by prescribing provider annually Functional Status Assessment - addresse cognitive and ambulation status, sensory ability, and functional independence. Pain Assessment - documentation of pain screening or pain management Advance Care Planning Medication List Medication Review Functional Status Assessment Pain Assessment HCPCS , 99605, 99606, (TCM 14 Day), (TCM 7 Day) S0257 G8427 Category II 1157F, 1158F 1159F 1160F 1170F 1125F, 1126F HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

24 COL Colorectal Cancer Screening The percentage of members years of age who had appropriate screening for colorectal cancer by December 31, Tips: 1. A fecal occult test done in the office via a digital rectal exam does not count HCPCS ICD-9 PCS LOINC Fecal occult blood test (gfobt - 3 samples- or ifobtin 2016) 82270, G , , , , , , , , , , , , , , , FIT-DNA test (between 2014 and 2016) G , Flexible Sigmoidoscopy (between 2012 and 2016) , , , G Colonoscopy (between 2007 and 2016) CT Colonography (between 2012 and 2016) Measure Exclusion Criteria: , 44397, , 45355, , G0105, G0121 ICD-9 CM , 154, 154.1, 197.5, V10.05, V , 45.23, 45.25, 45.42, Exclusion: Evidence of Colorectal Cancer or Total Colectomy through December 31, Exclusion Colorectal Cancer Exclusion Total Colectomy , , ICD-9 PCS ICD-10 CM C18.0-C18.9, C19, C20, C21.2, C21.8, C78.5, Z85.038, Z ICD-10 PCS 0DTE0ZZ, 0DTE4ZZ, 0DTE7ZZ, 0DTE8ZZ HCPCS G0213, G0214, G0215, G0231 HCPCS HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

25 IMA Immunizations for Adolescents The percentage of adolescents turning 13 years of age in 2016 who received one dose of meningococcal conjugate vaccine between their 11th & 13th birthday, one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) between their 10th & 13th birthday and three doese of human papillomavirus (HPV) vaccine between their 9th and 13th birthday. The measure calculates a rate for each vaccine and two combination rates: Tdap and Meningococcal conjugate Tdap, Meningococcal conjugate and HPV Common Chart Deficiencies and Tips: 1. Participate in State Immunization registries, where available 2. Devote time during each visit to review immunization record and look for opportunities to catch-up on missing immunizations 3. If available, record date and immunization(s) provided at the health department in the medical record 4. Educate teens and parents/guardians about the importance of these CVX Tdap Meningococcal 90644, , 136, 148 Human Papillomavirus 90649, 90650, , 118, 165 Measure Exclusion Criteria: Exclusion: Exclude children who had a contraindication for a specific vaccine. Exclusion ICD-10 CM Anaphylactic Reaction T80.52XA, T80.52XD, T80.52XS HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

26 LSC Lead Screening in Children The percentage of children turning 2 years of age in 2016 who had one or more capillary or venous lead blood test for lead poisoning by their second birthday. Common Chart Deficiencies and Tips: 1. Lead screening is considered late if performed after the child turns 2 years of age 2. A lead risk assessment does not satisfy the venous blood lead requirement for Medicaid members regardless of the risk score 3. Options exist for in-office lead testing, including blood lead analyzer and MedTox filter paper testing LOINC Lead Tests , , , , , , , , , HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

27 MMA Medication Management for People With Asthma The percentage of members 5 85 years of age in 2016 who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported: 1. The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period. 2. The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period. Asthma ICD-9 CM Asthma Controller Medications Prescriptions ICD-10 CM J45.20-J45.22, J45.30-J45.32, J45.40-J45.42, J45.50-J45.52, J J45.902, J45.909, J J45.991, J Antiasthmatic Combinations Dyphylline-guaifenesin Guaifenesin-theophylline Antibody Inhibitor Inhaled Steroid Combinations Inhaled Corticosteroids Leukotriene Modifiers Mast Cell Stabilizers Methylxanthines Acute Respiratory Failure Chronic Respiratory Conditions Due to Fumes/Vapors COPD Cystic Fibrosis Emphysema Obstructive Chronic Bronchitis Omalizumab Budesonide-formoterol Mometasone-formoterol Beclomethasone Budesonide Ciclesonide Montelukast Zafirlukast Cromolyn Aminophylline Dyphylline , , , Fluticasone-salmeterol Flunisolide Fluticasone CFC free Mometasone Zileuton Theophylline Codes to Identify Exclusions (anytime in history) ICD-9 CM ICD-10 CM J96.00-J96.02, J96.20-J J68.4 J44.0, J44.1, J44.9 E84.0, E84.11, E84.19, E84.8, E84.9 J43.0-J43.2, J43.8-J43.9

28 Other Emphysema 518.1, J98.2, J98.3 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

29 OMW Osteoporosis Management in Women Who Had a Fracture The percentage of women years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after the fracture. HCPCS ICD-9 PCS ICD-10 PCS Bone Mineral Density Test Biphosphonates Other agents 76977, 77078, , G0130 FDA-Approved Osteoporosis Therapies Prescriptions Alendronate Alendronatecholecalciferol Ibandronate sodium Calcitonin Denosumab Risedronate Zoledronic acid Raloxifene Teriparatide BP48ZZ1, BP49ZZ1, BP4GZZ1, BP4HZZ1, BP4LZZ1, BP4MZZ1, BP4NZZ1, BP4PZZ1, BQ00ZZI, BQ01ZZ1, BQ03ZZ1, BQ04ZZ1, BR00ZZ1, BR07ZZ1, BR09ZZ1, BR0GZZ1 J Codes J1740, J3487, J3488, J3489, Q2051 J0630, J0897, J3110 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

30 PBH Persistence of Beta-Blocker Treatment After a Heart Attack The percentage of members 18 years of age and older in 2016 who were hospitalized and discharged from July 1, 2015 to June 30, 2016 with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge. ICD-9 CM ICD-10 CM AMI 410.X1 I21.01-I21.4 Beta-Blocker Medications Prescriptions Noncardioselective betablockers Cardioselective betablockers Antihypertensive combinations Labetalol Measure Exclusion Criteria: Carvedilol Nadolol Penbutolol Acebutolol Atenolol Betaxolol Atenolol-chlorthalidone Bendroflumethiazide-nadolol Bisoprolol-hydrochlorothiazide Pindolol Propranolol Timolol Sotalol Bisoprolol Metoprolol Nebivolol Hydrochlorothiazide-metoprolol Hydrochlorothiazide-propranolol Patients identified as having an intolerance or allergy to beta-blocker therapy. Any of the following anytime during the member s history through 179 days after discharge: Codes to Identify Exclusions ICD-9 CM ICD-10 CM History of Asthma 493 J45.20-J COPD , 496 J44.0, J44.1, J44.9 Obstructive Chronic Bronchitis Hypotension 458 I95.0-I95.9 Heart Block>1 degree 426.0, , , I44.1-I44.7, I45.10-I45.3, 426.4, , I45.6, I49.5 Sinus Bradycardia , R00.1 Chronic Respiratory Conditions Due to Fumes/Vapors J68.4 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

31 W15 Well-Child Visits in the First 15 Months of Life The percentage of members who turned 15 months old in 2016 and who had the following number of well-child visits with a PCP during their first 15 months of life: No well-child visits One well-child visit Two well-child visits Three well-child visits Four well-child visits Five well-child visits Six well-child visits The comprehensive well care visit includes: Health and developmental history (physical and mental) Complete physical exam Health education/anticipatory guidance (age appropriate) Common Chart Deficiencies and Tips: 1. Missing or undocumented anticipatory guidance 2. Sick visit in calendar year without well-child visit 3. Turn a sick visit into a well-child visit 4. Schedule next visit at end of each appointment HCPCS ICD-10 CM Office Visit , , G0438, G0439 Z00.11-Z00.129, Z00.5, Z00.8, Z02.0-Z02.9 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

32 W34 Well-Child Visits in the Third, Fourth, Fifth, and Sixth years of Life The percentage of members 3 6 years of age who had one or more well-child visits with a PCP in The comprehensive well care visit includes: Health and developmental history (physical and mental) Complete physical exam Health education/anticipatory guidance (age appropriate) Common Chart Deficiencies and Tips: 1. Missing or undocumented anticipatory guidance 2. Sick visit in calendar year without well-child visit 3. Turn a sick visit into a well-child visit HCPCS ICD-10 CM Office Visit , G0438, G0439 Z Z00.129, Z00.5, Z00.8, Z02.0-Z02.9 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA). 31

33 WCC Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents The percentage of members 3 17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition, and counseling for Physical activity in Common Chart Deficiencies and Tips: 1. BMI percentile or BMI percentile plotted on growth chart for members 3-17 years of age 2. Must include documentation indicating counseling for nutrition and HCPCS ICD-10 CM UB Revenue Office /Other Outpatient Service BMI Percentile , , , , , , , , , 99420, 99429, G0402, G0438, G0439, G0463, T1015 Z68.51-Z , , , 0982, 0983 Nutrition Counseling G0270, G0271, G0447, S9449, S9452, S9470 Z71.3 Physical Activity Counseling G0447 (face to face behavioral counseling for obesity 15 minutes), S9451 (Exercise classes non-physician provider) Z02.5 (Sports physical) Measure Exclusion Criteria: Any diagnosis of pregnancy during 2016 counts as an exclusion for this measure HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

34 ADV Annual Dental Visit The percentage of members 2 20 years of age who had at least one dental visit in This measure applies only if dental care is a covered benefit in the organization s Medicaid contract. Tips: 1. Educate parents/guardians about the importance of dental care starting when the child is young. 2. Ask when the last dental appointment was during every well visit HCPCS/CDT (Current Dental Terminology) Dental Visits 70300, 70310, 70320, 70350, D0120-D0999, D1110-D2999, D3110-D3999, D4210- D4999, D5110-D5899, D5994, D6010-D6205, D7111- D7999, D8010-D8999, D9110-D9999 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

35 FUH Follow-Up After Hospitalization for Mental Illness The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses in 2016 and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: The percentage of discharges for which the member received follow-up within 30 days of discharge. The percentage of discharges for which the member received follow-up within 7 days of discharge. ICD-10 CM Mental Health Diagnosis F03.90, F03.91, F20.0-F25.9, F28- F34.9, F39, F40.00-F45.9, F48.1-F48.9, F50-F53, F59-F60.9, F63-F66, F68.10-F68-13, F68.8, F69, F80-F82, F84- F84.9, F88, F89 F90.0-F99 Codes to Identify Follow-Up Visits With a Mental Health Practitioner HCPCS , 99078, , , , , , , , , , 99211, 99412, G0155, G0176, G0177, G0409-G411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T , 90792, , , 90845, 90847, 3, 5 7, 9, 11-15, 20, 22, 24, WITH 90849, 90853, , 90875, , 49, 50, 52, 53, 71, , , 99238, 99239, WITH 52, 53 UB Revenue POS Provider Type 513, , 907, , 919 No specific provider type 510, , , , 982, 983 With a mental health provider or together with a mental health diagnosis code HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

36 SSD Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications The percentage of members years of age with schizophrenia or bipolar disorder, who were dispensed antipsychotic medcation and had a diabetes screening test during the measuremnet year. Common Chart Deficiencies and Tips: 1. Order a diabetes screening test every year and check every visit to verify that it has been completed. 2. Educate the patient about the importance of this test. Diagnosis Schizophrenia Bipolar Disorder Test Glucose Test HbA1C Test ICD-10 CM F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 F30.10-F30.13, F30.2-F30.4, F30.8-F30.9, F31.0, F31.1-F31.13, F31.2-F31.32, F31.4-F31.64, F31.7-F31.78 Code 80047, 80048, 80050, 80053, 80069, 82947, 82980, , 83037, 3044F-3046F HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

37 CDC Comprehensive Diabetes Care - Dilated Retinal Eye Exam Diabetes Members 18 to 75 years of age with diabetes (type 1 and type 2) who had a dilated retinal eye exam in 2016 or a dilated retinal eye exam that was negative for retinopathy in ICD-9 CM ICD-10 CM Diabetes Without Complications 250, 357.2, 362.0, , E10.10-E13.9, O O24.33, O O24.83 II Diabetic Retinal Screening Measure Exclusion Criteria: 67028, 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, , 92230, 92235, 92240, 92250, 92260, , , E10.9, E11.9, E F, 2022F, 2024F, 2026F HCPCS S3000, S0620, S0621 Identify members who do not have a diagnosis of diabetes, in any setting, during 2015 or 2016 and who meet either of the following criteria: A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during 2015 or Exclusion ICD-9 CM Diabetes Exclusions 249, 251.8, 962, 648.8, , 962 ICD-10 CM E08.00-E09.9, O O24.439, O O24.93 HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

38 IET Initiation and Engagement of Alcohol and Other Drug Dependence Treatment The percentage of adolescent (age 13 and older) and patients with a new episode of alcohol or other drug (AOD) dependence in 2016 who received the following: Initiation of AOD Treatment. The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis. Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit. Initiation of Treatment - AOD Diagnosis with Outpatient, Intensive Outpatient, and Partial Hospitalization Visit ICD-10 CM AOD Dependence F10.10-F10.99, F11.10-F11.99, F12.10-F12.99, F13.10-F13.99, F14.10-F14.99, F15.10-F15.99, F F16.99, F18.10-F18.99, F19.10-F , 99078, , , , , , , , , , , Codes to Identify Outpatient Visits HCPCS G0155, G0176, G0177, G0396, G0397, G0409-G411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0020, H0022, H0031, H0034- H0037, H0039, H0040, H2000, H2001, H2010-H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012, T1015 Codes to Identify Intensive Outpatient Visits 90791, 90792, , , 90845, 90847, 90849, 90853, 90875, WITH Codes to Identify Intensive Partial Hospitalization Visits UB Revenue 0510, 0513, , , , 0900, , , 0919,0944, 0945, 0982,0983 POS 3, 5 7, 9, 11-20, 22, 33, 49, 50, 52, 53, 57, 71, , , 99238, 99239, WITH 52, 53 Codes to Identify Detoxification Visits HCPCS ICD-9 PCS ICD-10 PCS UB Revenue

39 H0008-H0014 HZ2ZZZZ Codes to Identify Emergency Department Visits UB Revenue , 0126, 0136, 0146, , 0451, 0452, 0456, 0459, 0981 Codes to Identify AOD Procedures ICD-10 PCS HZ30ZZZ-HZ39ZZZ, HZ3BZZZ, HZ3CZZZ, HZ40ZZZ-HZ40ZZZ, HZ4BZZZ, HZ4CZZZ, HZ50ZZZ-HZ59ZZZ, HZ5BZZZ-HZ5DZZZ, HZ81ZZZ-HZ89ZZZ, HZ91ZZZ-HZ99ZZZ HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

40 ADD Follow-Up Care for Children Prescribed ADHD Medication The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication in 2016 who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported. Initiation Phase. The percentage of members 6 12 years of age with an ambulatory prescription dispensed for ADHD medication, who had one followup visit with practitioner with prescribing authority during the 30-day Initiation Phase. Continuation and Maintenance (C&M) Phase. The percentage of members 6 12 years of age with an ambulatory prescription dispensed for ADHD medication, whom remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended. Common Chart Deficiencies and Tips 1. No refills until the initial follow-up visit is complete 2. Conduct initial follow-up visit 2-3 weeks after member starts medication therapy 3. Schedule additional 2 visits within 9 months of medication at the time of the initial follow-up visit 4. If member cancels an appointment, reschedule appointment right away ADHD Medications Prescriptions Amphetaminedextroamphetamine Lisdexamfetamine CNS stimulants Dexmethylphenidate Methamphetamine Dextroamphetamine Methylphenidate Alpha-2 receptor agonists Clonidine Guanfacine Miscellaneous ADHD medications Atomoxetine

41 WITH , , 99238, 99239, WITH 52, 53 Measure Exclusion Criteria: Exclusion Diagnosis of Narcolepsy Codes to Identify Follow-Up Visits - Initiation Phase HCPCS UB Revenue , , 99078, , , , , , , , , , 99411, 99412, G0155, G0176, G0177, G0409-G411, G0463, H0002, H0004, H0031, H0034- H0037, H0039, H0040, H2000, H2001, H2010- H2020, M0064, S0201, S9480, S9484, S9485, T , 90792, , , 90845, 90847, 90849, 90853, 90875, Codes to Identify Follow-Up Visits - C&M Phase All the codes listed above for the Initiation Phase PLUS one follow-up visit can be telephonic Telephone Visits , ICD-10 CM G47.411, G47.419, G47.421, G HEDIS stands for Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA). 0510, 0513, , , , 0900, , 0907, , 0919, 0982, 0983 POS 3, 5 7, 9, 11-20, 22, 33, 49, 50, 52, 53, 71, 72