Hedis Behavioral Health Measures

Transcription

1 Hedis Behavioral Health Measures Generating better health outcomes and improving HEDIS scores is a positive outcome for everyone. Magellan Complete Care is offering support by providing the details of specific measures and giving you other valuable tips. This will help optimize HEDIS scores in a way that accurately reflects your performance as a provider. HEDIS MEASURE and DESCRIPTION RECOMMENDATIONS FOR QUALITY PERFORMANCE CODES THAT COUNT TOWARD MEASURE Antidepressant Medication Management (AMM) Members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported. 1. Effective Acute Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks). 2. Effective Continuation Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 180 days (6 months) Timeframe: May 1 April 30 Note: This measure is for members who have a negative medication history for antidepressants for 3.5 months prior to the new prescription start date. Use objective assessments to identify who would benefit from medication. Offer supportive therapy instead of or in addition to medication. Educate patients about their medications: How antidepressants work, their benefit and how long they should be used Help them understand it may take up to 12 weeks for full medication effectiveness. Emphasize the importance of taking medications for at least six months even if they feel better. Discuss side effects and the importance of medication adherence. Note: Samples will not count toward HEDIS since there would be no pharmacy claims. : F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9 AMM Stand Alone visits CPT Codes: , 99078, , , , , , , , , , , HCPCS: G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000,H2001,H2010-H2020, M0064, S0201, S9480, S9484, S9485,T1015 UBREV: 510, 513, , , , , 907, , 919, 982, 983 ED Visits CPT Codes: UBREV: , 0456, 0459, 0981 Telephone Visits CPT Codes: ; HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA) Providers should always bill codes appropriate to the services rendered. Participating providers should consult their contract and the member s benefits to confirm whether a particular code is a covered service.

2 Follow-Up After Hospitalization for Mental Illness (FUH) Members 6 years and older who were discharged after hospitalized treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are reported: 1. The percentage of discharges for which the member received follow-up within 7 days of discharge. 2. The percentage of discharges for which the member received follow-up within 30 days of discharge. Timeframe: Jan. 1 Dec. 31 Educate inpatient and outpatient providers about the measure and the clinical practice guidelines. Make sure that the patient has two appointments before they leave the facility. One within seven days of discharge, and another within 30 days of discharge. Visits that occur on the date of discharge do not count toward this measure. If the patient is a child or adolescent be sure to engage parents/caregiver in the treatment plan at the time of discharge. Advise them about the importance of these follow-up appointments. Make sure that the referral process is secured to the BH provider and the PCP who will care for the patient after the hospitalization. Visits must be with a mental health provider. AMM visits with POS CPT Codes: 90791, 90792, , , 90845, 90847, 90849, 90853, , 90875, 90876, , , 99238, 99239, Use with POS: 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 Telephone Visits: , Inpatient Stay UBREV: 0100, 0101, , , , , , , 0164, 0167, , 0179, , , , 0219, : Use the appropriate code family: F Stand-Alone Visits (7 and 30 days post discharge) CPT Codes: , 99078, , , , , , , , , , 99411, 99412, HCPCS Codes: G0155, G0176, G0177, G0409- G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 Follow-up Visits with POS Group 1 CPT Codes: 90791, 90792, , , 90845, 90847, 90849, 90853, , 90875, Use with POS: 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 Group 2 CPT Codes: , , 99238, 99239, Use with POS: 52, 53 Transitional Care CPT Codes: (14 Days, used for 30-Day Follow-up indicator) and (7 Days) UBREV Group 1: 513, , 907, , 919 Group 2: 510, , , , 982, 983

3 Follow-Up Care for Children Prescribed ADHD Medication (ADD) Children 6 12 years old newly prescribed attentiondeficit/hyperactivity disorder (ADHD) medication 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: A follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase. Continuation and Maintenance Phase: children that 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 on different dates of service with a practitioner within 270 days (9 months) after the Initiation Phase ended. (Telehealth is eligible for one visit for the C&M phase). Timeframe: Mar 1 Feb 28 Note: This measure is for members who have a negative medication history for ADHD for 4 months prior to the new prescription start date. Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) Members years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test (glucose test or HbA1c test) during the measurement year. When prescribing a new ADHD medication for a patient, schedule the initial follow-up appointment before the patient leaves the office. Schedule the initial follow-up for 2-3 weeks after starting the medication. Don t prescribe refills unless the child has the initial follow-up visit. After the initial follow-up visit, schedule at least 2 more visits over the next 9 months to check the child s progress. One of the 2 may be a telephone or telehealth visit. Educate parents/caregiver that their child must be seen within 30 days of starting the medication to make sure it is working. One follow up visit can also be completed by phone for the continuation and maintenance appointment. The initial visit must be with a provider with prescribing authority to count towards HEDIS. Document all elements of the exam including medications, diagnosis and results of A1c Ensure patient (and/or caregiver) is aware of the risk of diabetes and have awareness of the symptoms of new onset of diabetes while taking antipsychotic medication Schedule lab screening test through PCP prior to next appointment The Behavioral health (BH) provider can order diabetic lab tests for patients who do not have regular Stand-Alone Visits CPT codes: , , 99078, , , , , , , , , , 99411, 99412, HCPCS G0155, G0176, G0177, G0409, G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 UBREV 0510, 0513, , , , 0900, , 0907, , 0919, 0982, 0983 Follow-up Visits with POS CPT Codes Group 1: 90791, 90792, , , 90845, 90847, 90849, 90853, 90875, Use with POS: 3, 4, 7, 9, 11-20, 22, 33, 49, 50, 52, 53, 71, 72 Group 2: , , 99238, 99239, Use with POS: 52, 53 Telephone Visits: , Schizophrenia: F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 Bipolar Disorder: F30.10-F30.13, F30.2-F30.4, F30.8, F30.9, F31.0, F31.10-F31.13, F31.2, F31.30-F31.32, F31.4, F31.5, F31.60-F31.64, F31.70-F31.78 Other Bipolar Disorders: F31.81, F31.89, F31.9 Glucose Tests CPT Codes: 80047, 80048, 80050, 80053, 80069, 82947, 82950, 82951, 83036, CPT II Codes: 3044F, 3045F, 3046F LOINC: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , HbA1c Tests CPT Codes: 83036, CPT II Codes: 3044F, 3045F. 3046F LOINC: , ,

4 Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD) Members years of age with schizophrenia and diabetes who had both an LDL-C test and an HbA1c test during the measurement year. Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC) Members years of age with schizophrenia and cardiovascular disease, who had an LDL-C test during the measurement year. Order a direct LDL if patient is not fasting to avoid a missed opportunity. Some lab order forms have conditional orders if fasting, LDL-C; if not fasting, direct LDL. Order diabetic lab tests through the Behavioral Health (BH) provider for patients who do not have regular Adjust therapy to improve HbA1c, LDL, and BP levels; follow-up with patients to monitor changes Give any patient caregiver instructions on the course of treatment, labs or future appointment dates Monitor body mass index, plasma glucose level, lipid profiles and signs of prolactin elevation at each appointment Members with chronic conditions can be referred to our Disease Management Program at my-plan/programs/disease-management-programenrollment.aspx Order lab tests through a Behavioral Health (BH) provider for patients who do not have regular Review cardiovascular services needed at each office visit and ensure lipid levels, blood pressure and glucose are monitored at every appointment Educate patient (and caregiver) about the risks associated with antipsychotic medications and cardiovascular disease and the importance of a healthy lifestyle. This includes nutrition, exercise and smoking cessation. For LDLs, if patient is not fasting, order direct LDL to avoid a missed opportunity Adjust therapy to improve HbA1c, LDL, and BP levels; follow-up with patients to monitor changes Members with chronic conditions can be referred to our Disease Management Program at my-plan/programs/disease-management-programenrollment.aspx Schizophrenia: F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 Diabetes: Use the appropriate code family: E or O (preexisting DM in pregnancy) CPT Codes HbA1C tests: 83036, LDL-C tests: 80061, 83700, 83701, 83704, CPT II Codes: 3044F, 3045F, 3046F, 3048F, 3049F, 3050F LOINC Codes HbA1c: , , LDL-C: , , , , , , Schizophrenia: F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 Cardiovascular Disease: Use the appropriate code family for AMI, CABG, PCI or IVD CPT Codes LDL-C Test: 80061, 83700, 83701, 83704, CPT II Codes: 3048F, 3049F, 3050F

5 Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA) Members years of age during the measurement year with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period. Measures the period of time beginning on the prescription start date through Dec 31. Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM) Children and adolescents 1 17 years of age who had two or more antipsychotic prescriptions and had metabolic testing. Consider prescribing long-acting injections as an alternative Schedule appropriate follow-up with members to evaluate if medication is taken as prescribed Review missing services list for pharmacy refills to ensure patients are getting timely refills Place reminder calls to remind patients of their appointment Educate patients on the following: The importance of staying on the medication Strategies for remembering to take the antipsychotic on a daily basis Common side effects, how long the side effects may last and how to manage them Order lab tests through the Behavioral Health (BH) provider for patients who do not have regular Monitor children on antipsychotic medications to help to avoid metabolic health complications such as weight gain and diabetes Establish a baseline and continuously monitor metabolic indices to ensure appropriate management of side-effects of antipsychotic medication therapy Schizophrenia: F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 HCPCS Long-Acting Injections: 14-day supply: J day supply: J0401, J1631, J2358, J2426, J2680 Glucose Tests CPT Codes: 80047, 80048, 80050, 80053, 80069, 82947, 82950, LOINC: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , HbA1c Tests CPT Codes: 83036, CPT II Codes: 3044F, 3045F, 3046F LDL-C Tests CPT Codes: 80061, 83700, 83701, 83704, 83721, CPT II Codes: 3048F, 3049F, 3050F Cholesterol Tests Other than LDL: CPT: 82465, 83718, LOINC: , , ,

6 Follow-Up After Emergency Department Visit for Mental Illness (FUM) Members 6 years of age and older with a principal diagnosis of mental illness, who had a follow-up visit with any practitioner for mental illness. Two rates are reported: 1. The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days). 2. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days). Timeframe: Date of ED visit through 30 days after ED visit NOTE: Visits that occur on the date of the ED visit count toward this measure. Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC) Children and adolescents 1 17 years of age who were on two or more concurrent antipsychotic medications for at least 90 consecutive days during the measurement year. Note: A lower rate indicates better performance. Schedule the 7 Day Follow-Up visit within 5 days of ED visit to allow flexibility in rescheduling. If appointment doesn t occur within first 7 days, schedule within 30 days after the ED visit. The follow-up visit can be done with any practitioner as long as the principal diagnosis is a mental health disorder. Avoid the simultaneous use of multiple antipsychotic medications for children and adolescents per The American Academy of Child and Adolescent Psychiatry Ask members/parents/guardians to bring all medications to every appointment to ensure medication list is current and you can verify that all medications in the patient s possession should currently be taken by the patient. Have the members/parents/guardians acknowledge understanding when a medication should be discontinued. Encourage them to dispose of the discontinued medication so they do not take it by mistake. Monitor children and adolescents prescribed antipsychotics closely as they are more at risk for serious health concerns, including weight gain, extrapyramidal side effects, hyperprolactinemia and some metabolic effects Follow-Up Visit Codes CPT: , 99078, , , , , , , , , , 99411, 99412, HCPCS G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 Follow-up Visits with POS CPT Codes Group 1 CPT: 90791, 90792, , , 90845, 90847, 90849, 90853, , 90875,90876 Use with POS: 03, 05, 07, 09, 11 20, 22, 24, 33, 49, 50, 52, 53, 71, 72 Group 2 CPT: , , 99238, 99239, with POS: 52, 53 UB Rev Codes for a visit at a behavioral healthcare facility: 0513, , 907, , 919 UB Rec Codes for visits at a non-behavioral healthcare facility with a mental health provider or with a diagnosis of mental illness: 0510, , , , Applies to all first and second generation Antipsychotic Medications.

7 Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA) Members 13 years of age or older who had an ED visit with a principal diagnosis of alcohol or other drug abuse or dependence (AOD), and who had follow up visit for AOD with any practitioner within 30 days and 7 days after the ED visit. Two rates are reported: The percentage of ED visits for which the member received follow-up 30 days of the ED visit. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit Timeframe: Date of ED visit through 30 days after ED visit NOTE: Visits that occur on the date of the ED visit count toward the measure for both rates. Schedule the 7 Day Follow-Up visit within 5 days of ED visit to allow flexibility in rescheduling. If appointment doesn t occur within first 7 days, schedule within 30 days after the ED visit. The follow-up visit can be done with any practitioner as long as the principal diagnosis alcohol or other drug abuse or dependence. : Use the appropriate code family for Alcohol or other drug abuse or dependence: F Stand Alone Visit CPT Codes: , 99078, , , , , , , , , , 99408, 99409, 99411, 99412, HCPCS: G0155, G0176, G0177, G0396, G0397, G0409-G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015. H0016, H0022, H0031, H0034-H0037, H0039, H0040, H0047, H2000, H2001, H2010-H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012, T1015 UBREV: 510, 513, , , , 900, , , 919, 944, 945, 982, 983 Follow-up Visits with POS CPT Codes Group 1 CPT Codes: 90791, 90792, 90832, 90834, , 90845, 90847,90849, 90853, 90875, POS: 03, 05, 07, 09, 11-20, 22, 33, 49, 50, 52, 53, 57, 71, 72 Group 2 CPT Codes: , , 99238, 99239, POS: 52, 53 Telephone Visits CPT Codes: , MagellanCompleteCareofFL.com C-T13 (9/17) 2017 Magellan Health, Inc.