Cardiovascular Health and Diabetes Screening for People with Schizophrenia

Transcription

1 Cardiovascular Health and Diabetes Screening for People with Schizophrenia The percentage of members 25 years and older with a schizophrenia diagnosis and who were prescribed any antipsychotic medication, who received a cardiovascular health screening and a diabetes screening during the measurement year. Two rates are reported. The percentage of members with schizophrenia and who were prescribed any antipsychotic medication during the measurement year who received a cardiovascular health screening. The percentage of members with schizophrenia and who were prescribed any antipsychotic medication during the measurement year who received a diabetes screening. Eligible Population Product lines Ages Continuous enrollment Allowable gap Anchor date Benefits Event/ diagnosis Medicaid 25 years and older as of December 31 of the measurement year. The measurement year. No more than one gap in enrollment of up to 45 days during the measurement year. To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not considered continuously enrolled). December 31 of the measurement year. Medical and pharmacy. Two separate claims with schizophrenia as a primary diagnosis or one inpatient claim with schizophrenia as a primary diagnosis and a prescription for any antipsychotic medication in the measurement year.

2 Cardiovascular and Diabetes Screening Table A: Codes to Identify Schizophrenia Diagnosis ICD-10-CM Diagnosis 295 F20, F25.9 Cardiovascular and Diabetes Screening Table B: Antipsychotic Medications 1 Miscellaneous antipsychotic agents Phenothiazine antipsychotics Psychotherapeutic combinations Thioxanthenes Administrative Specification Typical (lowpotency) prochlorperazine chlorpromazine thioridazine mesoridazine Typical (midpotency) loxapine molindone perphenazine trifluoperazine Prescription fluphenazine thiothixene Atypical aripiprazole clozapine olanzapine paliperidone quetiapine risperidone ziprasidone Typical (highpotency) haloperidol pimozide fluoxetineolanzapine Denominator Numerators LDL-C Screening The eligible population. One or more screenings relating to cardiovascular care. Appropriate screenings are defined by one of the following criteria. An LDL-C test performed during the measurement year, as identified by claim/ encounter or automated laboratory data. Use any code listed in (Table C). The organization may use a calculated or direct LDL for LDL-C screening and control indicators. Cardiovascular and Diabetes Screening Table C: Codes to Identify LDL-C Screening CPT CPT Category II LOINC 80061, 83700, 83701, 83704, F, 3049F, 3050F , , , , , , , , Exclusion (required) Coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI). Members discharged alive for CABG or PCI in the measurement year or the year prior to the measurement year. Refer to (Table D) and use codes for PCI and CABG only. CABG cases should be from inpatient claims/encounters only. Include all cases of PCI, regardless of setting (e.g., inpatient, outpatient, ED). Ischemic vascular disease (IVD). Members who met at least one of the following criteria during both the measurement year and the year before the measurement year. Criteria need not be the same across both years. 1 Medications come from current NCQA measure (Potentially Harmful Drug-Disease Interactions in the Elderly) Sorting was developed from guidance from the Chief Resident (General Preventive Medicine) at Johns Hopkins Bloomberg School of Public Health

3 At least one outpatient visit (Table F) with an IVD diagnosis (Table E), or At least one acute inpatient claim/encounter (Table F) with an IVD diagnosis (Table E) Chronic heart failure (CHF). Members who had at least one encounter, in any setting, with a code to identify CHF. Refer to (Table G) and use codes for CHF only. Look as far back as possible in the member s history through December 31 of the measurement year. Prior Myocardial infarction (MI). Members who had at least one encounter, in any setting, with any code to identify MI (Table H). Look as far back as possible in the member s history through December 31 of the measurement year. Cardiovascular and Diabetes Screening Table D: Codes to Identify AMI, PCI and CABG CPT HCPCS ICD-9-CM Procedure AMI (include only inpatient claims) CABG (include only inpatient claims) , , , x1 S2205-S , 36.2 PCI 92980, 92982, G , 36.06, Cardiovascular and Diabetes Screening Table E: Codes to Identify IVD IVD 411, 413, 414.0, 414.2, 414.8, 414.9, 429.2, , 440.1, 440.2, 440.4, 444, 445 Cardiovascular and Diabetes Screening Table F: Codes to Identify Visit Type CPT UB Revenue Outpatient , , , , , , , , , 99411, 99412, 99420, 99429, 99455, Acute inpatient , , 99238, 99239, , x, , , 057x-059x, 0982, x, , 0119, , 0129, , 0139, , 0149, , 0159, 016x, 020x,021x, 072x, 0987 Cardiovascular and Diabetes Screening Table G: Codes to Identify Clinical Category CHF 428 AMI 410 Angina 413 Cardiovascular and Diabetes Screening Table H: Codes to Identify Required Exclusions for HbA1c Control <7% for a Selected Population CPT HCPCS ICD-9-CM Diagnosis MI 410, 412 ICD-9-CM Procedure UB Revenue UB Type of Bill Diabetes A glucose test performed during the measurement year as identified in (Table I). Screening Cardiovascular and Diabetes Screening Table I: Codes to Identify Diabetes Screening 2 CPT ICD-9 Glucose Test 82947, 82950, V77.1 POS 2

4 Exclusion (required) Draft Document for Public Comment Obsolete After October 14, 2011 There are two ways to identify members with diabetes: by pharmacy data and by claim/encounter data. The organization must use both methods to identify the eligible population, but a member only needs to be identified by one method to be included in the measure. Members may be identified as having diabetes during the measurement year or the year prior to the measurement year. Pharmacy data. Members who were dispensed insulin or oral hypoglycemics/antihyper-glycemics during the measurement year or year before the measurement year on an ambulatory basis (Table J). Cardiovascular and Diabetes Screening Table J: Prescriptions to Identify Members With Diabetes Alpha-glucosidase inhibitors acarbose miglitol Amylin analogs Antidiabetic combinations Insulin pramlinitide glimepiride-pioglitazone glimepiride-rosiglitazone glipizide-metformin insulin aspart insulin aspart-insulin aspart protamine insulin detemir insulin glargine insulin glulisine insulin inhalation insulin isophane beef-pork insulin isophane human insulin isophane pork insulin isophane-insulin regular Meglitinides nateglinide repaglinide Miscellaneous antidiabetic agents Sulfonylureas exenatide acetohexamide chlorpropamide sitagliptin glimepiride glipizide Thiazolidinediones pioglitazone rosiglitazone Prescription glyburide-metformin metformin-pioglitazone metformin-rosiglitazone metformin-sitagliptin insulin lispro insulin lispro-insulin lispro protamine insulin regular beef-pork insulin regular human insulin regular pork insulin zinc beef-pork insulin zinc extended human insulin zinc human insulin zinc pork glyburide tolazamide tolbutamide Note: Glucophage/metformin is not included because it is used to treat conditions other than diabetes; members with diabetes on these medications are identified through diagnosis codes only. Claim/encounter data. Members who had two face-to-face encounters, in an outpatient setting or nonacute inpatient setting, on different dates of service, with a diagnosis of diabetes (Table I), or one face-to-face encounter in an acute inpatient or ED setting during the measurement year or the year prior to the measurement year. The organization may count services that occur over both years. Refer to (Table L) for codes to identify visit type.

5 Cardiovascular and Diabetes Screening Table K: Codes to Identify Diabetes Diabetes 250, 357.2, 362.0, , Cardiovascular and Diabetes Screening Table L: Codes to Identify Visit Type CPT UB Revenue Outpatient 92002, 92004, 92012, 92014, , , , , , , , , , 99411, 99412, 99420, 99429, 99455, Nonacute inpatient , 99315, 99316, 99318, , Acute inpatient , , 99238, 99239, , ED x, x, , , 057x-059x,, 082x- 085x, 088x, 0982, , 0128, 0138, 0148, 0158, 019x, 0524, 0525, 055x, 066x 010x, , 0119, , 0129, , 0139, , 0149, , 0159, 016x, 020x,021x, 072x, 080x, 0987