Quality Measures Guide. Medicare Star Rating and HEDIS measures

Transcription

1 Quality Measures Guide Medicare Star Rating and HEDIS measures February 2018

2 About the Quality Measures Guide A key component of our Quality Program is Healthcare Effectiveness Data and Information Set (HEDIS) reporting. HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) that was designed to measure the care and service provided by health plans, evaluate health plans effectiveness of care, access, use of services and member satisfaction. Each year, we are required to report information on the quality of care our patients receive to various sources for our Medicare and commercial members. The majority of HEDIS information is from claims; however, medical record results are also incorporated into our data. The medical records chosen for review are based on statistically valid samples of patients who meet criteria for inclusion in the HEDIS measure being reviewed. As providers, you can help facilitate and support the HEDIS process by: Providing the appropriate care within the designated timeframes Documenting all care in the patient s medical record Accurately coding all claims and encounters, including submitting results via CPT level II codes whenever possible. This guide is designed to share information about the criteria for the HEDIS measures, including the various codes and documentation required to meet compliance for each measure. Medicare Star Ratings are impacted by HEDIS scores for particular measures. In this guide, the Medicare Star Rating related measures are listed first, followed by all measures that impact commercial and Medicare patients. The diagnosis and/or procedure codes in this guide are in compliance with the HEDIS 2018 Volume 2 Technical Specifications, which apply to dates of service in HEDIS is a registered trademark of NCQA. Reimbursement for these services will be in accordance with the terms and conditions of your agreement with us. Quality Measures Guide Page 1 Revised February 2018

3 Medicare Star Rating measures (most also apply to all patients) Measure Measure definition and methodology Exclusions Codes used in measure Adult BMI assessment Measure assesses the calculation of BMI in adults. Ages Outpatient visit during measurement year BMI recorded within the last two years (including measurement year) Notes: Weight and BMI value must be in medical record and date the BMI was recorded Patient under age 20: height, weight and BMI percentile required as a value or plotted on an age-growth chart Pregnancy during current year and/or prior year BMI: ICD-10-CM: Z68.1, Z68.20-Z68.39, Z68.41-Z68.45, Z68.51-Z68.54 Outpatient visit: CPT: , , , , , , , , 99411, 99412, 99429, 99455, HCPCS: G0402, G0438, G0439, G0463, T1015 Breast cancer screening Ages as of December 31 of the measurement year Methodology: Claims and encounter data Measure addresses the prevalence of routine breast cancer screenings. Screening mammogram Notes: Primary screening only; no diagnosis or treatment included Date range for screening: October 1 two years prior through December 31 of the measurement year Any time in history: Bilateral mastectomy Unilateral mastectomy (with bilateral modifier) Two separate unilateral mastectomies on different dates at least 14 days apart. History of bilateral mastectomy Absence of right/left breast Mammogram: CPT: , , HCPCS: G0202, G0204, G0206 Methodology: Claims and encounter data Quality Measures Guide Page 2 Revised February 2018

4 Colorectal cancer Measure addresses the prevalence of the screening various colon cancer screening tests. Ages A colorectal cancer screening in the appropriate time (including measurement year): Colonoscopy-10 yrs CT colonography- 5 years Flexible sigmoidoscopy- 5 years FIT-DNA (Cologuard)-3 years FOBT-measurement year only FIT-measurement year only. Methodology: Claims, encounter data and medical record review Any time in history: Colorectal cancer Total colectomy Colonoscopy CPT: , 44397, , 45355, , CPT II: G0105, G0121 CT Colonography CPT: Flexible sigmoidoscopy CPT: , , , 45349, CPT II: G0104 FIT-DNA CPT: CPTII: G0464 FOBT CPT: 82270, CPT II: G0328 Quality Measures Guide Page 3 Revised February 2018

5 Comprehensive diabetes Measure is designed to assess the routine care-eye exam diabetes screening and monitoring. Ages Diagnosis of diabetes (type 1 or 2) during the measurement year or year prior by: o Two or more visits (not acute inpatient) on different dates of service with o diagnosis of diabetes, or One acute inpatient encounter with a diagnosis of diabetes Prescribed hypoglycemic/ antihyperglycemics or insulin on an ambulatory basis Retinal exam: Retinal or dilated eye exam by an optometrist or ophthalmologist A chart note or photograph of retina via fundus photography reviewed by eye care professional; must include results Bilateral eye enucleation anytime during the member s history through December 31 of the measurement year Note: Negative eye exam (done by optometrist or ophthalmologist) appropriate to use prior year test results Methodology: Claims, encounter data and medical record review Diagnosis of gestational or steroid-induced diabetes during the measurement year or the year prior and NO diagnosis of diabetes during the same time. Retinal eye exam CPT: 67028, 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, , 92230, 92235, 92240, 92250, CPT II: 2022F, 2024F, 2026F, 3072F HCPCS: S0620, S0621, S3000 Unilateral eye enucleation with bilateral modifier CPT: 65091, 65093, 65101, 65103, 65105, 65110, 65112, Modifier: 50, Unilateral eye enucleation left ICD-10-PCS: 08B10ZX, 08B10ZZ, 08B13ZX, 08B13ZZ, 08B1XZX, 08B1XZZ Unilateral eye enucleation right ICD-10-PCS: 08B00ZX, 08B00ZZ, 08B03ZX, 08B03ZZ, 08B0XZX, 08B0XZZ Quality Measures Guide Page 4 Revised February 2018

6 Comprehensive diabetes care- A1c control Ages Measure is designed to assess the routine diabetes screening and monitoring of diabetes control through the use of hemoglobin A1c testing. Diagnosis of diabetes (type 1 or 2) during the measurement year or year prior by: o Two or more visits (non acute inpatient) on different dates of service o with diagnosis of diabetes, or One acute inpatient encounter with a diagnosis of diabetes Prescribed hypoglycemic/antihyperglycemics or insulin on an ambulatory basis Notes: Results from the most recent HbA1c screening test during the measurement year. Value must be <8.0%. Any number above that value or if there is no value recorded, the record cannot be used. Can be identified in chart notes as A1c, hemoglobin A1c, HgbA1c, HbA1c or glycohemoglobin A1c. Methodology: Claims, encounter data and medical record review. Diagnosis of gestational or steroid-induced diabetes during the measurement year or the year prior and NO diagnosis of diabetes during the same time. HgbA1c blood test CPT: 83036, CPT II: o HbA1c Level Less Than 7.0%-3044F o HbA1c Level %-3045F o HbA1c Level > F Quality Measures Guide Page 5 Revised February 2018

7 Comprehensive diabetes care-hba1c poor control (>9.0%) Measure is designed to assess the routine diabetes screening and monitoring. Ages Diagnosis of diabetes (type 1 or 2) during the measurement year or year prior by: o o Two or more visits (non acute inpatient) on different dates of service with diagnosis of diabetes, or One acute inpatient encounter with a diagnosis of diabetes Prescribed hypoglycemic/ antihyperglycemics or insulin on an ambulatory basis HbA1c poor control: One or more HbA1c screenings where most recent result in the measurement year is >9.0% Methodology: Claims, encounter data and medical record review Diagnosis of gestational or steroid-induced diabetes during the measurement year or the year prior and NO diagnosis of diabetes during the same time. HgbA1c blood test CPT: 83036, CPT II: o HbA1c Level Less Than 7.0%-3044F o HbA1c Level %-3045F o HbA1c Level > F Quality Measures Guide Page 6 Revised February 2018

8 Comprehensive diabetes care-nephropathy monitoring Measure is designed to assess the routine diabetes screening and monitoring for the presence or progress of nephropathy. Ages Diagnosis of diabetes (type 1 or 2) during the measurement year or year prior by: o Two or more visits (not acute inpatient) on different dates of service o with diagnosis of diabetes, or One acute inpatient encounter with a diagnosis of diabetes Prescribed hypoglycemic/antihyperglycemics or insulin on an ambulatory basis Diagnosis of gestational or steroid-induced diabetes during the measurement year or the year prior and NO diagnosis of diabetes during the same time. ESRD and dialysis CPT: 36147, 36800, 36810, 36815, , , 90935, 90937, 90940, 90945, 90947, , 90989, 90993, 90997, 90999, CPTII: G0257, S9339 ICD-10-CM: N18.5, N18.6, Z91.15, Z99.2 Kidney transplant CPT: 50300, 50320, 50340, 50360, 50365, 50370, CPT II: S2065 ICD-10-CM: Z94.0 ICD-10-PCS: 0TY00Z0-0TY00Z2, 0TY10Z0-0TY10Z2 Nephropathy monitoring activities: ACE Inhibitor/ARB ambulatory prescription Albumin or protein urine test Visit to nephrologist Renal transplant Medical attention for diabetic nephropathy o ESRD o Chronic renal failure o Chronic kidney disease (CKD) o Renal insufficiency o Proteinuria o Albuminuria o Renal dysfunction o o Acute renal failure Dialysis, hemodialysis, or peritoneal dialysis Methodology: Claims, encounter data and medical record review. CKD stage 4 ICD-10-CM: N18.4 Urine protein test CPT: , 81005, , CPT II: 3060F, 3061F, 3062F Nephrologist visits CPT: , , , , , , , , 99411, 99412, 99420, 99429, 99455, CPT II: 3066F, 4010F, G0402, G0438, G0439, G0463, T1015 ICD-10-CM: E08.21, E08.22, E08.29, E09.21, E09.22, E09.29, E10.21, E10.22, E10.29, E11.21, E11.22, E11.29, E13.21, E13.22, E13.29, I12.9, I13.0, I13.10, I13.11, I13.2, I15.0, I15.1, N00.0-N07.9, N08, N14.0-N14.4, N17.0-N17.2, N17.8, N17.9, N18.1-N18.6, N18.6, N19, N25.0, N25.1, N25.81, N25.89, N25.9, N26.1, N26.2, N26.9, Q60.0-Q60.6, Q61.00-Q61.02, Q61.11, Q61.19, Q61.2-Q61.5, Q61.8, Q61.9, R80.0-R80.3, R80.8, R80.9 Quality Measures Guide Page 7 Revised February 2018

9 Controlling high blood Measure assesses the routine monitoring of Diagnosis of hypertension pressure the diagnosis of hypertension. ICD-10-CM: I10 Ages Diagnosis of hypertension (HTN) in the medical record Results of blood pressure documented as part of visit Blood pressure under control as per results of test Timing of blood pressure reading must be chronologically later than HTN diagnosis and within measurement year Controlled blood pressure: Ages Less than <140/90 Ages with diabetes-less than <140/90 Ages without diabetes-less than <150/90 Pregnancy End stage renal disease Kidney transplant Non-acute inpatient stay Blood pressures taken on the same day as a diagnostic test or diagnostic or therapeutic procedure requiring a change in medication or diet on or one day before the day of the test or procedure, except for fasting blood tests. Office visits CPT: , , , , , , , , 99411, 99412, 99429, 99455, HCPCS: G0402, G0438, G0439, G0463, T1015 Blood pressure CPT II: 3074F, 3075F, 3077F, 3078F, 3079F, 3080F Disease modifying anti-rheumatic drug therapy for rheumatoid arthritis Ages 18+ Methodology: Medical record review only Measure assesses the medical management of those with rheumatoid arthritis. Diagnosis of rheumatoid arthritis Two or more of the following between January 1 and November 30 of the measurement year: o Outpatient visits o Nonacute inpatient discharge Ambulatory prescription of disease-modifying anti-rheumatic drug (DMARD) during the whole measurement year (January 1 through December 31) During measurement year Pregnancy Any time in history: HIV Office visits CPT: , , , , , , , , 99411, 99412, 99429, 99455, HCPCS: G0402, G0438, G0439, G0463, T1015 Rheumatoid arthritis diagnosis DMARDs HCPCS: J0129, J0135, J0717, J1438, J1600, J1602, J1745, J3262, J7502, J7515-J7518, J9250, J9260, J9310 Methodology: Claims, encounter data or pharmacy data Quality Measures Guide Page 8 Revised February 2018

10 Initiation and engagement of alcohol and other drug abuse or dependence treatment Measure assesses the treatment and follow-up for those with a newly diagnosed drug or alcohol dependence/abuse. Ages 13+ Evidence of treatment for alcohol and/or other drugs (AOD). Initiation-An inpatient AOD admission, outpatient visit, telehealth, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis. Engagement-Of those initiating treatment who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit. Measurement period: January 1-November 14 of the measurement year Methodology: Claims and encounter data Members who had a claim/encounter with a diagnosis of Alcohol or Other Drug Abuse or dependence or Medication Assisted Treatment dispensing event during the 60 days before the Index Episode Start Date (IESD) Standalone visits CPT: , 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 Telehealth visits CPT: , Modifier: 95, GT Visits that require POS CPT: 90791, 90792, , 90845, 90847, 90849, 90853, 90875, 90876, , , 99238, 99239, POS: 02, 03, 05, 07, 09, 11-20, 22, 33, 49, 50, 52, 53, 57, 71, 72 Online assessments CPT: 98969, Alcohol abuse and dependence diagnosis Opioid abuse and dependence diagnosis Other drug abuse and dependence diagnosis Quality Measures Guide Page 9 Revised February 2018

11 Medication reconciliation post-discharge Ages 18+ Measure assesses the prevalence of transitions in care upon discharge from an inpatient setting. Target is medication management. Discharge from inpatient setting Reconciliation of discharge medications with outpatient medications Reconciliation must be performed by prescribing provider, clinical pharmacist, or RN Reconciliation must be completed within 31 days of discharge (discharge date + 30 days) Notes: If other staff in the office do not have the right credentials, the results must be reviewed and signed off by the provider or RN Chart note must reflect the outcome of the reconciliation/comparison Methodology: Claims, encounter data and medical record review Member is excluded if the inpatient discharge occurs after December 1 st of the measurement year. Medication reconciliation CPT: 99495, HCPCS: 1111F Quality Measures Guide Page 10 Revised February 2018

12 Osteoporosis management in women who had a fracture Measure assesses whether the treatment for osteoporosis is initiated after a fracture. Ages A new fracture during the intake period and A bone mineral density (BMD) test or a medication to treat osteoporosis within six months of the fracture Intake Period is a 12-month window July 1 of the year prior to June 30 of the measurement year. Index Episode Start Date (IESD) is the earliest service date during the Intake Period with a diagnosis of a fracture, including: Date of service for an outpatient or ED visit Date of discharge for an inpatient encounter Discharge date from the last admission for a direct transfer Methodology: Claims, encounter data and pharmacy data BMD test up to 24 months prior to the IESD Osteoporosis therapy or prescription during the 12 months prior to the fracture Visits or admissions CPT: , , , , , , , , , , 99411, 99412, 99429, 99455, HCPCS: G0402, G0438, G0439, G0463, T1015 Fractures code set BMD tests CPT: 76977, 77078, , 77085, HCPCS: G0130 ICD-10-PCS: BP48ZZ1, BP49ZZ1, BP4GZZ1, BP4HZZ1, BP4LZZ1, BP4MZZ1, BP4NZZ1, BP4PZZ1, BQ00ZZ1, BQ01ZZ1, BQ03ZZ1, BQ04ZZ1, BR00ZZ1, BR07ZZ1, BR09ZZ1, BR0GZZ1 Quality Measures Guide Page 11 Revised February 2018

13 Pharmacotherapy management of COPD exacerbation Measure assesses the distribution of the appropriate medications for the treatment/management of COPD Ages 40+ Acute inpatient discharge or emergency department (ED) visit with a principal diagnosis of COPD Dispensing of a systemic corticosteroid and/or bronchodilator within the appropriate timeline. o systemic corticosteroid-14 days o bronchodilator-30 days Intake period: January 1 through November 30 of the measurement year during which an episode can occur Episode date: Date of discharge for acute inpatient stay or date of service for emergency department (ED) visit with principal diagnosis of COPD Note: If an acute inpatient discharge and ED visit occurred on same day, they are two different events. If there are repeat ED visits on the same day, counts as a single event. Methodology: Medical and pharmacy claims, encounter data ED visits resulting in an inpatient admission Non-acute inpatient stay No principal diagnosis of COPD, chronic bronchitis, or emphysema COPD ICD-10-CM: J44.0, J44.1, J44.9 Emphysema ICD-10-CM: J43.0-J43.2, J43.8, J43.9 Chronic bronchitis: ICD-10-CM: J41.0, J41.1, J41.8 Systemic corticosteroid medications Bronchodilator medications Quality Measures Guide Page 12 Revised February 2018

14 Plan all-cause readmissions Ages 18+ Measure assesses the prevalence of readmissions within a specific period of time after discharge from an inpatient setting. Acute inpatient stay occurring between January 1 and December 1 of the measurement year unplanned acute readmission for any diagnosis within 30 days of discharge Index hospital stay (IHS): Acute inpatient stays with a discharge during the measurement period Index admission date: IHS admission date Index discharge date: IHS discharge date Index readmission stay: Acute inpatient stay within 30 days of initial index discharge date Index readmission date: Admission date associated with the index readmission stay Classification period: 365 days prior to and including an index discharge date Methodology: Claims and encounter data Acute inpatient stay with principal diagnosis of pregnancy Non-acute inpatient stay A condition originating in the perinatal period Death during hospital stay Planned stays within 30 days of an unplanned stay with chemotherapy, rehabilitation or organ transplant Potentially planned procedure without a principal acute diagnosis Revenue and CPT codes reflect an acute inpatient stay. Follow Risk Adjustment Determination guide at end of document for further information. Quality Measures Guide Page 13 Revised February 2018

15 Use of high risk medications in the elderly Ages 66+ Measure assesses the dispensing of medications and risk level associated with these medications for certain populations. One or more different high-risk medications (HRM) dispensing during the measurement year based on the number of days prescribed or the dose as being high risk Two different measures are included: Percentage of members who had at least one dispensing event for a high-risk medication Percentage of members with at least two dispensing events for the same high-risk medication Methodology: Pharmacy claims Billing for this measure is reliant on pharmacy claims. The results are based on medication refill history for the specified medications (NDC codes). Quality Measures Guide Page 14 Revised February 2018

16 Statin therapy for patients with Measure is designed to assess the use of statins in those at higher risk of Event in measurement year or year prior: Outpatient visits CPT: , , cardiovascular disease cardiovascular events. o o Pregnancy In vitro fertilization , , , , , , Ages Males: Female: Presence of clinical atherosclerotic cardiovascular disease (ASCVD) o o o Clomiphene dispensing ESRD Cirrhosis 99411, 99412, 99429, 99455, HCPCS: G0402, G0438, G0439, G0463, T1015 determined by: During measurement year: o Event: MI with an inpatient stay, CABG, PCI, other revascularization during year o o Myalgia Myositis Inpatient stay prior to measurement year o Myopathy Acute inpatient stay o Diagnosis: Ischemic vascular disease o Rhabdomyolysis (IVD) based on outpatient visits or acute Ischemic vascular disease diagnosis inpatient stays Ambulatory prescriptions for high or moderate intensity statin dose Reported as two different rates: Those receiving at least one high or moderate intensive statin therapy during the measurement year Those remaining on high or moderate intensity statin therapy for 80% or more of the treatment period Index Prescription Start Sate (IPSD): The date the first statin prescription was dispensed Methodology: Medical and/or encounter data and pharmacy claim Myocardial infarction ICD-10-CM: I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I22.0-I22.2, I22.8, I22.9, I23.0-I23.8, I25.2 Coronary artery bypass graft CPT: , , , HCPCS: S2205-S2209 Percutaneous coronary intervention CPT: 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92980, 92982, HCPCS: C9600, C9602, C9604, C9606, C9607 Other revascularization CPT: 37220, 37221, , 37230, High- and moderate-intensity statin medications Quality Measures Guide Page 15 Revised February 2018

17 Statin therapy for Any of the following during the patients with diabetes year prior to the measurement Ages Measure assesses the use of statins for cholesterol management in those with diabetes. Diabetes diagnosis (requirements same as Comprehensive diabetes care measure) No clinical atherosclerotic cardiovascular disease (ASCVD) diagnosis Reported as two different rates: One or more prescriptions of any intensity for statin therapy (one or more dispensing during the measurement year) Statin therapy of any intensity for at least 80% of the measurement year. Index prescription start date (IPSD): The date the first statin prescription was dispensed Treatment period: Period from IPSD to the end of the measurement year Methodology: Pharmacy claims. year: o Myocardial infarction o Coronary artery bypass graft o Percutaneous coronary intervention o Other revascularization Event in both the measurement year and the year prior: o Ischemic vascular disease diagnosis Event in measurement year or year prior: o Pregnancy o In vitro fertilization o Clomiphene dispensing o ESRD o Cirrhosis During measurement year only: o Myalgia o Myositis o Myopathy o Rhabdomyolysis Diagnosis of gestational or steroid induced diabetes during the measurement year or the year prior to the measurement year and no diagnosis of diabetes during the same time. Outpatient visits CPT: , , , , , , , , , , 99411, 99412, 99429, 99455, HCPCS: G0402, G0438, G0439, G0463, T1015 Non-acute inpatient stay Acute inpatient stay Inpatient stay Diabetes diagnosis High- and moderate-intensity statin medications Low-intensity statin medications Quality Measures Guide Page 16 Revised February 2018

18 Commercial and non-star Rating Medicare Measures Measure Measure definition and methodology Exclusions Codes used in measure Adolescent well care Measure assesses the prevalence of well care visits visits in the adolescent population. Ages One or more comprehensive well-care visits with a PCP or an OB/GYN during the measurement year Visit must include the following: o A health history o A physical development history o A mental development history o o A physical exam Health education and/or anticipatory guidance Inpatient visits Emergency room visits Well-care visit with PCP or OB/GYN CPT: , , HCPCS: G0438, G0439 ICD-10-CM: Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0 -Z02.6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9 Adult s access to preventive/ ambulatory health services Ages 20+ Methodology: Claims and encounter data Measure assesses the prevalence of and use of ambulatory health services for routine wellness checks. Ambulatory or preventive care visit -measurement year only -measurement year or one of the two years prior Methodology: Claims and encounter data Ambulatory or preventive care visits CPT: 92002, 92004, 92012, 92014, , , , , 99315, 99316, 99318, , , , , , , , 99411, 99412, HCPCS: G0402, G0438, G0439, G0463, S0620, S0621, T1015 ICD-10-CM: Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9 Quality Measures Guide Page 17 Revised February 2018

19 Annual monitoring for patients on persistent medications Measure assesses whether routine follow-up blood tests are being used for management of specific classes of medications. ACE inhibitor/arb medications Diuretic medications Ages 18+ At least 180 days of treatment with ACE Inhibitors or ARBs during the measurement year. At least one serum potassium and serum creatinine therapeutic monitoring test in the measurement year. At least 180 days of treatment with diuretic medications Acute inpatient stay or non-acute inpatient stay during the measurement year. Serum potassium test CPT: 80051, Serum creatinine test: CPT: 82565, Appropriate treatment for children with upper respiratory infection Ages 3mo-18years Methodology: Medical and pharmacy claims, and encounter data Measure assesses whether the appropriate treatment is put into place when addressing upper respiratory infections Diagnosis of upper respiratory infection (URI) NDC and prescribing history for medication prescribed. Intake period: 12-month window from July 1 of the prior year to June 30 of the measurement year. Index episode start date (IESD): earliest date in intake period with a diagnosis of a URI. Office or ED visit with competing diagnosis (pharyngitis, etc). ED visits or observation visits that result in an inpatient stay. Outpatient visit codes: CPT: , , , , , , , , , , 99411, 99412, 99429, 99455, HCPCS: G0402, G0438, G0439, G0463, T1015 URI diagnosis: ICD-10-CM: J00, J06.0, J06.9 Pharyngitis diagnosis: ICD-10-CM: J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91 Antibiotic medications Notes: Antibiotics prescribed previously (more than 30 days before episode) cannot be active at diagnosis There cannot be a competing diagnosis within three days of the episode date Methodology: Medical and pharmacy claims Quality Measures Guide Page 18 Revised February 2018

20 Antidepressant medication management Measure assesses the prescription of antidepressants for treatment of major depression. Ages 18+ Major depression diagnosis New prescription and refill history for antidepressant medication Intake period: 12-month window from May 1 of the year prior ending on April 30 of the measurement year. Index prescription start date (IPSD): earliest prescription dispensing date during the intake period for an antidepressant Treatment days: number of calendar days covered (requires 180 days). No diagnosis of major depression within 60 days prior and 60 days after dispensing an antidepressant Prior antidepressant prescription within 105 days of the IPSD Stand-alone outpatient visits 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 Visits that require POS CPT: 90791, 90792, , , 90845, 90847, 90849, 90853, , 90875, 90876, , , 99238, 99239, POS: 02, 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 Two phases included in measure: Acute at least 84 days of continuous treatment with antidepressant medication during the 114 days period following the IPSD Continuation at least 180 days of continuous treatment during the 231 days following the IPSD Methodology: Medical claims, pharmacy claims and encounter data Telehealth visits CPT: , Modifier: 95, GT Inpatient stay Major depression diagnosis ICD-10-CM: F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9 Antidepressant medications Quality Measures Guide Page 19 Revised February 2018

21 Appropriate testing for children with pharyngitis Measure assesses the use of strep test for diagnosis and treatment of pharyngitis for children. Ages 3-18 Pharyngitis diagnoses Group A streptococcus (strep) test Antibiotic prescription dispensing Intake period: 12-month window from July 1 of the year prior through June 30 of the measurement year Episode date: Date of service for outpatient or ED visits during the intake period with only a diagnosis of pharyngitis Index episode start date (IESD): Earliest episode date linked to a dispensed antibiotic prescription Note: Must have a 30-day negative medication history prior to the episode date Methodology: Medical claims, pharmacy claims and encounter data Visits with any of the following: o Any diagnosis other than Pharyngitis on the same date of service. o ED visits or observation visits resulting in an inpatient stay. o new or refill prescription for an antibiotic was not filled within three days after episode. o Prior to this episode, if a dispensed prescription remained active on the Episode Date. Outpatient visits CPT: , , , , , , , , , , 99411, 99412, 99429, 99455, HCPCS: G0402, G0438, G0439, G0463, T1015 Pharyngitis diagnosis ICD-10-CM: J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91 Group A streptococcus test CPT: 87070, 87071, 87081, 87430, , Antibiotic medications Quality Measures Guide Page 20 Revised February 2018

22 Asthma medication ratio Ages 5-85 Measure assesses whether the controller medications dispensed for asthma are in the right proportion. Persistent asthma diagnosis Refill history for controller medications Refill history of all asthma medications. Persistent asthma can be identified by any of these scenarios within the measurement year: At least one ED visit with a principal diagnosis of asthma At least one acute inpatient encounter with a principal diagnosis of asthma At least four outpatient visits or observation visits on different dates of service with any diagnosis of asthma and at least two asthma medication dispensing events At least four asthma medication dispensing events Notes: A ratio of 0.50 or greater of controller medications to total asthma medications for the measurement year. Each injection or intravenous infusion counts as one dispensing event. Methodology: Medical claims, pharmacy claims and encounter data At any point in history through December 31 of measurement year: o Emphysema o COPD o Obstructive chronic bronchitis o Chronic respiratory conditions due to fumes/vapors o Cystic fibrosis o Acute respiratory failure Any time during the measurement year: o No asthma medication history Outpatient visits CPT: , , , , , , , , , , 99411, 99412, 99429, 99455, HCPCS: G0402, G0438, G0439, G0463, T1015 Asthma diagnosis ICD-10-CM: J45.20-J45.22, J45.30-J45.32, J45.40-J45.42, J45.50-J45.52, J45.901, J45.902, J45.909, J45.990, J45.991, J Additional items included in measure Acute inpatient codes Asthma reliever medications Asthma controller medications Quality Measures Guide Page 21 Revised February 2018

23 Avoidance of antibiotic treatment in adults with acute bronchitis Measures assesses bronchitis treatment unnecessary antibiotics. Ages Acute bronchitis diagnosis Knowledge of antibiotic prescriptions for treatment Intake period: From January 1 to December 24 of the measurement year Episode date: Service date for any outpatient or ED visit with an acute bronchitis diagnosis Index episode start date (IESD)-earliest episode date during the intake period that meets all of the following: Negative medication history: Must be at least 30 days after any prior illness and treatment with antibiotics with no continuing active antibiotics. Negative comorbid condition history prior to and including the episode date, Negative competing diagnosis present from 30 days prior to the episode date through seven days after the episode date. Continuous enrollment from one year prior to the episode date through seven days after the episode date. Methodology: Medical claims, pharmacy claims and encounter data ED visits or observation visits that result in an inpatient stay. Encounters where the member has a diagnosis for a comorbid condition during the 12 months prior to or on the episode date: o HIV o Malignant Neoplasms o Emphysema o COPD o Cystic Fibrosis o Comorbid Conditions o Disorders of the Immune System New prescription or refill for an antibiotic medication 30 days prior to the episode date, or active on the episode date Encounter where the member had a diagnosis of Pharyngitis or some competing diagnosis* 30 days prior to the episode date through 7 days after the episode date Outpatient visits: CPT: , , , , , , , , , , 99411, 99412, 99429, 99455, HCPCS: G0402, G0438, G0439, G0463, T1015 Acute bronchitis diagnosis: ICD-10-CM: J20.3-J20.9 Pharyngitis diagnosis: ICD-10-CM: J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91 Antibiotic medication Quality Measures Guide Page 22 Revised February 2018

24 Cervical cancer screening Ages as of December 31 st of the measurement year. Measures assesses preventive cervical cancer screenings based on the following criteria: years old women-cervical cytology every three years years old women-cervical cytology/ and HPV co-testing every five years Cervical cancer screening HPV testing (if appropriate) Note: For medical record review, count any cervical cancer screening method that includes collection and microscopic analysis of cervical cells Any of the following any time during the member s history through December 31 of the measurement year: Hysterectomy with no residual cervix, cervical agenesis, or acquired absence of cervix Exclude incomplete labs and labs where results indicate no cervical cells were present. Exclude biopsies Cervical cytology (Pap tests): CPT: , 88147, 88148, 88150, , , 88174, HCPCS: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 HPV tests: CPT: , 87624, HCPCS: G0476 Methodology: Claims, encounter data and medical record review Members in hospice Quality Measures Guide Page 23 Revised February 2018

25 Childhood Immunization Status Age 2 years of age during the measurement year Measure assesses the immunization history of children at two years of age based on recommended standards. Requires Diphtheria, tetanus and acellular pertussis (DTaP)-four doses Polio (IPV)-three doses Measles, mumps and rubella (MMR)-one dose H influenza type B (HiB)-three dose Hepatitis B (HepB)-three doses Varicella (chicken pox) (VZV)-one dose Pneumococcal conjugate (PCV)-four doses Hepatitis A (HepA)-one dose Rotavirus (RV)-two or three doses dependent on vaccine Influenza (Flu)-two doses Notes: For MMR, Hep B, VZV and Hep A, antigen or combination vaccine, documented history of the illness, or a seropositive test will count as evidence of presence/need. For DTaP, IPV, HiB, pneumonia, rotavirus and influenza, count only evidence of the antigen or combination vaccine. Each antigen is reported separately so make sure all immunizations are reflected in claim submitted for visit. Any individuals with a contraindication for any single specific vaccine or immunization. Contraindications include: o Anaphylaxis o Encephalopathy with a vaccine adverse effect code o Immunodeficiency HIV o Lymphoreticular cancer, Multiple myeloma, or Leukemia o History of Intussusception Reaction to Streptomycin, Polymyxin B, or Neomycin Reaction to baker s yeast DTaP: CPT: 90698, 90700, 90721, IPV: CPT: 90698, 90713, MMR: CPT: , ICD-10-CM: B05.0-B05.4, B05.81, B05.89, B05.9, B06.00-B06.02, B06.9, B06.81, B06.82, B06.89, B06.9, B26.0-B26.3, B26.81-B26.85, B26.89, B26.9 HiB: CPT: , 90698, 90721, HepB: CPT: 90723, 90740, 90744, 90747, HCPCS: G0010 ICD-10-PCS: 3E0234Z VZV: CPT: 90710, ICD-10-CM: B01.0, B01.11, B01.12, B01.2, B01.81, B01.89, B01.9, B02.0, B02.1, B02.21-B02.24, B02.29-B02.34, B02.39, B02.7-B02.9, PCV: CPT: 90669, HCPCS: G0009 Methodology: Claims, encounter data and medical record review. HepA: CPT: ICD-10-CM: B15.0, B15.9 RV: CPT: 90680, Flu: CPT: 90655, 90657, 90661, 90662, 90673, HCPCS: G0008 Quality Measures Guide Page 24 Revised February 2018

26 Children and adolescents access to primary care practitioners Measure assesses routine access to primary care providers. Ages 12 months-19 years Requires (dependent on age): 12 months through 6 years-by end of measurement year (December 31); one or more visits years by end of measurement year; one or more visits in prior year or during current measurement year. Ambulatory visits: CPT: , , , , , , , , 99411, 99412, HCPCS: G0402, G0438, G0439, G0463, T1015 ICD-10-CM: Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9 Chlamydia screening in women Ages Methodology: Claims and encounter data. Measures annual chlamydia testing for young women who are sexually active. Documentation of sexual activity status (active or not) Chlamydia testing Methodology: Claim and encounter data. Members who had a pregnancy test during the measurement year and a prescription for isotretinoin on the date of the pregnancy test or the 6 days after the pregnancy test. Members who had a pregnancy test during the measurement year and an x-ray on the date of the pregnancy test or the 6 days after the pregnancy test. Pregnancy tests CPT: 81025, 84702, Chlamydia test: CPT: 87110, 87270, 87320, , Pregnancy diagnosis Sexual activity codes Contraceptive medications Quality Measures Guide Page 25 Revised February 2018

27 Comprehensive diabetes care-bp control (<140/80mm/hg) or (<140/90mm/hg) Measure is designed to assess the routine diabetes screening and monitoring of blood pressure. Ages Diagnosis of diabetes (type 1 or 2) during the measurement year or year prior: Two or more visits (non acute inpatient) on different dates of service with diagnosis of diabetes. OR one acute inpatient encounter with a diagnosis of diabetes. Prescribed insulin or hypoglycemic/antihyperglycemics on an ambulatory basis. Medical records with blood pressure readings. Note: Measure uses the most recent blood pressure (BP) reading. When multiple BP s recorded for a single date, use the lowest systolic and lowest diastolic BP on that date as the representative BP. Methodology: Claims, encounter data and medical record review. Diagnosis of gestational or steroid-induced diabetes during the measurement year or the year prior and NO diagnosis of diabetes during the same time. Blood pressure CPT II: 3074F, 3075F, 3077F, 3078F, 3079F, 3080F Quality Measures Guide Page 26 Revised February 2018

28 Follow-up after Measure assesses follow-up after an ED visit resulting in emergency department visit for alcohol and emergency department (ED) visit for alcohol or drug dependence. Two different time frames are inpatient care within 30 days of the visit. other drug dependence reported-7 and 30 days, respectively. Ages 13+ years Requires ED visit Primary diagnosis of alcohol or drug dependence Documentation of a follow-up visit within the correct time frame. Note: Rate is based on visits, not members Stand-alone visits: CPT: , 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 Methodology: Claims and encounter data Telehealth visits: CPT: , Modifier: 95, GT Visits that require POS: CPT: 90791, 90792, , 90845, 90847, 90849, 90853, 90875, 90876, , , 99238, 99239, POS: 02, 03, 05, 07, 09, 11-20, 22, 33, 49, 50, 52, 53, 57, 71, 72 Online assessments: CPT: 98969, Alcohol Abuse and Dependence Diagnosis Quality Measures Guide Page 27 Revised February 2018

29 Follow-up after emergency department visit for mental illness Ages 6+ years as of date of ED visit Measure assesses follow-up after an emergency department (ED) visit when mental illness is the primary diagnosis. Two different time frames are reported-7 and 30 days, respectively. ED visit Primary diagnosis of mental illness Documentation of a follow-up visit within the correct time frame. ED visit resulting in inpatient care within 30 days of the visit. Stand-alone visits: 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 Notes: Follow-up visit must be completed by any practitioner with a principle diagnosis of mental illness. Each time frame is reported separately (seven days and 30 days after discharge, respective) Rate is based on visits, not members Methodology: Claims and encounter data Visits that require POS: CPT: 90791, 90792, , , 90845, 90847, 90849, 90853, , 90875, 90876, , , 99238, 99239, POS: 02, 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 Telehealth Modifier: 95, GT Behavioral healthcare setting: UB Rev: 0513, , 0907, , 0919 Non-behavioral healthcare setting: UB Rev: 0510, , , , 0982, 0983 Mental illness diagnosis Quality Measures Guide Page 28 Revised February 2018

30 Follow-up after hospitalization for mental illness Measure assesses treatment follow-up after discharge from hospital setting with a primary diagnosis of mental illness. Ages 6+ as of the visit date Inpatient hospital visit Mental illness diagnoses, primary Follow-up outpatient, intensive outpatient, partial hospitalization with a mental health practitioner. Time frame in which this follow-up visit occurred Note: For this measure, there are two different rates to report, follow-up within seven days and/or 30 days of discharge. Methodology: Claims and encounter data. Non-acute inpatient stays. Discharges after December 1 of the measurement year. Discharges followed by a readmission or direct transfer to a non-acute facility, regardless of principal diagnosis, within the 30-day follow-up period Discharges followed by a readmission or direct transfer to an acute facility, if principal diagnosis was for non-mental illness, within the 30-day follow-up period Stand-alone visits: 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 Visits that require POS: CPT: 90791, 90792, , , 90845, 90847, 90849, 90853, , 90875, 90876, , , 99238, 99239, POS: 02, 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 Telehealth Modifier: 95, GT Behavioral healthcare setting: UB Rev: 0513, , 0907, , 0919 Non-behavioral healthcare setting: UB Rev: 0510, , , , 0982, 0983 Transitional Care Management Services: CPT: 99495, Mental illness diagnosis Quality Measures Guide Page 29 Revised February 2018

31 Follow-up care for children prescribed ADHD medications Ages 6-12 years at first prescription Measure assesses the follow-up care of children beginning treatment with attention deficit hyperactivity disorder (ADHD) medications. Ambulatory prescription for ADHD medication Documentation of follow-up visits within a 10-month period-first within 30 days of beginning treatment. Initiation phase: Index Prescription Start Date (IPSD)-first ambulatory prescription dispensed with at least one follow-up visit with practitioner with prescribing authority during the 30-day period. Continuation and maintenance (C&M): Once treatment is started and if it continues for at least 210 days, the expectation is there will be two or more follow-up visits in this phase. Intake period: 12-month window starting March 1 of the prior year through February 28 of the measurement year. Negative medication history: Period of 120 days prior to the prescription start date in which there were no new or refills of ADHD medications Methodology: Medical, pharmacy claims and encounter data. Acute inpatient encounters with a principal mental health diagnosis during the 30 days after the IPSD Acute inpatient encounters with a principal chemical dependency diagnosis during the 30 days after the IPSD Narcolepsy Stand-alone visits: 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 Visits that require POS: CPT: 90791, 90792, , , 90845, 90847, 90849, 90853, 90875, 90876, , , 99238, 99239, POS: 03, 05, 07, 09, 11-20, 22, 33, 49, 50, 52, 53, 71, 72 Telehealth visits: CPT: , Modifier: 95, GT POS: 02 ADHD medications Quality Measures Guide Page 30 Revised February 2018

32 Immunizations for Measure assesses the immunization status of Meningococcal: adolescents adolescent children at 13 years of age. CPT: Ages 13 during the measurement year Before the age of 13, following immunizations: Meningococcal conjugate vaccine-one dose Tdap-one dose Human papillomavirus (HPV) vaccines-two or three doses Notes: The antigen and date it was administered must be documented. Two dose HPV requires 146 days between doses. Standard schedule: Meningococcal between 11th and 13th birthday. Tdap between 10th and 13th birthday HPV between 9th and 13th birthday Methodology: Claims, encounter data and medical record review. Anaphylactic reaction to the vaccine or its components any time on or before the member s 13th birthday Anaphylactic reaction to the vaccine or its components with a date of service prior to October Tdap: CPT: HPV: CPT: Quality Measures Guide Page 31 Revised February 2018

33 Medication management for people with asthma Measure assesses the prescribing and use of medications for an appropriate length of time in the treatment and control of persistent asthma. ED visits: CPT: years for Commercial patients Diagnosis of persistent asthma Asthma control medications Persistent asthma is defined by at least one event in the measurement year and prior year (does not have to be the same): One or more acute inpatient stays with asthma as the principal diagnosis One or more emergency department visits with asthma as the principal diagnosis Four or more outpatient/observation visits on different service dates with asthma as a diagnosis AND at least two asthma medications must be dispensed At least four asthma medications dispensed Index prescription start date (IPSD) is the earliest prescription dispensing date for any asthma controller medication during the measurement year Treatment period starts with the IPSD and continues through the end of the measurement year. Portion of days covered (PDC) is the number of days covered by at least one asthma controller medication prescription, divided by the number of days in the treatment period. Note: Rates are based on PDC as a percentage of treatment continued at 50% and 75% of the total treatment period. Each injection or intravenous infusion counts as one dispensing event. Methodology: Medical claims, pharmacy claims and encounter data Any of the following anytime during the member s history through December 31 st of the measurement year: o Emphysema o COPD o Obstructive chronic bronchitis o Chronic respiratory conditions due to fumes/vapors o Cystic fibrosis o Acute respiratory failure No asthma controller medications dispensed during the measurement year. Outpatient visits: CPT: , , , , , , , , , 99411, 99412, 99429, 99455, HCPCS: G0402, G0438, G0439, G0463, T1015 Asthma diagnosis: ICD-10-CM: J45.20-J45.22, J45.30-J45.32, J45.40-J45.42, J45.50-J45.52, J45.901, J45.902, J45.909, J45.990, J45.991, J Acute inpatient stay Asthma controller medications Asthma reliever medications Quality Measures Guide Page 32 Revised February 2018