2018 Global Quality IPA Pay For Performance (P4P) Program Guide

Transcription

1 2018 Global Quality IPA Pay For Performance (P4P) Program Guide Contact: Published: December 15, 2017 Page 1

2 Program IEHP is pleased to provide an update for the Global Quality Pay for Performance (GQ P4P) Program for IPAs in In this third year of the program, IEHP has made enhancements based on feedback from Providers and in an effort to continually improve program effectiveness. The IEHP GQ P4P Independent Physician Associations (IPAs) was designed to reward IPAs for high performance and year-over-year improvement in key quality performance measures. This program overview is designed for IPAs and their staff as an easy guide to help maximize GQ P4P. In its third year, the GQ P4P Program is an expansion of IEHP s 2017 GQ P4P Program and provides financial rewards to IPAs for improving healthcare quality across multiple domains and measures. The 2018 GQ P4P program focuses on performance-based incentives to IPAs for services rendered in 2018 and will be provided to IPAs for high performance and for year-overyear improvement. If you would like to get more information about IEHP s GQ P4P Program or best practices to help improve quality scores and outcomes, visit our Secure Provider Portal at the Quality Team at QualityPrograms@iehp.org or call the IEHP Provider Relations Team at What s New? Two (2) measures retired o Annual Monitoring for Patients on Persistent Medications - Total o Childhood Immunizations - Combo 3 Three (3) measures added to the Clinical Quality Domain o Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis o Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents o Concurrent Use of Opioids and Benzodiazepines (monitoring only) New Tier 1 and Tier 2 goal methodology to include a practical significance standard Budget reduced from $30 million to $20 million, with removal of the condition to pass through 33-50% of the funding to PCPs that was in place for previous program years Eligibility and Participation To be eligible for incentive payments in the 2018 GQ P4P Program, IPAs must meet the following criteria: Page 2

3 Have at least 5,000 IEHP Medi-Cal Members assigned as of January 2018 Have at least 30 Members in the denominator as of December 2018 for each quality measure to qualify Submit a GQ P4P Quality Work Plan to IEHP by March 1, 2018 in order to enroll in the program (see Work Plan details in Appendix 5) Meet minimum Encounter Data Gates in order to qualify for incentive payments Minimum Data Requirements Encounter Data Encounter data is foundational to performance scoring and is essential to success in the GQ P4P Program. Complete, timely and accurate encounter data should be submitted through normal reporting channels for all services rendered to IEHP Members. Please reference the codes listed in Appendix 2 to help with proper coding to meet measure requirements. Lab Results Lab results data is also foundational to performance scoring in the Program. Providers should ensure submission of complete lab results data for services rendered to IEHP Members. IPAs should work with their network providers to ensure the appropriate lab vendors are used for IEHP Members and lab results data are being sent to IEHP. Lab results that are performed in the office (e.g., point of care HbA1c testing, urine tests, etc.) should be coded and submitted through providers encounter data. Immunizations To maximize performance in immunization-based measures, IEHP strongly encourages all Providers to report all immunizations via the California Immunization Registry (CAIR2). For more information on how to register for CAIR2, please visit IEHP is working closely with CAIR in establishing a data sharing arrangement to be used in Global Quality P4P reporting. IEHP s Traditional P4P Data provided to IEHP as part of Traditional P4P Programs will be used as a data source to support the performance scoring methodology for measures in the Clinical Quality domain. P4P Program data are not used in scoring methodology for encounter data performance measures. P4P data is subject to retrospective data validation and must pass all quality assurance checks prior to inclusion into final provider performance scores. Page 3

4 Financial Providers are eligible to receive financial rewards for performance excellence and for performance improvement. Financial rewards are based on a tiered system, providing increasing financial rewards for reaching higher tiered level performance. The 2018 GQ P4P Program incentive pool is $20 million for the IPA program. Incentive dollars for the 2018 performance period are scheduled to be made in January 2019 (interim) and July 2019 (final). IPA Encounter Data Gates IPA encounter data submissions must meet minimum adequacy requirements in order to receive GQ P4P Program incentive dollars. IPA encounter data performance is based on all professional encounters submitted by the IPA for services rendered during the measurement year (i.e dates of service). IPA encounter data volume will be compared to established encounter data benchmarks for SPD and Non-SPD membership. IPA performance will be calculated against each IPA s proportion of SPD and Non-SPD membership. Encounter data benchmarks have been established and correspond to an encounter data gate, reflecting higher encounter data volumes. As IPAs reach higher levels of encounter data performance, they become eligible for a larger percentage of the total possible GQ P4P incentive. Encounter rates are expressed as the number of encounters per Member per year (PMPY). An encounter is defined as a unique visit per Member per Provider per day. Below is a table describing the Encounter Data Gates, performance levels, and their impact to IPA GQ P4P Program incentive payments. % of Possible Incentive Payment Encounter Data Gate Non-SPD PMPY SPD PMPY 50% Gate % Gate % Gate Encounter data gating methodology only applies to the IPA methodology. Encounter data must be submitted to IEHP timely and adhering to reporting timeframes established in IEHP s Provider Policy and Procedure Manual - Policy 21A. Performance Measures Appendix 1 provides a list of the twenty-two (22) measures included in the 2018 GQ P4P Program including thresholds and benchmarks associated with respective tier goals. These measures have been categorized into 4 domains: Clinical Quality; Behavioral Health Integration; Patient Experience; Encounter Data. Most measures included in the Clinical Quality Domain primarily uses standard Healthcare Effectiveness Data and Information Set (HEDIS ) process and outcomes measures based on the specifications published by the National Committee for Quality Assurance (NCQA). Non-HEDIS Page 4

5 measures included in the Clinical Quality domain come from the Department of Healthcare Services (DHCS) Medi-Cal Managed Care Quality Program and the Pharmacy Quality Alliance. Clinical Quality Measures: Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (New) Breast Screening Screening Childhood Immunizations Combo 10 Comprehensive Diabetes Care Eye Exam Comprehensive Diabetes Care HbA1c Control < 8 Concurrent Use of Opioids and Benzodiazepines (New) Immunizations for Adolescents Combo 2 Initial Health Assessment Medication Management for People with Asthma 75% rate Timely Postpartum Care Timely Prenatal Care Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (New) o Counseling for Physical Activity o Counseling for Nutrition o BMI Percentile Life IEHP s HEDIS 2019 data set (measurement year 2018) will be used to evaluate Providers yearend performance. This measure set undergoes an independent audit review prior to rate finalization. The Initial Health Assessment measure follows IEHP s IHA internal compliance monitoring methodology and is not a HEDIS measure. The Concurrent Use of Opioids and Benzodiazepines measure specification is developed and maintained by the Pharmacy Quality Alliance (PQA). This measure will not be used for incentive calculations but will be collected to establish a baseline rate for See Appendix 2 listed in this program guide for measure details. Behavioral Health Integration Domain Measures: Measures included in the Behavioral Health Integration Domain include two (2) measures derived from the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) measure set 1. 1 For information on the PQRS measure set: Instruments/PQRS/index.html Page 5

6 Screening for Clinical Depression in Primary Care Positive Depression Screening with Follow-Up Plan Patient Experience Domain Measures: Measures included in the Patient Experience Domain include Member Satisfaction Survey questions that are included in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey published by the Agency for Healthcare Research and Quality (AHRQ). IEHP fields a Member Satisfaction Survey that is a modified CAHPS survey and is the sole data source supporting the performance scoring methodology for this measure domain. The IEHP Member Satisfaction Survey is fielded between June and December of each year. Surveys received from the 2018 Member Satisfaction Survey will be used to calculate the Patient Experience domain measures. A copy of the current Member Satisfaction Survey is available in Appendix 4 listed in this program guide. Access to Care Needed Right Away Access to Routine Care Coordination of Care Encounter Data Domain Measures: The fourth measure domain is Encounter Data. IPAs eligible for the GQ P4P Program become eligible for receiving payment dollars once meeting the minimum encounter data gate. Reaching higher encounter gate performance qualifies an IPA to receive a higher percentage of incentive dollars. See the IPA Encounter Data Gates section listed in this program guide for additional details on this methodology. Page 6

7 2018 IPA Global Quality P4P Scoring and Payment Flowchart Program Eligibility Requirements Membership will be determined as of 01/2018 IPAs with 5,000 or more assigned Members Scoring Method Incentive eligible IPAs will receive a Quality Score for each Measure. IPAs must have 30 or more Members in each Measure to be eligible for a Quality Score. The Quality Score is averaged to determine the Global Quality Performance Score. At least three Measures are required to determine the Global Quality Performance Score IPA Payment Calculation [Global Quality Performance Score] X [# Medi Cal Average Member Months] = Member Points [Member Points] X [Payment Amount per Member Point] = Max Payment Amount [Max Payment Amount] X [Encounter Gate] = Final Payment Amount Page 7

8 Scoring Methodology Payment will be awarded to IPAs based on individual performance for reaching established Quality Goals (i.e., Tier Goals for each measure). In the Clinical Quality Domain, HEDIS measure results are based on each measure s total eligible population assigned to the IPA. The eligible population is defined as the set of Members that meet the denominator criteria specified in the current year HEDIS Technical Specifications (Volume 2) published by NCQA. Members in the eligible population are attributed to the assigned PCP on each measure s anchor date, as defined within the HEDIS measure. Members contribute to a IPA s HEDIS measure denominator if continuous enrollment criteria are met at the health plan level. For each measure, the HEDIS score reflects the proportion of the eligible population that is in compliance with the numerator criteria, as defined in the current HEDIS technical specifications (Volume 2). In the Clinical Quality Domain, non-hedis measure (i.e., Initial Health Assessment) results are based on new health plan Members assigned to the IPA during the measurement year and who remain enrolled with the Plan and the IPA through the 120 day post enrollment period. See Appendix 2 listed in this program guide for measure details. In the Patient Experience Domain, monthly Member satisfaction survey measures are based on Members who meet eligibility criteria to receive a mailed survey between June and December of the measurement year. Members eligible for receiving a Member Satisfaction Survey must have met continuous enrollment with IEHP for at least 6 months in the measurement year (2018) and must have an office visit in the prior 6 months based on encounter data submitted to IEHP. Members who meet the survey eligibility criteria are randomly sampled to receive a survey. Survey measure results are attributed to the Member s assigned IPA on the most recent encounter that qualified the Member to be eligible for the survey. A Member is eligible to receive only one survey per calendar year. For IPAs, the Encounter Data Domain measures assess the volume of IPA encounters received for all assigned IPA Members. The denominator is all assigned Medi-Cal Members each month of the measurement year (2018). All monthly assigned Members are summed to create the denominator (i.e., member months). The numerator is the sum of all unique encounters (i.e., unique Member, Provider, date of service) in the measurement year for all assigned Members in the denominator. A Per Member Per Year (PMPY) rate is calculated following this formula: Total Unique Encounters / Total Member Months x 12 = PMPY Page 8

9 Payment Methodology IPA performance on each quality measure will be given a point value (i.e., a Quality Score). Points are assigned based on the tier goal achieved (i.e. tier 1 = 1 point, tier 2 = 2 points, tier 3 = 3 points) for each measure. IPAs who have at least three (3) quality measures that meet the minimum denominator size (n = 30) will be considered for payment calculations. An average of all eligible Quality Scores will determine the overall GQ Performance Score. GQ P4P Program payments will be awarded according to the following formula: [Global Quality Performance Score] X [# Medi-Cal Average Member Months] = Member Points [Member Points] X [Payment Amount per Member Point] = Incentive Payout Total The payment amount per member point is dependent on the total incentive money available for IPAs. Using the formula below, the payment amount per member point is calculated as follows: Max Global Quality # Medi-Cal Average Member Member Points Performance Score X Months Total* = 3 700,000 2,100,000 * This calculation is for illustration purposes only. Provider Total Incentive Dollars Member Points Payment per Member Available Point IPA $20,000,000 2,100,000 = $9.52 * Final payment per Member point value will be finalized in the Spring of Figures above are for illustration purposes only. Rates will be shared with IPAs at least quarterly to track progress toward goals. Initial IPAs reports will be available in March Getting Help Please direct questions and/or comments related to this program to IEHP s Provider Call Center at or to IEHP s Quality Department at QualityPrograms@iehp.org. Page 9

10 Program Terms and Conditions Participation in IEHP s GQ P4P Program, as well as acceptance of incentive payments, does not in any way modify or supersede any terms or conditions of any agreement between IEHP and Providers or IPAs, whether that agreement is entered into, prior to or subsequent to, the date of this communication. There is no guarantee of future funding for, or payment under, any IEHP Provider incentive program. The IEHP GQ P4P Program and/or its terms and conditions may be modified or terminated at any time, with or without notice, at IEHP s sole discretion. Criteria for calculating incentive payments are subject to change at any time, with or without notice, at IEHP s sole discretion. In consideration of IEHP s offering of the IEHP GQ P4P Program, participants agree to fully and forever release and discharge IEHP from any and all claims, demands, causes of action, and suits, of any nature, pertaining to or arising from the offering by IEHP of the IEHP GQ P4P Program. The determination of IEHP regarding performance scoring and payments under the IEHP GQ P4P Program is final. As a condition of receiving payment under the IEHP GQ P4P Program, Providers and IPAs must be active and contracted with IEHP and have active assigned Members at the time of payment. Page 10

11 Appendix IPA Global Quality P4P Program Measures 2018 GQ P4P Program Measure List Domain Measure Name Population Tier 1 Tier 2 Tier 3 Clinical Quality Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis ⱡ Adult 38.7% Clinical Quality Breast Screening Women 71.4% Clinical Quality Screening Women 69.9% Clinical Quality Comprehensive Diabetes Care Eye Exam Adult 68.1% Clinical Quality Comprehensive Diabetes Care - HbA1c Control <8 Adult 58.4% Clinical Quality Childhood Immunizations - Combo 10 Child Improvement Improvement 46.5% Immunizations for Adolescents - Demonstrated Demonstrated Clinical Quality Combo 2 Child by Meeting by Meeting 32.3% the following the following Clinical Quality Initial Health Assessment All 2 conditions: 2 conditions: 50.0% Medication Management for People Clinical Quality with Asthma - 75% Adult 10% 20% 48.4% Clinical Quality Timeliness of Prenatal Care Women reduction in reduction in 91.0% noncomplianccompliance 73.6% non- Clinical Quality Postpartum Care Women Clinical Quality Well-Child Visits 3- Life Child AND AND 83.0% Weight Assessment and Counseling for Improvement Improvement Nutrition and Physical Activity for of at least 2.0 of at least 3.0 Clinical Quality Children and Adolescents ⱡ Child percentage percentage points points Clinical Quality Counseling for Physical Activity Child 71.6% Clinical Quality Counseling for Nutrition Child 79.5% Clinical Quality BMI Percentile Child 86.4% Behavioral Health Integration Screening for Clinical Depression in Primary Care Adult and Adolescent 50.00% Behavioral Health Integration Clinical Quality Patient Experience Patient Experience Patient Experience Positive Depression Screening with Follow-Up Plan Adult and Adolescent 90.00% Concurrent Use of Opioids and Benzodiazepines ⱡ** All Baseline Reporting Year Member Satisfaction Survey - Access to Care Needed Right Away All 84% 86% 88% Member Satisfaction Survey - Coordination of Care All 82% 85% 86% Member Satisfaction Survey Access to Routine Care All 82% 84% 86% Encounter Data Encounter Data for PMPY - SPD All Encounter Data Encounter Data for PMPY - Non-SPD All ⱡ New Measure for 2018 **Reporting Only Measure, Not eligible for incentive dollars *** Encounter Data measure benchmarks are gates not tiers Page 11

12 Appendix 2 Measures Page 12

13 Clinical Domain Measure Name: Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAB) Methodology: HEDIS Measure Description: The percentage of adults years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription on or three days after the Index Episode Start Date (IESD). Episode Date is the date of service for any outpatient or ED visit during the Intake Period (1/1/ /24/18) with a diagnosis of acute bronchitis. IESD: the earliest Episode Date during the Intake Period with a diagnosis of acute bronchitis that meets all of the following criteria: 1. Episode Date is the date of service for any outpatient or ED visit during the Intake Period with a diagnosis of acute bronchitis. 2. A 30-day Negative Medication History prior to the Episode Date. 3. A 12-month Negative Comorbid Condition History prior to and including the Episode Date. 4. A Negative Competing Diagnosis during the 38-day period from 30 days prior to the Episode Date through 7 days after the Episode Date. 5. The member was continuously enrolled 1 year prior to the Episode Date through 7 days after the Episode Date. The measure is reported as an inverted rate [1 (numerator/eligible population)]. A higher rate indicates appropriate treatment of adults with acute bronchitis (i.e., the proportion for whom antibiotics were not prescribed). Members in hospice are excluded from the eligible population. Exclude denied claims when assessing numerator criteria. AAB Antibiotic Medications Description Aminoglycosides Amikacin Gentamicin Prescription Streptomycin Aminopenicillins Amoxicillin Ampicillin Beta-lactamase inhibitors First-generation cephalosporins Fourth-generation cephalosporins Ketolides Amoxicillin-clavulanate Ampicillin-sulbactam Piperacillin-tazobactam Tobramycin Ticarcillin-clavulanate Cefadroxil Cefazolin Cephalexin Cefepime Telithromycin Lincomycin derivatives Clindamycin Lincomycin Macrolides Azithromycin Erythromycin Erythromycin Page 13

14 Miscellaneous antibiotics Natural penicillins Penicillinase resistant penicillins Quinolones Rifamycin derivatives Second-generation cephalosporin Clarithromycin Aztreonam Chloramphenicol Dalfopristin-quinupristin Penicillin G benzathineprocaine Penicillin G potassium Erythromycin ethylsuccinate Daptomycin Erythromycinsulfisoxazole Linezolid Penicillin G procaine Penicillin G sodium lactobionate Erythromycin stearate Metronidazole Vancomycin Dicloxacillin Nafcillin Oxacillin Ciprofloxacin Gemifloxacin Rifampin Cefaclor Cefotetan Levofloxacin Moxifloxacin Cefoxitin Cefprozil Sulfonamides Sulfadiazine Sulfamethoxazole-trimethoprim Penicillin V potassium Penicillin G benzathine Norfloxacin Ofloxacin Cefuroxime Tetracyclines Doxycycline Minocycline Tetracycline Third-generation cephalosporins Urinary anti-infectives Cefdinir Cefditoren Cefixime Fosfomycin Nitrofurantoin Nitrofurantoin macrocrystals Cefotaxime Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Nitrofurantoin macrocrystals-monohydrate Trimethoprim Page 14

15 Measure Name: Medication Management for People with Asthma 75% rate (MMA) Methodology: HEDIS Measure Description: The percentage of Members 5 64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. (Treatment Period: The period of time beginning on the Index Prescription Start Date through 12/31/2018.) 1. The percentage of Members who remained on an asthma controller medication for at least 75% of their treatment period Asthma Controller Medications: Description Prescriptions Antiasthmatic combinations Dyphylline-guaifenesin Guaifenesin-theophylline Antibody inhibitors Omalizumab Anti-interleukin-5 Mepolizumab Reslizumab Inhaled steroid combinations Inhaled corticosteroids Budesonide-formoterol Fluticasone-salmeterol Beclomethasone Budesonide Ciclesonide Fluticasone-vilanterol Mometasone-formoterol Flunisolide Fluticasone CFC free Mometasone Leukotriene modifiers Montelukast Zafirlukast Zileuton Mast cell stabilizers Cromolyn Methylxanthines Dyphylline Theophylline Page 15

16 Measure Name: Breast Screening (BCS) Methodology: HEDIS Measure Description: The percentage of women years of age who had a mammogram to screen for breast cancer any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year (2018). Codes used to identify mammography Service Code Type Code Code Description Breast Screening CPT Mammography Unilateral Breast Screening CPT Mammography Bilateral Breast Screening CPT Screening Mammography Bilateral (2-view Film Study Of Each Breast) Breast Screening CPT Digital Breast Tomosynthesis Unilateral Breast Screening CPT Digital Breast Tomosynthesis Bilateral Screening Digital Breast Tomosynthesis Bilateral (list Separately In Addition To Code For Primary Procedure) Breast Screening CPT Breast Screening CPT Breast Screening CPT Breast Screening CPT Breast Screening HCPCS G0202 Breast Screening HCPCS G0204 Breast Screening HCPCS G0206 Diagnostic Mammography W/computeraided Detection; Unilateral Diagnostic Mammography W/computeraided Detection; Bilateral Screening Mammography Bilateral (2-view Film Study Of Each Breast Including Computer-aided Detection (cad) Screening Mammography, Bilateral (2-view Study Of Each Breast), Including Computeraided Detection (cad) When Performed (g0202) Diagnostic Mammography, Including Computer-aided Detection (cad) When Performed; Bilateral (g0204) Diagnostic Mammography, Including Computer-aided Detection (cad) When Performed; Unilateral (g0206) Breast Screening ICD9PCS Xerography Of Breast Breast Screening ICD9PCS Other Mammography Page 16

17 Exclusions: Members who have had a bilateral mastectomy anytime during their history through December 31, 2018 may be excluded. To exclude Members who meet the exclusion criteria, please complete Member Historical Data Form and fax to IEHP s Quality Informatics Team at: A copy of the Historical Data Form is available in Appendix 3 Page 17

18 Measure Name: Screening (CCS) Methodology: HEDIS Measure Description: 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 every 3 years. Women age who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years Codes to Identify Cytology Service Code Type Code Code Description Screening CPT Screening CPT Screening CPT Screening CPT Screening CPT Screening CPT Screening CPT Screening CPT Screening CPT Cytopathology Or Vaginal (any Reporting System) Requiring Interpretation By Physician (List separately In addition to code for technical service.) Cytopathology Or Vaginal (any Reporting System) Collected In Preservative Fluid Automated Thin Layer Preparation Manual screening under physician supervision Cytopathology Or Vaginal (any Reporting System) Collec Ted In Preservative Fluid Automated Thin Layer Preparation; manual screening under physician supervision: With manual screening and rescreening under physician supervision Cytopathology Smears Or Vaginal Screening By Automated System Under Physician Supervision Cytopathology Smears Or Vaginal Screening By Automated System With Manual Rescreening Under Physician Supervision Cytopathology Slides Or Vaginal Manual Screening Under Physician Supervision Cytopathology Slides Or Vaginal With Manual Screening And Computer-assisted Rescreening Under Physician Supervision Cytopathology Slides Or Vaginal With Manual Screening And Rescreening Under Physician Supervision Cytopathology Slides Or Vaginal With Manual Screening And Computer-assisted Rescreening Using Cell Selection And Review under physician supervision Screening CPT Cytopathology Slides Or Vaginal (the Bethesda System) Manual Screening Under Physician Supervision Screening CPT Cytopathology Slides Or Vaginal (the Bethesda System) With Manual Screening And Rescreening Under Physician Supervision CPT Cytopathology Slides Or Vaginal (the Bethesda System) Page 18

19 Screening Screening CPT Screening CPT Screening CPT Screening HCPCS G0123 Screening HCPCS G0124 Screening HCPCS G0141 Screening HCPCS G0143 Screening HCPCS G0144 Screening HCPCS G0145 Screening HCPCS G0147 Screening HCPCS G0148 Screening HCPCS P3000 Screening HCPCS P3001 With Manual Screening And Computer-assisted Rescreening Under Physician supervision Cytopathology Slides Or Vaginal (the Bethesda System) With Manual Screening And Computer-assisted Rescreening Using cell selection and review under physician supervision Cytopathology Or Vaginal (any Reporting System) Collected In Preservative Fluid Automated Thin Layer Preparation Cytopathology Or Vaginal (any Reporting System) Collected In Preservative Fluid Screening Automated By System Screening Cytopathology, Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, Screening By Cytotechnologist Under Physician Supervision (g0123) Screening Cytopathology, Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, Requiring Interpretation By Physician (g0124) Screening Cytopathology Smears, Or Vaginal, Performed By Automated System, With Manual Rescreening, Requiring Interpretation By Physician (g0141) Screening Cytopathology, Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, With Manual Screening And Rescreening By Cytotechnologist Under Physician Supervision (g0143) Screening Cytopathology, Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, With Screening By Automated System, Under Physician Supervision (g0144) Screening Cytopathology, Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, With Screening By Automated System And Manual Rescreening Under Physician Supervision (g0145) Screening Cytopathology Smears, Or Vaginal, Performed By Automated System Under Physician Supervision (g0147) Screening Cytopathology Smears, Or Vaginal, Performed By Automated System With Manual Rescreening (g0148) Screening Papanicolaou Smear, Or Vaginal, Up To Three Smears, By Technician Under Physician Supervision (p3000) Screening Papanicolaou Smear, Or Vaginal, Up To Three Smears, Requiring Interpretation By Physician (p3001) Screening Papanicolaou Smear; Obtaining, Preparing And Conveyance Of Or Vaginal Smear To Laboratory (q0091) Screening HCPCS Q0091 Screening LOINC Microscopic Observation [identifier] In Cervix By Cyto Stain LOINC Microscopic Observation [identifier] In Cervix By Cyto Stain.thin Page 19

20 Prep Screening Screening LOINC General Categories [interpretation] Of Or Vaginal Smear Or Scraping By Cyto Stain Screening LOINC Statement Of Adequacy [interpretation] Of Or Vaginal Smear Or Scraping By Cyto Stain Screening LOINC Microscopic Observation [identifier] In Or Vaginal Smear Or Scraping By Cyto Stain Screening LOINC Microscopic Observation [identifier] In Or Vaginal Smear Or Scraping By Cyto Stain Narrative Screening LOINC Cytology Study Comment Or Vaginal Smear Or Scraping Cyto Stain Screening LOINC Cytology Or Vaginal Smear Or Scraping Study Screening LOINC Screening LOINC Cytology Report Of Or Vaginal Smear Or Scraping Cyto Stain.thin Prep Cytology Report Of Or Vaginal Smear Or Scraping Cyto Stain Codes to Identify HPV Tests Service Code Type Code Code Description Screening CPT Screening CPT Screening CPT Screening CPT Screening CPT Screening HCPCS G0476 Screening LOINC Infectious Agent Detection By Nucleic Acid (dna Or Rna) Papillom Avirus Human Direct Probe Technique Infectious Agent Detection By Nucleic Acid (dna Or Rna) Papillom Avirus Human Amplified Probe Technique Infectious Agent Detection By Nucleic Acid (dna Or Rna) Papillom Avirus Human Quantification Infectious Agent Detection By Nucleic Acid (dna Or Rna) Human Pap Illomavirus (hpv) High-risk Types (eg ) Infectious Agent Detection By Nucleic Acid (dna Or Rna) Human Pap Illomavirus (hpv) Types 16 And 18 Only Includes Type 45, If Performed Infectious Agent Detection By Nucleic Acid (dna Or Rna); Human Papillomavirus (hpv), High-risk Types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) For Screening, Must Be Performed In Addition To Pap Test (g0476) Human Papilloma Virus Dna [presence] In Cervix By Dna Probe Page 20

21 Screening LOINC Screening LOINC Screening LOINC Screening LOINC Screening LOINC Screening LOINC Screening LOINC Screening LOINC Screening LOINC Screening LOINC Screening LOINC Screening LOINC Screening LOINC Screening LOINC Human Papilloma Virus Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus 16 Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus 18 Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus E6+e7 Mrna [presence] In Cervix By Probe And Target Amplification Method Human Papilloma Virus Dna [presence] In Cervix By Probe And Target Amplification Method Human Papilloma Virus E6+e7 Mrna [presence] In Cervix By Probe And Target Amplification Method Human Papiloma Virus 16 And 18 And Dna [interpretation] In Cervix Human Papilloma Virus 16 Dna [presence] In Cervix By Probe And Target Amplification Method Human Papilloma Virus 18 Dna [presence] In Cervix By Probe And Target Amplification Method Human Papilloma Virus 16 And E6+e7 Mrna [identifier] In Cervix By Probe And Target Amplification Method Human Papilloma Virus 16 E6+e7 Mrna [presence] In Cervix By Probe And Target Amplification Method Human Papilloma Virus Dna [presence] In Cervix By Probe And Target Amplification Method Exclusions: Members whom have had a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix any time during their history through December 31, 2018 may be excluded To exclude Members who meet the exclusion criteria, please complete Member Historical Data Form and fax to IEHP s Quality Informatics Team at: A copy of the Historical Data Form is available in Appendix 3 Page 21

22 Measure Name: Childhood Immunizations (CIS) Combo 10 Methodology: HEDIS Measure Description: The percentage of Children 2 years of age 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 (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and two separate combination rates. Combo 10 includes the timely completion of the following antigens: o DTaP; IPV; MMR; HiB; HepB; VZV; PCV; HepA; Rotavirus; Flu Page 22 Childhood Immunization Code Set Antigen Code Type Code Code Description DTaP CPT Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And Hemophilus Influenza B Vaccine and activated poliovirus vaccine, (DTaP-IPV/Hib), for intramuscular use DTaP CPT Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine (dta P) For Intramuscular Use DTaP CPT Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And Hemophilus Influenza B Vaccine (dtap-hib) For Intramuscular Use DTaP CPT Diphtheria Tetanus Toxoids Acellular Pertussis Vaccine Hepatitis B, and Inactivated poliovirus vaccine (dtap-hepb-ipv), For Intramuscular use IPV CPT Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And Hemophilus Influenza B Vaccine and activated poliovirus vaccine, (DTaP-IPV/Hib), for intramuscular use IPV CPT Poliovirus Vaccine Inactivated (ipv) For Subcutaneous Use IPV CPT Diphtheria Tetanus Toxoids Acellular Pertussis Vaccine Hepatitis B, and Inactivated poliovirus vaccine (dtap-hepb-ipv), For Intramuscular use MMR CPT Measles Mumps And Rubella Virus Vaccine (mmr) Live For Subcuta Neous Use

23 MMR CPT HiB CPT HiB CPT HiB CPT HiB CPT HiB CPT HiB CPT HiB CPT HiB CPT HepB CPT HepB CPT HepB CPT HepB CPT Measles Mumps Rubella And Varicella Vaccine (mmrv) Live For Subcutaneous Use Meningococcal Conjugate Vaccine, Serogroups C & Y And Hemophilus Influenzae Type B Vaccine (hib-mency), 4 dose schedule, When Administered to children 6 wks to 18 mos of age, for intramuscular use Hemophilus Influenza B Vaccine (hib) Hboc Conjugate (4 Dose Sche Dule) For Intramuscular Use Hemophilus Influenza B Vaccine (hib) Prp-d Conjugate For Booster Use Only Intramuscular Use Hemophilus Influenza B Vaccine (hib) Prp-omp Conjugate (3 Dose S Chedule) For Intramuscular Use Hemophilus Influenza B Vaccine (hib)prp-t Conjugate (4 Dose Sche Dule) For Intramuscular Use Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And Hemophilus Influenza B Vaccine and activated poliovirus vaccine, (DTaP-IPV/Hib), for intramuscular use Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And Hemophilus Influenza B Vaccine (dtap-hib) For Intramuscular Use Hepatitis B And Hemophilus Influenza B Vaccine (hepb-hib) For In Tramuscular Use Diphtheria Tetanus Toxoids Acellular Pertussis Vaccine Hepatitis B, and Inactivated poliovirus vaccine (dtap-hepb-ipv), For Intramuscular use Hepatitis B Vaccine Dialysis Or Immunosuppressed Patient Dosage (3 Dose Schedule) For Intramuscular Use Hepatitis B Vaccine Pediatric/adolescent Dosage (3 Dose Schedule ) For Intramuscular Use Hepatitis B Vaccine Dialysis Or Immunosuppressed Patient Dosage (4 Dose Schedule) For Intramuscular Use Page 23

24 HepB CPT HepB HCPCS G0010 VZV CPT VZV CPT PCV CPT PCV CPT PCV HCPCS G0009 HepA CPT Rotavirus - 2 Dose CPT Rotavirus - 3 Dose CPT Flu CPT Flu CPT Flu CPT Flu CPT Flu CPT Flu CPT Flu CPT Hepatitis B And Hemophilus Influenza B Vaccine (hepb-hib) For In Tramuscular Use Administration Of Hepatitis B Vaccine (g0010) Measles Mumps Rubella And Varicella Vaccine (mmrv) Live For Subcutaneous Use Varicella Virus Vaccine Live For Subcutaneous Use Pneumococcal Conjugate Vaccine Polyvalent For Children Under Five Years For Intramuscular Use Pneumococcal Conjucate Vaccine 13 Valent For Intramuscular Use Administration Of Pneumococcal Vaccine (g0009) Hepatitis A Vaccine Pediatric/adolescent Dosage-2 Dose Schedule For Intramuscular Use Rotavirus Vaccine Human Attenuated 2 Dose Schedule Live For Oral Use. Rotavirus Vaccine Tetravalent Live For Oral Use Flu Virus Vaccine, Trivalent (iiv3), Split Virus, Preservative Free, 0.25ml Dosage, For Intramuscular Use Influenza Virus Vaccine Split Virus For Children 6-35 Months Of Age For Intramuscular Use Influenza Virus Vaccine Derived From Cell Cultures Subunit Preservative And Antibiotic Free For Intramuscular Use Influenza Virus Vaccine Split Virus Preservative Free Enhanced Immunogenicity Via Increased Antigen Content, For Intramuscular use Influenza Virus Vaccine Trivalent Derived From Recombinant Dna (r Iv3) Hemagglutinin (ha) Protein Only Preservative And Antibiotic Influenza Virus Vaccine Quadrivalent (II4V) Split Virus preservative free, 0.25 ml dosage, for Intramuscular use Influenza Virus Vaccine Quadrivalent (II4V) Split Virus preservative free, 0.5 ml dosage, for Page 24

25 Flu CPT Flu CPT Flu HCPCS G0008 Intramuscular use Influenza Virus Vaccine Quadrivalent (II4V) Split Virus, 0.25 ml dosage, for Intramuscular use Influenza Virus Vaccine Quadrivalent (II4V) Split Virus, 0.5 ml dosage, for Intramuscular use Administration Of Influenza Virus Vaccine (g0008) Page 25

26 Measure Name: Comprehensive Diabetes Care (CDC) HbA1c Control (<8.0) Methodology: HEDIS Measure Description: The percentage of Members years of age with diabetes (type 1 and type 2) who had the following: HbA1c Control (<8.0%) This includes diabetics whose most recent HbA1c test during the measurement year (2018) has a value <8.0%. o The Member is not numerator compliant if the result for the most recent HbA1c test is >8.0% or is missing a result, or if an HbA1c test was not done during the measurement year (2018). Codes to Identify HbA1c Tests Service Code Type Code Code Description HbA1c Test (<7.0%) CPT-CAT-II 3044F Hg A1c Level Lt 7.0% HbA1c Test CPT Hemoglobin Glycated HbA1c Test CPT Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use HbA1c Test CPT-CAT-II 3044F Most recent hemoglobin A1c (HbA1c) level < 7.0% HbA1c Test CPT-CAT-II 3045F Most recent hemoglobin A1c (HbA1c) level % HbA1c Test CPT-CAT-II 3046F Most recent hemoglobin A1c (HbA1c) level > 9.0% HbA1c Test LOINC Hemoglobin A1c/hemoglobin.total In Blood By Hplc HbA1c Test LOINC Hemoglobin A1c/hemoglobin.total In Blood HbA1c Test LOINC Hemoglobin A1c/hemoglobin.total In Blood By Electrophoresis Page 26

27 Measure Name: Comprehensive Diabetes Care (CDC) Eye Exam Methodology: HEDIS Measure Description: The percentage of Members years of age with diabetes (type 1 and type 2) who had the following: Eye Exam (retinal) performed This includes diabetics who had one of the following: o A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year (2018) o A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year (2018) Codes to Identify Eye Exams Code Service Type Code Code Description Diabetic Retinal Screening CPT Intravitreal Injection Of A Pharmacologic Agent (separate Procedure) Diabetic Retinal Screening CPT Discission Of Vitreous Strands (without Removal) Pars Plana Approach Diabetic Retinal Screening CPT Severing Of Vitreous Strands Vitreous Face Adhesions Sheets Membranes Or Opacities Laser Surgery (one Or More Stages) Diabetic Retinal Screening CPT Vitrectomy Mechanical Pars Plana Approach Diabetic Retinal Screening CPT Vitrectomy Mechanical Pars Plana Approach With Focal Endolaser Photocoagulation Diabetic Retinal Screening CPT Vitrectomy Mechanical Pars Plana Approach With Endolaser Panre Tinal Photocoagulation Diabetic Retinal Screening CPT Vitrectomy Mechanical Pars Plana Approach With Removal Of Preretinal Cellular Membrane (eg Macular Pucker) Diabetic Retinal Screening CPT Vitrectomy Mechanical Pars Plana Approach With Removal Of Internal Limiting Membrane Of Retina (eg For Repair Of Macular Hole Diabetic Retinal Screening CPT Vitrectomy mechanical pars plana approach, with removal of subretinal membrane (eg, Choroidal Neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) Diabetic Retinal Screening CPT Repair Retinal Detachment, Incld Drainage Of Subretinal Fluid When Performed; Cryotherapy Diabetic Retinal Screening CPT Repair Retinal Detachment, Incld Drainage Of Subretinal Fluid When Performed; Photocoagulation Diabetic Retinal Screening CPT Repair Of retinal detachment scleral buckling (such as lamellar scleral dissection, Imbrication or encircling procedure), including, when performed, implant, cryotherapy, photocoagulation, and drainage of subretinal fluid Diabetic Retinal Screening CPT Repair Of Retinal Detachment With Vitrectomy Any Method With OR Without Air Or Gas Tamponade Focal Endolaser Photocoagulation Diabetic Retinal Screening CPT Repair Of Retinal Detachment By Injection Of Air Or Page 27

28 Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Page 28 Other Gas (e G Pneumatic Retinopexy) Repair Of Retinal Detachment By Scleral Buckling Or Vitrectomy On Patient Having Previous Ipsilateral Retinal Detachment Repair Repair Of Complex Retinal Detachment (eg, Proliferative Vitreoretinopathy Stage C-1 or greater, diabetic Traction Retinal Detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, including, when performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens Removal Of Implanted Material Posterior Segment Intraocular Prophylaxis Of Retinal Detachment (eg, retinal break lattice degeneration) without drainage, 1 or more sessions; cryotherapy, diathermy Prophylaxis Of Retinal Detachment (eg, retinal break lattice degeneration) without drainage, 1 or more sessions; photocoagulation (laser or xenon arc) Destruction Of Localized Lesion Of Retina (eg Macular Edema Tumors) One Or More Sessions Cryotherapy Diathermy Destruction Of Localized Lesion Of Retina (eg Macular Edema Tumors) One Or More Sessions Photocoagulation Destruction Of Localized Lesion Of Retina (eg Macular Edema Tumors) One Or More Sessions Radiation By Implantation Of Source ( Destruction Of Localized Lesion Of Choroid (eg Choroidal Neovasc Ularization) Photocoagulation (eg Laser) One Or More Sessions Destruction Of Localized Lesion Of Choroid (eg Choroidal Neovasc Ularization) Photodynamic Therapy (includes Intravenous Infusion Destruction Of Extensive Or Progressive Retinopathy (eg Diabetic Retinopathy) One Or More Sessions Cryotherapy Diathermy Destruction of extensive or progressive retinopathy (eg, Diabetic Retinopathy), 1 or more sessions; Photocoagulation Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; Intermediate, new patient Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits Ophthalmological services: medical examination and evaluation with initiation or continuation of diagnostic and treatment program; intermediate, established patient

29 Diabetic Retinal Screening CPT Ophthalmological services: medical examination and evaluation with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits Diabetic Retinal Screening CPT Ophthalmological examination and evaluation under general anesthesia with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete Diabetic Retinal Screening CPT Ophthalmological examination and evaluation under general anesthesia with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; limited Diabetic Retinal Screening CPT Scanning computerized ophthalmic diagnostic imaging posterior segment, with interpretation and report, unilateral or bilateral: optic nerve Diabetic Retinal Screening CPT Ophthalmoscopy extended with retinal drawing (eg, for retinal detachment melanoma), with Interpretation and report; initial Diabetic Retinal Screening CPT Ophthalmoscopy Extended With Retinal Drawing (eg For Retinal Detachment Melanoma) With Interpretation And Report Subsequent Diabetic Retinal Screening CPT Remote imaging for detection of retinal disease (eg, Retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral Diabetic Retinal Screening CPT Remote imaging for monitoring and management of active retinal disease (eg, Diabetic Retinopathy) with physician review, interpretatation and report, unilateral or bilateral Diabetic Retinal Screening CPT Fluorescein Angioscopy With Interpretation And Report Diabetic Retinal Screening CPT Fluorescein Angiography (includes Multiframe Imaging) With Interpretation And Report (unilateral Or Bilateral) Diabetic Retinal Screening CPT Indocyanine-green Angiography (includes Multiframe Imaging) With Interpretation And Report (unilateral Or Bilateral) Diabetic Retinal Screening CPT Fundus Photography With Interpretation And Report Diabetic Retinal Screening CPT Ophthalmodynamometry Diabetic Retinal Screening CPT Office or other patient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history: A detailed exam: Medical decision making of low complexity. Diabetic Retinal Screening CPT Office or other patient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history: A comprehensive exam: Medical decision making of moderate complexity. Diabetic Retinal Screening CPT Office or other patient visit for the evaluation and management of a new patient, which requires these 3 Page 29

30 Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening HCPCS S0620 Diabetic Retinal Screening HCPCS S0621 Diabetic Retinal Screening HCPCS S3000 key components: A comprehensive history: A comprehensive exam: Medical decision making of high complexity. Office or other patient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components: An expanded problem focused history: An expanded problem focused examination: Medical decision making of low complexity. Office or other patient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components: A detailed history: A detailed exam: Medical decision making of moderate complexity. Office or other patient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components: A comprehensive history: A comprehensive exam: Medical decision making of high complexity. Office consultation for a new or established patient which requires these 3 key components: An expanded problem focused history: An expanded problem focused examination: and, Straightforward medical decision making. Office consultation for a new or established patient which requires these 3 key components: A detailed history: A detailed exam: and, Medical decision making of low complexity. Office consultation for a new or established patient which requires these 3 key components: A comprehensive history: A comprehensive examination: and, Medical decision making of moderate complexity. Office consultation for a new or established patient which requires these 3 key components: A comprehensive history: A comprehensive examination: and, Medical decision making of high complexity. Routine Ophthalmological Examination Including Refraction; New Patient (s0620) Routine Ophthalmological Examination Including Refraction; Established Patient (s0621) Diabetic Indicator; Retinal Eye Exam, Dilated, Bilateral (s3000) Page 30

31 Measure Name: Immunizations for Adolescents (IMA) Methodology: HEDIS Measure Description: The percentage of Adolescents 13 years of age who had one dose of meningococcal conjugate vaccine, one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine and three doses of the human papillomavirus (HPV) vaccine on or before their 13th birthday. The measure calculates a rate for each vaccine and a combination rate. At least one dose of meningococcal conjugate vaccine on or between the member s 11 th and 13 th birthdays At least one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine on or between the member s 11 th and 13 th birthdays At least two or three doses of the human papillomavirus (HPV) vaccine on or between the member s 9 th and 13 th birthdays; there must be at least 146 days between the first and second dose of the HPV vaccine Codes to Identify Meningococal Antigen Code Type Code Code Description Meningococcal conjugate CPT Meningococcal Conjugate Vaccine Serogroups A, C, Y and W-135, quadrivalent (MCV4 or MenACWY), for Intramuscular use Codes to Identify Tdap Code Antigen Code Type Tdap CPT Code Description Tetanus Diphtheria Toxoids And Acellular Pertussis Vaccine (Tdap) when Administered To Individuals 7 Years Or Older For Intramuscular Use Page 31

32 Codes to Identify HPV Code Antigen Code Type HPV CPT HPV CPT HPV CPT Code Description Human Papilloma Virus (hpv) Vaccine Types quadrivalent (4vHPV), 3 dose schedule, for intramuscular use Human Papilloma Virus (hpv) Vaccine Types 16, 18 bivalent (2vHPV) 3 dose schedule, for intramuscular use Human Papilloma Virus Vaccine , nonavalent (9vHPV) 3 dose schedule, for intramuscular use Page 32

33 Measure Name: Postpartum Care (PPC) Methodology: HEDIS Measure Description: The percentage of deliveries of live births on or between November 6, 2017 and November 5, 2018 that had a postpartum visit on or between 21 and 56 days after delivery. Codes to Identify Postpartum Care Service Code Type Code Code Description Postpartum Care CPT Diaphragm Or Cap Fitting With Instructions Postpartum Care CPT Insertion Of Intrauterine Device (iud) Postpartum Care CPT Postpartum Care Only (separate Procedure) Postpartum Care CPT Home Visit Postnatal Postpartum Care CPT-CAT- II 0503F Postpartum Care Visit Postpartum Care HCPCS G0101 Or Vaginal Screening; Pelvic And Clinical Breast Examination (g0101) Postpartum Care ICD10CM Z [z01.411] Encounter For Gynecological Examination (general) (routine) With Abnormal Findings Postpartum Care ICD10CM Z [z01.419] Encounter For Gynecological Examination (general) (routine) Without Abnormal Findings Postpartum Care ICD10CM Z01.42 [z01.42] Encounter For Smear To Confirm Findings Of Recent Normal Smear Following Initial Abnormal Smear Postpartum Care ICD10CM Z [z30.430] Encounter For Insertion Of Intrauterine Contraceptive Device Postpartum Care ICD10CM Z39.1 [z39.1] Encounter For Care And Examination Of Lactating Mother Postpartum Care ICD10CM Z39.2 [z39.2] Encounter For Routine Postpartum Follow-up Postpartum Care HCPCS Z1038 Postpartum Follow-Up Office Visit Page 33

34 Measure Name: Timeliness of Prenatal Care (PPC) Methodology: HEDIS Measure Description: The percentage of deliveries of live births on or between November 6, 2017 and November 5, 2018 that received a prenatal care visit as a Member of the organization in the first trimester, on the enrollment start date or within 42 days of enrollment in the organization. Codes to Identify Stand Alone Prenatal Visits Service Code Type Code Code Description Prenatal Visit CPT 0500F Initial Prenatal Care Visit Prenatal Visit CPT 0501F Prenatal Flow Sheet Prenatal Visit CPT 0502F Subsequent Prenatal Care Visit Prenatal Visit CPT Home Visit Prenatal Prenatal Visit HCPCS H1000 Prenatal Care, At-risk Assessment Prenatal Visit HCPCS H1001 Prenatal Care, At-risk Enhanced Service; Antepartum Management Prenatal Visit HCPCS H1002 Prenatal Care, At Risk Enhanced Service; Care Coordination Prenatal Visit HCPCS H1003 Prenatal Care, At-risk Enhanced Service; Education Prenatal Visit HCPCS H1004 Prenatal Care, At-risk Enhanced Service; Follow-up Home Visit Prenatal Visit HCPCS Z1032 Initial Antepartum Office Visit Prenatal Visit HCPCS Z1034 Antepartum Follow-Up Visit Prenatal care visit to an OB/GYN or other prenatal care practitioner or PCP. For visits to a PCP, a diagnosis of pregnancy must be present. Documentation in the medical record must include a note indicating the date when the prenatal care visit occurred, and evidence of one of the following. A basic physical obstetrical examination that includes auscultation for fetal heart tone, or pelvic exam with obstetric observations, or measurement of fundus height (a standardized prenatal flow sheet may be used). Evidence that a prenatal care procedure was performed, such as: Screening test in the form of an obstetric panel (must include all of the following: hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO blood typing), or TORCH antibody panel alone, or A rubella antibody test/titer with an Rh incompatibility (ABO/Rh) blood typing, or Echography of a pregnant uterus. Documentation of LMP or EDD in conjunction with either of the following. Prenatal risk assessment and counseling/education. Complete obstetrical history. Page 34

35 Measure Name: life (W34) Methodology: HEDIS Measure Description: The percentage of Members 3 6 years of age who had one or more well-child visits with a PCP during the measurement year (2018). Codes to Identify Well-Child Visits NOTE: These codes must be provided by a Primary Care Provider in an office setting. Service Life CPT Life CPT Life CPT Life CPT Life CPT Life CPT Life CPT Code Type Code Code Description Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient: infant (age younger than 1 year) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient: early childhood (age 1 through 4 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient: late childhood (age 5 through 11 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient: adolescent (age 12 through 17 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient: (age 18 through 39 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years) Page 35

36 Life CPT Life CPT Life CPT Life CPT Life HCPCS G0438 Life HCPCS G0439 ICD10C Life M Z00.00 Life Life Life Life Life Life Life Life ICD10C M Z00.01 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; (age 18 through 39 years) Initial Care Per Day For Evaluation And Management Of Normal Ne Wborn Infant Seen In Other Than Hospital Or Birthing Center Annual Wellness Visit; Includes A Personalized Prevention Plan Of Service (pps), Initial Visit (g0438) Annual Wellness Visit, Includes A Personalized Prevention Plan Of Service (pps), Subsequent Visit (g0439) Encounter For General Adult Medical Examination Without Abnormal Findings Encounter For General Adult Medical Examination With Abnormal Findings ICD10C M Z Health Examination For Newborn Under 8 Days Old ICD10C M Z Health Examination For Newborn 8 To 28 Days Old ICD10C M Z ICD10C M Z Encounter For Routine Child Health Examination With Abnormal Findings Encounter For Routine Child Health Examination Without Abnormal Findings ICD10C M Z00.5 Encounter For Examination Of Potential Donor Of Organ And Tissue ICD10C M Z00.8 Encounter For Other General Examination ICD10C M Z02.0 Encounter For Examination For Admission To Educational Institution Page 36

37 Life Life Life Life Life Life Life Life Life Life Life Life Life ICD10C M Z02.1 Encounter For Pre-employment Examination ICD10C M Z02.2 Encounter For Examination For Admission To Residential Institution ICD10C M Z02.3 Encounter For Examination For Recruitment To Armed Forces ICD10C M Z02.4 Encounter For Examination For Driving License ICD10C M Z02.5 Encounter For Examination For Participation In Sport ICD10C M Z02.6 Encounter For Examination For Insurance Purposes ICD10C M Z02.71 Encounter For Disability Determination ICD10C M Z02.79 Encounter For Issue Of Other Medical Certificate ICD10C M Z02.81 Encounter For Paternity Testing ICD10C M Z02.82 Encounter For Adoption Services ICD10C M Z02.83 Encounter For Blood-alcohol And Blood-drug Test ICD10C M Z02.89 Encounter For Other Administrative Examinations ICD10C M Z02.9 Encounter For Administrative Examinations, Unspecified Life ICD9CM V20.2 Routine Infant Or Child Health Check Life ICD9CM V20.31 Health Supervision For Newborn Under 8 Days Old Life ICD9CM V20.32 Health Supervision For Newborn 8 To 28 Days Old Life ICD9CM V70.0 Routine General Medical Examination At A Health Care Facility Page 37

38 Life ICD9CM V70.3 Other General Medical Examination For Administrative Purposes Life ICD9CM V70.5 Health Examination Of Defined Subpopulations Life ICD9CM V70.6 Health Examination In Population Surveys Life ICD9CM V70.8 Other Specified General Medical Examinations Life ICD9CM V70.9 Unspecified General Medical Examination Page 38

39 Measure Name: Initial Health Assessment (IHA) Methodology: IEHP-Defined Compliance Metric Measure Description: The IHA is a comprehensive assessment that is completed during the Member s initial encounter with a Primary Care Physician (PCP), appropriate Medical Specialist, or Non-Physician Medical Provider and must be documented in the Member s medical record. The IHA enables the Member s PCP to assess and manage the acute, chronic and preventive health needs of the Member. IEHP provides PCPs a monthly detailed Member roster on the IEHP Provider portal for all newly enrolled IEHP Members who are due for an initial health assessment (IHA) 120 days of enrollment. Eligible population is newly assigned Members with IEHP effective enrollment date of 1/1/18 through 12/31/18. Initial Health Assessment must be provided within 120 days of enrollment (e.g., Member enrolled in December 2018 must be seen by April 2019 and PCP must submit encounter by May 2019) Codes to Identify IHA Visits Code Code Type Description CPT Office/Outpt E&M New Minor CPT Office/Outpt E&M New Low-Mod CPT Office/Outpt E&M New Mod Seve CPT Office/Outpt E&M New Mod-Hi CPT Office/Outpt E&M New Mod-Hi CPT Office/Outpt E&M Estab 5 Min CPT Office/Outpt E&M Estab Minor CPT Office/Outpt E&M Estab Low-Mo CPT Office/Outpt E&M Estab Mod-Hi CPT Office/Outpt E&M Estab Mod-Hi CPT Office Cons New/Estab Minor CPT Office Cons New/Est Lo Sever CPT Office Cons New/Estab Mod CPT Office Cons New/Estab Mod-Hi CPT Office Cons New/Estab Mod-Hi CPT Nursing Facility Care Init CPT Nursing Facility Care Init CPT Nursing Facility Care Init CPT Nursing Fac Care Subseq CPT Nursing Fac Care Subseq CPT Nursing Fac Care Subseq CPT Nursing Fac Care Subseq CPT Nurs Facil D/C Da Mgmt; 30 M CPT Nurs Facil D/C Da Mgmt; > 30 Page 39

40 99318 CPT Annual Nursing Fac Assessmnt CPT Domicil/R-Home Visit New Pat CPT Domicil/R-Home Visit New Pat CPT Domicil/R-Home Visit New Pat CPT Domicil/R-Home Visit New Pat CPT Domicil/R-Home Visit New Pat CPT Domicil/R-Home Visit Est Pat CPT Domicil/R-Home Visit Est Pat CPT Domicil/R-Home Visit Est Pat CPT Domicil/R-Home Visit Est Pat CPT Home Visit E&M New Pt Lo Sev CPT Home Visit E&M New Pt Mod Se CPT Home Visit E&M New Pt Mod-Hi CPT Home Visit E&M New Pt Hi Sev CPT Home Visit E&M New Pt Unstbl CPT Home Visit E&M Estab Minor CPT Home Visit E&M Estab Low-Mod CPT Home Visit E&M Estab Mod-Hi CPT Home Visit E&M Estab Mod-Hi CPT Prolong Md Serv Outpt W/Pt; CPT Prolong Md Serv Outpt W/Pt; CPT Init Preven Meds E&M New Pt; CPT Init Preven Meds E&M New Pt; CPT Init Preven Meds E&M New Pt; CPT Init Preven Meds E&M New Pt; CPT Init Preven Meds E&M New Pt; CPT Init Preven Meds E&M New Pt; CPT Init Preven Meds E&M New Pt; CPT Preven Meds E&M Estab Pt; In CPT Preven Meds E&M Estab Pt; CPT Preven Meds E&M Estab Pt; CPT Preven Meds E&M Estab Pt; CPT Preven Meds E&M Estab Pt; CPT Preven Meds E&M Estab Pt; CPT Preven Meds E&M Estab Pt; CPT Preven Med Counsl (Sep Pro); CPT Preven Med Counsl (Sep Pro); CPT Preven Med Counsl (Sep Pro); CPT Preven Med Counsl (Sep Pro); CPT Preven Med Counsl Grp (Sep P CPT Preven Med Counsl Grp (Sep P CPT Admin/Intrpt Health Risk Ass CPT Unlisted Preven Meds Serv Page 40

41 99444 CPT Online E/M By Phys CPT Interprof Phone/Online CPT Interprof Phone/Online CPT Interprof Phone/Online CPT Interprof Phone/Online 31/> CPT Basic Life &/Or Disability E CPT Work Relat/Disabl Exam-Treat CPT Work Relat/Disabl Exam-Not T G0402 HCPCS Initial Preventive Exam G0438 HCPCS Ppps Initial Visit G0439 HCPCS Ppps Subseq Visit G0463 HCPCS Hospital Outpt Clinic Visit T1015 HCPCS Clinic Service Z00.00 ICD10CM Encntr For General Adult Z00.01 ICD10CM Encounter For General Ad Z ICD10CM Encounter For Routine Ch Z ICD10CM Encntr For Routine Child Z00.5 ICD10CM Encounter For Exam Of Po Z00.8 ICD10CM Encounter For Other Gene Z02.0 ICD10CM Encounter For Exam For A Z02.1 ICD10CM Encounter For Pre-Employ Z02.2 ICD10CM Encounter For Exam For A Z02.3 ICD10CM Encounter For Examinatio Z02.4 ICD10CM Encounter For Examinatio Z02.5 ICD10CM Encounter For Examinatio Z02.6 ICD10CM Encounter For Examinatio Z02.71 ICD10CM Encounter For Disability Z02.79 ICD10CM Encounter For Issue Of O Z02.81 ICD10CM Encounter For Paternity Z02.82 ICD10CM Encounter For Adoption S Z02.83 ICD10CM Encounter For Blood-Alco Z02.89 ICD10CM Encounter For Other Admi Z02.9 ICD10CM Encounter For Administra Page 41

42 Measure Name: Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (WCC) Methodology: HEDIS Measure Description: 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 the following during the measurement year (2018). Report each of the three indicators below. BMI percentile documentation*. Counseling for nutrition. Counseling for physical activity. * Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value. Codes to Identify BMI Percentile Code Code Type Description Z68.51 ICD10 Body Mass Index (BMI) Pediatric, Less Than 5th Percentile For Age Z68.52 ICD10 Body Mass Index (BMI) Pediatric, 5th Percentile To Less Than 85th Percentile For Age Z68.53 ICD10 Body Mass Index (BMI) Pediatric, 85th Percentile To Less Than 95th Percentile For Age Z68.54 ICD10 Body Mass Index (BMI) Pediatric, Greater Than Or Equal To 95th Percentile For Age V85.51 ICD9 Body Mass Index, Pediatric, Less Than 5th Percentile For Age V85.52 ICD9 Body Mass Index, Pediatric, 5th Percentile To Less Than 85th Percentile For Age V85.53 ICD9 Body Mass Index, Pediatric, 85th Percentile To Less Than 95th Percentile For Age V85.54 ICD9 Body Mass Index, Pediatric, Greater Than Or Equal To 95th Percentile For Age Page 42

43 Codes to Identify Counseling for Nutrition Code Code Type Description CPT Medical Nutrition Therapy Initial Assessment And Intervention Individual Face-to-face With The Patient Each 15 Minutes CPT Medical Nutrition Therapy Re-assessment And Intervention Individual Face-to-face With The Patient Each 15 Minutes CPT Medical Nutrition Therapy Group (2 Or More Individual(s)) Each 30 Minutes G0270 HCPCS Medical Nutrition Therapy; Reassessment And Subsequent Intervention(s) Following Second Referral In Same Year For Change In Diagnosis, Medical Condition Or Treatment Regimen (including Additional Hours Needed For Renal Disease), Individual, Face To Face G0271 HCPCS Medical Nutrition Therapy, Reassessment And Subsequent Intervention(s) Following Second Referral In Same Year For Change In Diagnosis, Medical Condition, Or Treatment Regimen (including Additional Hours Needed For Renal Disease), Group (2 Or More Individuals) G0447 HCPCS Face-to-face Behavioral Counseling For Obesity, 15 Minutes (G0447) S9449 HCPCS Weight Management Classes, Non-physician Provider, Per Session (S9449) S9452 HCPCS Nutrition Classes, Non-physician Provider, Per Session (S9452) S9470 HCPCS Nutritional Counseling, Dietitian Visit (S9470) Z71.3 ICD10 Dietary Counseling And Surveillance Codes to Identify Counseling for Physical Activity Code Code Type Description G0447 HCPCS Face-to-face Behavioral Counseling For Obesity, 15 Minutes S9451 HCPCS Exercise Classes, Non-physician Provider, Per Session Z02.5 ICD10 Encounter For Examination For Participation In Sport Z71.82 ICD10 Exercise Counseling Exclusions: Female members who have a diagnosis of pregnancy during the measurement year (2018) are excluded. A diagnosis of pregnancy will be determined using claims and encounter data only. Page 43

44 Measure Name: Concurrent Use of Opioids and Benzodiazepines Methodology: IEHP-Defined Compliance Metric Measure Description: The Concurrent Use of Opioids and Benzodiazepines measure specification is developed and maintained by the Pharmacy Quality Alliance (PQA). This measure examines the percentage of individuals 18 years and older with concurrent use of prescription opioids and benzodiazepines. The denominator includes individuals 18 years and older by the first day of the measurement year with 2 or more prescription claims for opioids filled on 2 or more separate days, for which the sum of the days supply is 15 or more days during the measurement period. The numerator includes individuals from the denominator with 2 or more prescription claims for benzodiazepines filled on 2 or more separate days, and concurrent use of opioids and benzodiazepines for 30 or more cumulative days. Exclusion: Patients in hospice care and those with a cancer diagnosis are excluded. Page 44

45 Behavioral Health Integration Domain Measure Name: Screening for Clinical Depression in Primary Care Methodology: IEHP-defined Quality Metric Modified from PQRS measure (NQF 0418) Measure Description: The percentage of Members aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool during the measurement year (2018). Denominator: All Members aged 12 years and older with a Primary Care Provider (PCP) visit in the measurement year. Member counted only once in the denominator Primary Care Provider Visit Codes: Code Type Code Code Description Service Screening for Clinical Depression in Primary Care CPT Psychiatric diagnostic evaluation Screening for Clinical Depression in Primary Care CPT Psychiatric diagnostic evaluation with medical services Screening for Clinical Depression in Primary Care CPT Psychotherapy 30 minutes with patient Screening for Clinical Depression in Primary Care CPT Psychotherapy 45 minutes with patient Screening for Clinical Depression in Primary Care CPT Psychotherapy 60 minutes with patient Screening for Clinical Depression in Primary Care CPT Psychotherapy for crisis first 60 minutes Screening for Clinical Depression in Primary Care CPT Assessment of tinnitus Screening for Clinical Depression in Primary Care CPT Nubhvl status xm pr hr f2f w/pt interpj&prepj Screening for Clinical Depression in Primary Care CPT Nuropsyc tstg pr hr f2f w/pt + interpj time Screening for Clinical Depression in Primary Care CPT Assess hlth/behave init Screening for Clinical Depression CPT Assess hlth/behave subseq Page 45

46 in Primary Care Screening for Clinical Depression in Primary Care CPT Occupational therapy evaluation Screening for Clinical Depression in Primary Care CPT Screening for Clinical Depression in Primary Care CPT Screening for Clinical Depression in Primary Care CPT Screening for Clinical Depression in Primary Care CPT Screening for Clinical Depression in Primary Care CPT Screening for Clinical Depression in Primary Care CPT Screening for Clinical Depression in Primary Care CPT Screening for Clinical Depression in Primary Care CPT Screening for Clinical Depression in Primary Care CPT Screening for Clinical Depression in Primary Care HCPCS G0101 Screening for Clinical Depression in Primary Care HCPCS G0402 Screening for Clinical Depression in Primary Care HCPCS G0438 Screening for Clinical Depression in Primary Care HCPCS G0439 Office or other outpatient visit for the evaluation and managemen t of a new patient which requires these three key components: a Office or other outpatient visit for the evaluation and managemen t of a new patient which requires these three key components: an Office or other outpatient visit for the evaluation and managemen t of a new patient which requires these three key components: a Office or other outpatient visit for the evaluation and managemen t of a new patient which requires these three key components: a Office or other outpatient visit for the evaluation and managemen t of a new patient which requires these three key components: a Office or other outpatient visit for the evaluation and managemen t of an established patient which requires at least two of these Office or other outpatient visit for the evaluation and managemen t of an established patient which requires at least two of these Office or other outpatient visit for the evaluation and managemen t of an established patient which requires at least two of these Office or other outpatient visit for the evaluation and managemen t of an established patient which requires at least two of these or vaginal cancer screening; pelvic and clinical breast examination Initial preventive physical examination face-to-face visits services limited to new beneficiary during the first 12 months Annual wellness visit includes a personalized prevention plan of service (pps) initial visit Annual wellness visit includes a personalized prevention plan of service (pps) subsequent visit Screening for Clinical Depression in Primary Care HCPCS G0444 Annual depression screening 15 minutes Page 46

47 Numerator: Members screened for clinical depression on the date of the encounter using an age appropriate standardized tool Codes to Identify Screening for Clinical Depression Service Code Type Code Code Description Screening for Clinical Depression in Primary Care CPT 1220F Patient screened for depression (sud) Screening for Clinical Depression in Primary Care CPT 3351F Screening for Clinical Depression in Primary Care CPT 3352F Screening for Clinical Depression in Primary Care CPT 3353F Screening for Clinical Depression in Primary Negative screen for depressive symptoms as categorized by using a standardized depression screening/assessment tool (mdd) No significant depressive symptoms as categorized by using a stan dardized depression assessment tool (mdd) Mild to moderate depressive symptoms as categorized by using a standardized depression screening/assessment tool (mdd) Clinically significant depressive symptoms as categorized by usin g a standardized depression screening/assessment tool (mdd) Care CPT 3354F Screening for Clinical Depression in Primary Care CPT 3725F Screening for depression performed (dem) Screening for Clinical Depression in Primary Care HCPCS G0444 Annual depression screening 15 minutes Screening for Clinical Depression in Primary Care HCPCS G8431 Screening for Clinical Depression in Primary Care HCPCS G8433 Screening for Clinical Depression in Primary Care HCPCS G8510 Screening for Clinical Depression in Primary Care HCPCS G8511 Screening for Clinical Depression in Primary Care HCPCS G8940 Positive screen for clinical depression using a standardized tool and a follow-up plan documented Screening for clinical depression using a standardized tool not documented patient not eligible/appropriate Negative screen for clinical depression using a standardized tool patient not eligible/appropriate for follow-up plan documented Screen for clinical depression using a standardize tool documented follow up plan not documented reason not specified Screening for clinical depression documented follow-up plan not documented patient not eligible/appropriate Page 47

48 Definitions: Screening Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms. Standardized Depression Screening Tool A normalized and validated depression screening tool developed for the Member population in which it is being utilized. The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. Examples of depression screening tools include but are not limited to: Adolescent Screening Tools (12-17 years): Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire (MFQ), Center for Epidemiologic Studies Depression Scale (CES-D), and PRIME MD-PHQ2 Adult Screening Tools (18 years and older): Patient Health Questionnaire (PHQ-9 or PHQ-2), Beck Depression Inventory (BDI or BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke Anxiety-Depression Scale (DADS), Geriatric Depression Scale (GDS), Cornell Scale Screening, and PRIME MD-PHQ2 Page 48

49 Measure Name: Positive Depression Screening with Follow Up Plan Methodology: IEHP-defined Quality Metric Modified from PQRS measure (NQF 0418) Measure Description: The percentage of Members aged 12 years and older who screened positive for clinical depression using an age appropriate standardized depression screening tool who also have a follow-up plan documented during the measurement year (2018). Denominator: All Members aged 12 years and older with a Primary Care Provider (PCP) visit with a positive depression screening in the measurement year. Member counted only once in the denominator Codes to Identify Positive Depression Screening During a Primary Care Provider Visit: Service Positive Depression Screening with Follow Up Plan CPT 3353F Positive Depression Screening with Follow Up Plan CPT 3354F Positive Depression Screening with Follow Up Plan HCPCS G8431 Positive Depression Screening with Follow Up Plan HCPCS G8511 Positive Depression Screening with Follow Up Plan HCPCS G8940 Code Type Code Code Description Mild to moderate depressive symptoms as categorized by using a standardized depression screening/assessment tool (mdd) Clinically significant depressive symptoms as categorized by using a standardized depression screening/assessment tool (mdd) Positive screen for clinical depression using a standardized tool and a follow-up plan documented Screen for clinical depression using a standardize tool documented follow up plan not documented reason not specified Screening for clinical depression documented follow-up plan not documented patient not eligible/appropriate Numerator: Members screened positive for clinical depression with a follow-up plan documented during the measurement year. Page 49

50 Codes to Identify Positive Depression Screening with Follow Up Plan Service Positive Depression Screening with Follow Up Plan CPT 0545F Positive Depression Screening with Follow Up Plan HCPCS G8431 Positive Depression Screening with Follow Up Plan HCPCS G8940 Definitions: Code Type Code Code Description Plan for follow-up care for major depressive disorder documented (mdd adol) Positive screen for clinical depression using a standardized tool and a follow-up plan documented Screening for clinical depression documented follow-up plan not documented patient not eligible/appropriate Follow-Up Plan Documented follow-up for a positive depression screening must 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 Page 50

51 Patient Experience Domain Measure Name: Access to Care Needed Right Away Methodology: Monthly Member Satisfaction Survey Measure Description: In the last 6 months, when you needed care right away, how often did you get care as soon as you needed? Valid response: never, sometimes, usually, always Target response: usually, always Measure Support: To help identify opportunities to improve customer service, IEHP conducts a monthly Member Satisfaction Survey between June-December annually. Member survey responses are analyzed and shared at the IPA level. Measure Name: Access to Routine Care Methodology: Monthly Member Satisfaction Survey Measure Description: In the last 6 months, how often did you get an appointment for a check-up or routine care at a Doctor s office or clinic as soon as you needed? Valid response: never, sometimes, usually, always Target response: usually, always Measure Support: To help identify opportunities to improve customer service, IEHP conducts a monthly Member Satisfaction Survey between June-December annually. Member Survey responses are analyzed and shared at the IPA level. Page 51

52 Measure Name: Coordination of Care Methodology: Monthly Member Satisfaction Survey Measure Description: In the last 6 months, how often did your Personal Doctor seem informed and up-to-date about the care you got from these doctors or other health providers? Valid response: never, sometimes, usually, always Target response: usually, always Measure Support: To help identify opportunities to improve customer service, IEHP conducts a monthly Member Satisfaction Survey between June-December annually. Member Survey responses are analyzed and shared at the IPA level. Measure Name: Rating of Personal Doctor Methodology: Monthly Member Satisfaction Survey Measure Description: Using any number from 0 to 10, where 0 is the worst Personal Doctor possible and 10 is the best Personal Doctor possible, what number would you use to rate your Personal Doctor? Valid response: 0-10 Target response: 8, 9 or 10 Measure Support: To help identify opportunities to improve customer service, IEHP conducts a monthly Member Satisfaction Survey between June-December annually. Member Survey responses are analyzed and shared at the IPA level. Page 52

53 Appendix 3. Historical Data Form Page 53