NCQA that the exclusion still applies.

Transcription

1 Measure Name: Pharyngitis Treatment for Children Owner: NCQA (CWP) Measure Code: PHR Lab Data: Y Rule Description: The percentage of children 2-18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic, received a group A streptococcus (strep) test for the episode. Applicable Provider Specialty: Allergy, Family Practice, Pediatrics General Criteria Summary 1. Measurement period: 1 year prior to measurement period end date 2. Continuous enrollment: From 30 days prior to the date of the first eligible pharyngitis encounter to 3 days after that date (34 days) 3. Index Episode based: Yes 4. Anchor date: Episode date 5. Gaps in enrollment: No 6. Medical coverage: Yes 7. Drug coverage: Yes 8. Attribution time frame: Episode date 9. Exclusions apply: None 10. Age range: Intake period: July1 to June 30 (6 months earlier than the measurement year) Summary of changes for NCQA replaced all coding table references with value set references: The following code changes were made in the denominator: added CPT codes , , 99381, 99386, 99387, 99391, 99396, 99397, 99455, 99456, HCPCS codes G0402, G0438, G0439. These are all visit types. 2. NCQA does not include a statement in Physician Measurement to exclude ED visits resulting in admission. However, this is stated in Health Plans Volume I confirmed with NCQA that the exclusion still applies. 3. NCQA does not include a statement in Physician Measurement to exclude ED visits resulting in admission. However, this is stated in Health Plans Volume I confirmed with NCQA that the exclusion still applies. We will remove the Room & Board flag in the denominator to denote an admission. We will rely on place of service /or revenue codes for exclusion criteria Denominator Description: All children aged 2 to 18 years who were diagnosed with pharyngitis dispensed an antibiotic Inclusion Criteria: Children aged 2 to 18 years during the intake period, who had a pharyngitis encounter with no other diagnosis present, an antibiotic prescribed within 3 days of the encounter, no antibiotic medication prescribed or refilled within 30 days prior to the encounter or still active on the date of the encounter. The intake period is from six months prior to the beginning of the measurement year to six months prior to the end of the measurement year. Page 1

2 Eligibility Criteria Condition Description # Evnt Detailed Criteria Timeframe Age is 2 to 18 years Age in Years = 2-18 At least 2 years of age at the beginning of the intake period; no greater than 18 years of age at the end of the intake period Claim Criteria Condition # Detailed Criteria Timeframe Description Evnt (At least one outpatient visit with only a diagnosis of pharyngitis (Claim can only include one diagnosis code) 1 (dx must be on same claim as proc or rev code) Diagnosis Code Principal = Pharyngitis Value Set Diagnosis Code = ~ (missing) (CPT Procedure Code = Outpatient, Observation Value Set or HCPCS Procedure Code = Outpatient Value Set or Revenue Code UB = Outpatient Value Set) From six months prior to the beginning of the measurement year to six months prior to the end of the measurement year OR At least one emergency department visit with only a diagnosis of pharyngitis (Claim can only include one diagnosis code, ER visit cannot be part of an admission)) 1 (dx place code must be on same claim as proc or rev code) Diagnosis Code Principal = Pharyngitis Value Set Diagnosis Code = ~ (missing) Place of Service Code Medstat <> 21, 25, 51, 55 (CPT Procedure Code = ED Value Set Or From six months prior to the beginning of the measurement year to six months prior to the end of the measurement year Page 2

3 AND An antibiotic medication prescribed within 3 days of the pharyngitis visit AND No antibiotic medication prescribed or refilled within 30 days prior to the pharyngitis visit or still active on the date of the visit (Note: Identify all visits that meet the above criteria. Then select the visit with the earliest date use that as the eligible encounter.) Exclusion Criteria: None Revenue Code UB =ED Value Set) 1 NDC Number Code = Table CWP-C: Antibiotic Medications, ISMeasures/HEDIS2014/HEDIS2014FinalNDCLists.as px 1 No new, refilled, or active drug prescriptions where NDC Number Code = Table CWP-C: Antibiotic Medications, ISMeasures/HEDIS2014/HEDIS2014FinalNDCLists.as px A prescription is active if the prescription was filled more than 30 days prior to the pharyngitis visit date the Days Supply is greater than or equal to the number of days between the prescription fill date the pharyngitis visit date. From six months prior to the beginning of the measurement year to six months prior to the end of the measurement year On or up to 3 days following the date of the pharyngitis visit During the 90 day period prior to the pharyngitis visit date (Note: 90 days is required to determine if there was a mail order prescription filled that is still active on the visit date.) Continuous Enrollment Criteria: Patients continuously enrolled with medical coverage drug coverage from 30 days prior to the date of the first eligible pharyngitis encounter to 3 days after that date Condition Description # Evnt Detailed Criteria Timeframe Continuous enrollment Continuous Enrollment is 34 out of 34 days From 30 days prior to the date of the first eligible pharyngitis encounter to 3 days after that date AND Has medical coverage Coverage Indicator Medical = Y From 30 days prior to the date of the first eligible pharyngitis encounter to 3 days after that date Page 3

4 AND Has drug coverage Coverage Indicator Drug = Y From 30 days prior to the date of the first eligible pharyngitis encounter to 3 days after that date Numerator Description: For each patient who meets the denominator criteria, those who received a group A streptococcus (strep) test in the period from three days prior to the pharyngitis encounter to three days after the encounter Inclusion Criteria: Patients who had at least one group A streptococcus test in the period from three days prior to the date of the first eligible pharyngitis encounter to three days following that encounter Condition Description # Evnt Detailed Criteria Timeframe At least one group A streptococcus test 1 CPT Procedure Code = Group A Strep Tests Value Set Or LOINC = Group A Strep Tests Value Set From 3 days prior to the first eligible pharyngitis encounter to 3 days following that encounter Page 4

5 Appendix Pharyngitis Value Set 462 ICD-9-CM Diagnosis Acute pharyngitis 463 ICD-9-CM Diagnosis Acute tonsillitis ICD-9-CM Diagnosis Streptococcal sore throat Outpatient Value Set CPT New patient, office or other outpatient service CPT Established patient, office or other outpatient service CPT Hospital observation services, observation care discharge services CPT Office or other outpatient consultations, New or established patient CPT Home services, New patient CPT Home services, Established patient CPT Init Pm E/M - New Pat - Inf CPT Init Pm E/M - New Pat 1-4 Yrs CPT Prev Visit - New - Age CPT Preventive medicine services, years, new patient CPT Per Pm Reeval - Est Pat - Inf CPT Prev Visit - Est - Age CPT Prev Visit - Est - Age CPT Preventive medicine services, years, established patient CPT Preventive medicine, individual counseling, new or established, 15 min CPT Preventive medicine, individual counseling, new or established, 30 min CPT Preventive medicine, individual counseling, new or established, 45 min CPT Preventive medicine, individual counseling, new or established, 60 min Page 6

6 99411 CPT Preventive medicine, group counseling, 30 min CPT Preventive medicine, group counseling, 60 min CPT Other preventive medicine services, administration interpretation CPT Other preventive medicine services, unlisted 99455, CPT Work related or medical disability evaluation services G0402 HCPCS Initial preventive physical; f-f visit, new G0438 HCPCS Annual wellness visit; personalized prevention plan, initial G0439 HCPCS Annual wellness visit; personalized prevention plan, subsequent 0510 UB Revenue CLINIC 0511 UB Revenue CHRONIC PAIN CL 0512 UB Revenue DENTAL CLINIC 0513 UB Revenue PSYCH CLINIC 0514 UB Revenue OB-GYN CLINIC 0515 UB Revenue PEDS CLINIC 0516 UB Revenue URGENT CLINIC 0517 UB Revenue FAMILY CLINIC 0519 UB Revenue OTHER CLINIC 0520 UB Revenue FREESTAND CLINIC 0521 UB Revenue RURAL/CLINIC 0522 UB Revenue RURAL/HOME 0523 UB Revenue FR/STD FAMILY CLINIC 0526, 0527, 0528 UB Revenue FR/STD URGENT CLINIC 0529 UB Revenue OTHER FR/STD CLINIC 0982 UB Revenue PRO FEE/OUTPT 0983 UB Revenue PRO FEE/CLINIC Observation Value Set CPT Observation Care Discharge CPT Observation Care Page 7

7 ED Value Set Code Code Type Description CPT Emergency services, new or established patient 0450 UB Revenue EMERG ROOM 0451 UB Revenue ER/EMTALA 0452 UB Revenue ER/BEYOND EMTALA 0456 UB Revenue URGENT CARE 0459 UB Revenue OTHER EMER ROOM 0981 UB Revenue PRO FEE/ER Group A Strep Tests Value Set CPT Culture, bacterial; any other source except urine, blood or stool, aerobic, w isol/presumptive identification of isolates CPT Culture, bacterial; quant, aerobic w isolation/presumptive id of isolates, any source except urine, blood or stool CPT Culture, presumptive, pathogenic organisms, screening only; CPT Infectious agent antigen detection by enzyme immunoassay tech, qualitative or semiquantitative, multi-step method; CPT Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique CPT Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique CPT Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification CPT Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A LOINC Streptococcus test LOINC Streptococcus test LOINC Streptococcus test LOINC Streptococcus test LOINC Streptococcus test LOINC Streptococcus test LOINC Streptococcus test LOINC Streptococcus test LOINC Streptococcus test LOINC Streptococcus test LOINC Streptococcus test LOINC Streptococcus test LOINC Streptococcus test Page 8