Keystone First Gaps in Care Coding Details

Transcription

1 INDICATION_OF_CAD ICDDx: , 4140*, 4148*, 4149*, V4581, V4582 CPTPx: 33140, , , , , , 92984, INDICATION_OF_DIABETES ICDDx: 250*, 3572*, , 36641, RxCategory: DIABETES* INDICATION_OF_LVSD CPTPx: 3021F, 78414, 78468, , , 78483, 78494, , , 93312, , 93317, 93350, AMBULATY_INSULIN_HYPOGLYCEMIC_RX RxCategory: DIABETES13 and exclude SupplyFlag=Y ACEARB_PREGNANCY_EXCLUSION ICDDx: V220-V239 GIC_CAD_EXCLUSION Provider reported exclusion on worksheet ACEI/ARB Therapy (CAD) ACE_INHIBIT ARB_PRESCRIPTION NDC: RxCategory: ACEARB13 with Claim Status=D or I ACE_ARB_THERAPY CPTPx:4010F without CPTMod: 1P, 2P, 3P NDC: RxCategory: ACEARB* ACEARB_EXCLUSION CPTPx:4010F with CPTMod: 1P, 2P, 3P ICDDx: 2776, 3950*, 3952*, 3960*, 3962*, 3968*, 40301, 40311, 40391, 40402, 40403, 40412, 40413, 40492, 40493, 4251*, 4401*, 5845*, 5849*, 5855, 5856, 586*, 74722, 7885*, V560*, V568* ICDPx: 3995, 5498 ACEI/ARB Therapy (HF) ACE_INHIBIT ARB_PRESCRIPTION NDC: RxCategory: ACEARB13 with Claim Status=D or I ACE_ARB_THERAPY CPTPx:4010F without CPTMod: 1P, 2P, 3P NDC: RxCategory: ACEARB* DIAGNOSIS_HEART_FAILURE ICDDx: Begins with 402 with digit 4=0,1,9 and digit 5=1 Begins with 404 with digit 4=0,1,9 and digit 5=1,3 Begins with 428 with digit 4=0,1,9 Begins with 428 with digit 4=2,3,4 and digit 5=0,1,2,3 INDICATION_OF_LVSD CPTPx: 3021F, 78414, 78468, , , 78483, 78494, , , 93312, , 93317, 93350, ACEARB_PREGNANCY_EXCLUSION ICDDx: V220-V239 GIC_HF_EXCLUSION Provider reported exclusion on worksheet ACEARB_EXCLUSION CPTPx:4010F with CPTMod: 1P, 2P, 3P ICDDx: 2776, 3950*, 3952*, 3960*, 3962*, 3968*, 40301, 40311, 40391, 40402, 40403, 40412, 40413, 40492, 40493, 4251*, 4401*, 5845*, 5849*, 5855, 5856, 586*, 74722, 7885*, V560*, V568* ICDPx: 3995, 5498 WELL_CHILD_VISIT_ADL ((CPTPx: , ) (PCPFlag=Y or ProvType=GYN, NPCP, OB, PCP, PNC) (EXCLUDE: POS=ER, IA, IN)) ((ICDDx: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9) (PCPFlag=Y or ProvType=GYN, NPCP, OB, PCP, PNC) (EXCLUDE: POS=ER, IA, IN)) ((HCPCSPx:G0438, G0439) (PCPFlag=Y or ProvType=GYN, NPCP, OB, PCP, PNC) (EXCLUDE: POS=ER, IA, IN)) Adolescent Well Care GIC_WELLVISIT Provider reported Well Child Visit via GIC worksheet HomegrownPx: "GIC_WELLVISIT" Page 1 of 13

2 AMBULATY_PREVENTIVE_VISIT HCPCS:G0344, G0402, G0438, G0439, S0620, S0621 ICDDx: V70, V70.3, V70.5, V70.6, V70.8, V70.9 Adults Access to Care CPTPx: 92002, 92004, 92012, 92014, , , , , 99315,99316,99318, , , , , , , , , 99420, UBRevCode: , GIC_OFFICEVISIT Provider reported Office Visit via GIC worksheet DENTAL_VISIT Provider Type=DN CPTPx: 70300, 70310, 70320, 70350, Annual Dental Visit 2 to 21 Years Provider Type=DN HCPCSPx: D0120-D0999, D1110-D2999, D3110-D3999, D4210-D4999, D5110- D5899, D6010-D6205, D7111-D7999, D8010-D8999, D9110-D9999 GIC_ADV Provider reported Dental Visit via GIC worksheet Annual Developmental Screen Annual Hearing Test GIC_EPSDT_DEVELOPMENTAL SCREENING CPTPx: 96110, Provider reported Developmental Screen via GIC worksheet EPSDT_HEARING_TEST CPTPx: 92551, Provider reported Hearing Test via GIC worksheet Annual Vision Screen EPSDT VISION SCREEN CPTPx:99173 Provider reported Vision Screen via GIC worksheet Anti-coagulant Therapy (HF) WARFARIN/ANTICOAGULANT_THERAPY (CPTPx: 4012F without CPTMod: 1P, 2P, 3P) NDC: Large, manually entered NDC listing including comprehensive list of anticoagulant drugs. DIAGNOSIS_HEART_FAILURE ICDDx: Begins with 402 with digit 4=0,1,9 and digit 5=1 Begins with 404 with digit 4=0,1,9 and digit 5=1,3 Begins with 428 with digit 4=0,1,9 Begins with 428 with digit 4=2,3,4 and digit 5=0,1,2,3 ATRIAL_FIBRILLATION ICDDx: WARFARIN_EXCLUSION ICDDx: , 2800*, 2809*, 2851*, 2860*-2867*, 2869*, , 28739, 2874*, 2875*, 430*-431*, 4320*, 4321*, 4329*, 4373*, 4590*, 5307*, 53100, 53101, 53120, 53121, 53140, 53141, 53160, 53161, 5693*, 570*, 5712*, 5715*, 5780*, 5781*, 5789*, 5997* 7863* CPTPx: 4012F with CPTMod 1P, 2P, 3P WARFARIN_ADVERSE_EFFECT ICDDx: 9950*, 9951*, 99527, 99529, E9342* HF_PROVIDER REPTED EXCLUSION Provider reported exclusion via GIC worksheet Page 2 of 13

3 INDICATION_OF_CAD CPTPx: 33140, , , , , , 92984, ICDDx: , 4140*, 4148*, 4149*, V4581, V4582 Antiplatelet Therapy (CAD) ANTIPLATELET_THERAPY ADVERSE_EFFECT_CODE ICDDx:9950*, 9951*, 99527, ICDDx:E9348* or E9353* ANTIPLATELET_EXCLUSION CPTPx:4011F with CPTMod: 1P, 2P, 3P CAD_PROVIDER REPTED EXCLUSION Provider reported CAD exclusion DMARD_PRESCRIPTION NDC: RxCategory DMARD13 RHEUMATOID_ARTHRITIS_VISIT [ICDDx: 7140*, 7141*, 7142*, 71481* CPTPx: , , , , , , , , , 99411, 99412, 99420, 99429, ] [UB RevCode: , , , ICDDx: 7140*, 7141*, 7142*, 71481*] RHEUMATOID_ARTHRITIS_NONACUTE_DISCH RoomBoardFlag:Y POS:IN Anti-Rheumatic Drug Therapy [HCPCSPx: J0129, J0135, J0718, J1438, J1600, J1745, J3262*, J7502, J7515-J7518, J9250, J9260, J9310 EXCLUDE POS: IA, IN] Provider reported anti-rheumatic drug reported via worksheet Currently enrolled members between the ages of 5-64 during the reporting period. ASTHMA_MEDICATION_DEN_LEUKOTRINE_13 Large NDC listing based on RxCategory AML13_* and Claim Status D or I ASTHMA_MEDICATION_DEN_NON_LEUKOTRINE_13 Large NDC listing based on RxCategory AMN13_* and Claim Status D or I ASTHMA_INHALER_DEN_LEUKOTRINE_13 Large NDC listing based on RxCategory AIL13_* and Claim Status D or I ASTHMA_INHALER_DEN_NON_LEUKOTRINE_13 Large NDC listing based on RxCategory AIN13_* and Claim Status D or I ASTHMA_OUTPATIENT_VISIT_13 ICDDx: 4930*, 4931*, 4938*, 4939* CPTPx: , , , , , , , , , , 99420,99429 ASTHMA_CONTROLLER_MEDICATION_MMA_13 NDC: RxCategory: AQI13_, AQO13_ ASTHMA_ER_VISIT_13 [ICDDxPri: 4930*, 4931*, 4938*,4939* CPTPx: ] [UBRevCode: , 0981 ICDDxPri: 4930*, 4931*, 4938*,4939*] ASTHMA_HOSPITALIZATION_13 [ICDDxPri: 4930*, 4931*, 4938*,4939* CPTPx: , , , , 99291] [ICDDxPri: 4930*, 4931*, 4938*,4939* UBRevCode: , 0119, , 0129, , 0139, , 0149, , 0159, , , , 0987] ANY_ASTHMA_DIAGNOSIS_13 ICDDxPri: 4930*, 4931*, 4938*,4939* GIC_ASM_EXCLUSION_13 Provider reported asthma exclusion via GIC worksheet using HomegrownPx Code=GIC_ASM_EXCLUSION COPD_DIAGNOSIS_13 ICDDx: 4912*, 4932*, 496*, 5064* EMPHYSEMA_DIAGNOSIS_13 ICDDx: 492*, 5181*, 5182* ACUTE_RESPIRITY_FAILURE_DIAGNOSIS_13 ICDDx: CYSTIC_FIBROSIS_DIAGNOSIS_13 ICDDx: 2770 Asthma Medication Adherence ASTHMA_CONTROLLER_MEDICATION_MMA_13 NDC: RxCategory: AQI13_, AQO13_ Page 3 of 13

4 Asthma Medication Management ASTHMA_MEDICATION NDC: RxCategory: AQI13_, AQO13_ ATHSMA_MEDICATION_NON_LEUKOTRINE Large NDC listing based on RxCategory AMN13_* and Claim Status D or I ASM_MEDICATION_LEUKOTRINE_GIC_13 NDC: , , , , , Large NDC listing based on RxCategory AML13_* and Claim Status D or I ASTHMA_INHALER_LEUKOTRINE Large NDC listing based on RxCategory AIL13_* and Claim Status D or I ASTHMA_INHALER_DEN_NON_LEUKOTRINE_13 Large NDC listing based on RxCategory AIN13_* and Claim Status D or I ASTHMA_OUTPATIENT_VISIT ICDDx: 4930*, 4931*, 4938*, 4939* CPTPx: , , , , , , , , , , 99420,99429 ASTHMA_ER_VISIT ICDDxPri: 4930*, 4931*, 4938*,4939* CPTPx: ] ASTHMA_HOSPITALIZATION [ICDDxPri: 4930*, 4931*, 4938*,4939* CPTPx: , , , , 99291] [ICDDxPri: 4930*, 4931*, 4938*,4939* UBRevCode: , 0119, , 0129, , 0139, , 0149, , 0159, , , , 0987] ASTHMA_DIAGNOSIS ICDDxPri: 4930*, 4931*, 4938*,4939* COPD_DIAGNOSIS_13 ICDDx: 4912*, 4932*, 496*, 5064* EMPHYSEMA_DIAGNOSIS ICDDx: 492*, 5181*, 5182* ASTHMA PROVIDER REPTED_EXCLUSION Provider reported asthma exclusion via GIC worksheet INDICATION_OF_CAD CPTPx: 33140, , , , , , 92984, ICDDx: , 4140*, 4148*, 4149*, V4581, V4582 PRI_MYOCARDIAL_INFARCTION ICDDx: , 412* Beta Blocker Prior MI (CAD) BETA_BLOCKER_PRESCRIPTION RxCategory: BETABL13 and Claim Status 'D' or 'I' Large custom NDC listing CPT 4008F without CPTMod 1P, 2P, 3P BETA_BLOCKER_EXCLUSION ICDDx: 42781, 42789, 4580*, 4581*, 45821, 45829, 4588*, 4589*, AV_BLOCK ICDDx: 4260*, 42612, PERMANENT_PACEMAKER ICDDx: V4501 CAD PROVIDER REPTED_EXCLUSION Provider reported exclusion on worksheet DIAGNOSIS_HEART_FAILURE ICDDx: Begins with 402 with digit 4=0,1,9 and digit 5=1 Begins with 404 with digit 4=0,1,9 and digit 5=1,3 Begins with 428 with digit 4=0,1,9 Begins with 428 with digit 4=2,3,4 and digit 5=0,1,2,3 INDICATION_OF_LVSD CPTPx: 3021F, 78414, 78468, , , 78483, 78494, , , 93312, , 93317, 93350, BETA_BLOCKER_EXCLUSION ICDDx: 42781, 42789, 4580*, 4581*, 45821, 45829, 4588*, 4589*, AV_BLOCK ICDDx: 4260*, 42612, PERMANENT_PACEMAKER ICDDx: V4501 HF PROVIDER REPTED_EXCLUSION Provider reported exclusion on GIC worksheet Beta Blocker Therapy (HF) BETA_BLOCKER_PRESCRIPTION RxCategory: BETABL13 and Claim Status 'D' or 'I' Large custom NDC listing CPT 4008F without CPTMod 1P, 2P, 3P Page 4 of 13

5 BILATERAL_MASTECTOMY_14 ICDPx: 8542, 8544, 8546, 8548 [CPTPx: 19180*, 19200*, 19220*, 19240*, 19303*-19307* CPTMod: 50*] Breast Cancer Screen MAMMOGRAM_14 CPTPx: UBRevCode: 0401, 0403 ICDPx: 8736, 8737 HCPCSPx: G0202, G0204, G0206 BCS PROVIDER REPTED Provider reported breast cancer screening via GIC worksheets MR_BILATERAL_MASTECTOMY_PRI_YEARS Medical Record evidence of Bilateral Mastectomy [LT_UNILATERAL_MASTECTOMY_14 CPTPx: 19180, 19200, 19220, 19240, ICDPx: 8541*, 8543*, 8545*, 8547* CPTMod=LT RT_UNILATERAL_MASTECTOMY_14 CPTPx: 19180, 19200, 19220, 19240, ICDPx: 8541*, 8543*, 8545*, 8547* CPTMod=RT] BCS PROVIDER REPTED_EXCLUSION Provider reported exclusion on GIC worksheet Cervical Cancer Screen Step 1 Numerator Codes: PAP TEST_14 CPTPx: , 88147, 88148, 88150, , , 88174,88175 HCPCSPx: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 ICDPx: 9146 UBRev: 0923 LOINC: , , , , , , , , , MR_PAP_TEST_PRI_YEARS Medical record documentation of pap test in prior years. GIC_CCS Provider reported cervical cancer screening via GIC worksheets Step 2 Numerator Codes: HPV_TEST_14 LOINC: , , , , CPTPx: 87620, 87621, MR_PAP_TEST_PRI_YEARS Medical record documentation of HPV test in prior years. HYSTERECTOMY_NO_RESIDUAL_CERVIX_14 CPTPx:51925,56308,57540,57545,57550,57555,57556,58150,58152,58200,58210,58240,58 260,58262,58263,58267,58270,58275,58280,58285,58290,58291,58292,58293,58548, , ,58951, ,58956,59135 ICDPx: 684, 6841, 6849, 685, 6851, 6859, 686, 6861, 6869, 687, 6871, 6879, 688 ICDDx: EXCLUDE POS=LA EXCLUDE CPTPx=8* 6185*, 75243*, V6701*, V7647,V8801, V8803 MR_HYSTERECTOMY_PRI_YEARS Medical record documentation of hyterectomy in prior years. CCS PROVIDER REPTED EXCLUSION Provider reported exclusion on GIC worksheet Chicken Pox Vaccine CHICKEN_POX_VACCINATION CPTPx: 90710, Provider reported chicken pox vaccination via GIC worksheets. Medical record documentation of chicken pox vaccination Medical record documentation of anaphylactic reaction in prior years. HIV_INFECTED HIV_HOUSEHOLD ICDDx: 042*, V08* Medical record documentation of HIV-infected patient or household in prior years. IMMUNODEFICIENCY_INCL_GENETIC ICDDx: 279* Medical record documentation of immunodeficiency in prior years. LEUKEMIA ICDDx: 204*-208* Medical record documentation of leukemia in prior years. LYMPHETICULAR_HISTIOCYTIC_CANCER ICDDx: 200*-202* Medical record documentation of lymphoma/cancer history in prior years. REACTION_TO_NEOMYCIN Medical record documentation of reaction to neomycin in prior years. CHICKEN_POX_HISTY ICDDx: 052*-053* Medical record documentation of chicken pox n in prior years. MULTIPLE MYELOMA Page 5 of 13

6 Chlamydia Screening CHLAMYDIA_SCREENING_14 CPTPx: 87110, 87270, 87320, 87490, 87491, 87492, LOINC: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,4993-2, , , ,557-9,560-3,6349-5,6354-5, GIC_CHL_SCREEN Provider reported chlamydia screening on GIC worksheet CONTRACEPTIVE_PRESCRIPTION_14 RxCategory: CHLYMALL14 PREGNANCY_14 ICDDx: Any of an extremely large set of pregnancy-related diagnosis codes (too many to list in this format), where POS <>LA CHLAMYDIA_SCREENING_14 CPTPx: 87110, 87270, 87320, 87490, 87491, 87492, LOINC: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,4993-2, , , ,557-9,560-3,6349-5,6354-5, SEXUAL_ACTIVITY_14 ICDDx: Any of an extremely large set of sexual activity-related diagnosis codes (too many to list PREGNANCY_TEST_14 in this format) CPTPx: 81025,84702,84703 CPTPx: Any of an extremely large set of sexual activity-related procedure codes (too many to UBRevCode:0925 list in this format) LOINC: , , , ,2106-3,2107-1,2110-5,2111-3,2112-1,2113-9,2114-7,2115- UBRevCode: 0112, 0122, 0132, 0142, 0152, , 0724, 0729, ,2118-8,2119-6, , , , , , , , LOINC: Any of an extremely large set of sexual activity-related LOINC codes (too many to list in this format) GIC_CHL_EXCLUSION HCPCS:G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, G0450, H1000- Provider reported exclusion on GIC worksheet H1001, H1003-H1005, P3000, P3001, Q0091, S0199, S4981, S8055 ICDPx: Any of an extremely large set of sexual activity-related ICD procedure codes (too many to list in this format) Colorectal Cancer Screen FLEXIBLE_SIGMOIDOSCOPY CPTPx: , , ICDPx: 4524 HCPCSPx: G0104 COLONOSCOPY CPTPx: , 44397, 45355, , ICDPx:4522, 4523, 4525, 4542, 4543 HCPCSPx: G0105, G0121 FECAL_OCCULT_BLOOD_TEST CPTPx: 82270, LOINC: , , , , , , , , , , , , , , HCPCSPx: G0328 PROVIDER REPTED_COLECTAL_SCREENING Provider reported colorectal screening via GIC worksheets. COLECTAL_CANCER_DIAGNOSIS HCPCSPx: G0213-G0215, G0231 TOTAL_COLECTOMY CPTPx: , , PROVIDER REPTED COL EXCLUSION Provider reported exclusion on worksheet Controlling High Blood Pressure <140/90 GIC_BP_DIASTOLIC_LT_90 Diastolic <90 GIC_BP_SYSTOLIC_LT_140 Systolic <140 MR_BP_DIASTOLIC_LT_80_PRI_YEARS Diastolic <80 MR_BP_DIASTOLIC_LT_90_13_PRI_YEARS Diastolic <90 MR_BP_SYSTOLIC_LT_140_PRI_YEARS Systolic<140 BP_DIASTOLIC_LT_80_13 Diastolic <80 BP_DIASTOLIC_LT_90_13 Diastolic<90 BP_SYSTOLIC_LT_140_13 Systolic <140 Currently enrolled members between the ages of during the reporting period. OUTPATIENT_DX_OF_HYPERTENSION_13: ICDDx: 401* CPTPx: , , , , END_STAGE_RENAL_DISEASE_13: CPTPx: 36145, 36147, 36800, 36810, 36815, , , 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90920, 90921, 90924, 90925, 90935, 90937, 90940, 90945, 90947, , 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999,99512 HCPCS: G0257, G0308-G0319, G0322, G0323, G0326, G0327, G0392, G0393, S9339 ICDDx: 5855*, 5856*, V420*, V451* ICDPx: 3895, 3927, 3942, 3943, 3953, , 5498, 556* UBRevCode: 0367, , , TOB begins between Z HCFAPOS: 65 MR_END_STAGE_RENAL_DISEASE_PRI_YEARS: Medical record evidence of end stage renal disease in prior years NONACUT_CARE_EXCLUSION_TO_CPB_FUH_13: HCPCSPx: H0017-H0019, T2048 UBRevCode: 0115,0125, 0128, 0135, 0138, 0145, 0148, 0155, 0158, , 0650,0655,0656,0658,0659,1001,1002 TOB begins between Z, Z, Z, Z, Z, Z HCFAPOS: 31,32,34,54-56,61 MR_NONACUTE_INPAT_EPISODE_PRI_YEARS: Medical record evidence of non-acute inpatiend episode in prior years GIC_HTN_EXCLUSION_13: Provider reported exclusion on worksheet (HomegrownPx=GIC_HTN_EXCLUSION) GIC_BP_DIASTOLIC_GE_90 Diastolic >=90 GIC_BP_DIASTOLIC_LT_90 Diastolic <90 GIC_BP_SYSTOLIC_GE_140 Systolic >=140 GIC_BP_SYSTOLIC_LT_140 Systolic <140 MR_BP_DIASTOLIC_LT_80_13 Diastolic <80 MR_BP_DIASTOLIC_LT_80_PRI_YEARS Diastolic <80 MR_BP_DIASTOLIC_LT_90_13 Diastolic <90 MR_BP_DIASTOLIC_LT_90_13_PRI_YEARS Diastolic <90 Page 6 of 13

7 OUTPATIENT_DX_OF_HYPERTENSION ICDDx: 401* CPTPx: , , , , END_STAGE_RENAL_DISEASE CPTPx: 36145, 36147, 36800, 36810, 36815, , , 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90920, 90921, 90924, 90925, 90935, 90937, 90940, 90945, 90947, , 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999,99512 HCPCS: G0257, G0308-G0319, G0322, G0323, G0326, G0327, G0392, G0393, S9339 ICDDx: 5855*, 5856*, V420*, V451* ICDPx: 3895, 3927, 3942, 3943, 3953, , 5498, 556* UBRevCode: 0367, , , TOB begins between Z MR_END_STAGE_RENAL_DISEASE_PRI_YEARS: Medical record evidence of end stage renal disease in prior years Controlling High Blood Pressure - Medication Adherence ANTIHYPERTENSIVE MEDS NONACUTE_CARE_EXCLUSION_TO_CBP_FUH_ HCPCSPx: H0017-H0019, T2048 UBRevCode: 0115,0125, 0128, 0135, 0138, 0145, 0148, 0155, 0158, , 0650,0655,0656,0658,0659,1001,1002 TOB begins between Z, Z, Z, Z, Z, Z HCFAPOS: 31,32,34,54-56,61 MR_NONACUTE_INPAT_EPISODE_PRI_YEARS: Medical record evidence of non-acute inpatient episode in prior years HYPERTENSION PROVIDER REPTED EXCLUSION Provider reported exclusion on GIC worksheet Diabetes Eye Exam RETINAL_OPHTHALMOSCOPIC_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, 92260, , , and Prov Type=VC ICDPx: , 149, 950, 950 and Prov Type=VC HCPCSPx:(S0620, S0621, S3000 and Prov Type=VC), S0625 CPT2: 2022F, 2024F, 2026F, 3072F Medical record doumentation of retinal exam in prior years. PROVIDER REPTED EYE EXAM Provider reported eye exam via GIC worksheets. HCFAPOS: 65 AMBULATY_NON_ACUTE_DIABETIC_VISIT [CPTPx: , , , , , , 99318, , , , , , , , , 99420, 99429, ICDDx: 250*, 3572*, 3620*, 36641, 6480] [UBRevCode: 0118, 0128, 0138, 0148, 0158, , , , , , , , CDDx: 250*, 3572*, 3620*, 36641, 6480] ACUTE_ER_DIABETIC_VISIT [UBRevCode: , , 0119, , 0129, , 0139, , 0149, , 0159, , , , , , 0981, 0987 ICDDx: 250*, 3572*, 3620*, 36641, 6480] [ICDDx: 250*, 3572*, 3620*, 36641, 6480 CPTPx: , , , , 99291] AMBULATY_INSULIN_HYPOGLYCEMIC_RX NDC: RxCategory DIABETES13 EXCLUDE SupplyFlag=Y STEROID_INDUCED_DIABETES ICDDx: 249*, 2518*, 9620* GESTATIONAL_DIABETES ICDDx: 6488* Medical record documentation of gestational diabetes in prior years. POLYCYSTIC_OVARIES_13: ICDDx: 2564* Medical record documentation of polycystic ovary disease in prior years. PROVIDER REPTED CDC_EXCLUSION Provider reported CDC exclusion via GIC worksheet Diabetes HbA1c Test HBA1C_TEST CPT: 83036, CPT2: 3044F, 3045F, 3046F LOINC: , , , , , Provider reported HbA1c test via GIC worksheets. Medical record documentation of an HbA1c test in prior years AMBULATY_NON_ACUTE_DIABETIC_VISIT [CPTPx: , , , , , , 99318, , , , , , , , , 99420, 99429, ICDDx: 250*, 3572*, 3620*, 36641, 6480] [UBRevCode: 0118, 0128, 0138, 0148, 0158, , , , , , , , CDDx: 250*, 3572*, 3620*, 36641, 6480] ACUTE_ER_DIABETIC_VISIT [UBRevCode: , , 0119, , 0129, , 0139, , 0149, , 0159, , , , , , 0981, 0987 ICDDx: 250*, 3572*, 3620*, 36641, 6480] [ICDDx: 250*, 3572*, 3620*, 36641, 6480 CPTPx: , , , , 99291] AMBULATY_INSULIN_HYPOGLYCEMIC_RX NDC: RxCategory DIABETES13 EXCLUDE SupplyFlag=Y STEROID_INDUCED_DIABETES ICDDx: 249*, 2518*, 9620* GESTATIONAL_DIABETES ICDDx: 6488* Medical record documentation of gestational diabetes in prior years. POLYCYSTIC_OVARIES ICDDx: 2564* Medical record documentation of polycystic ovary disease in prior years. GIC_CDC_EXCLUSION Provider reported exclusion on GIC worksheet Page 7 of 13

8 Diabetes Macroalbumin Test GIC_ALBUMIN Provider response from GIC worksheet. MACROALBUMINURIA_TEST_POSTIIVE CPT: , CPT2: 3062F LOINC: , , , Medical record documentation of macroalbuminuria POS in prior years NEPHROPATHY_SCREENING CPTPx: , CPT2: 3060F, 3061F NEPHROPATHY_ATTENTION CPTPx: 36147, 36800, 36810, 36815, 36818, 36819, 36820, 36821, , 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947, , 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, UBRevCode: 0367, , , Provider Type: NEPH ICDPx: 3895, 3927, 3942, 3943, 3953, 3993, 3995, 5498, ICDDx: 2504*, 403*, 404*, 40501, 40511, 40591, 580*-588*, 7530*, 7531*, 7910*, V420*, V451* CPT2: 3066F, 4009F, 4010F HCPCSPx: G0527, S9339 NDC: RxCategory ACEARB13 AMBULATY_NON_ACUTE_DIABETIC_VISIT AMBULATY_INSULIN_HYPOGLYCEMIC_RX [CPTPx: , , , , , NDC: RxCategory DIABETES , 99318, , , , , , , , , 99420, 99429, EXCLUDE SupplyFlag=Y STEROID_INDUCED_DIABETES ICDDx: 249*, 2518*, 9620* ICDDx: 250*, 3572*, 3620*, 36641, 6480] [UBRevCode: 0118, 0128, 0138, 0148, 0158, , , , , , , , GESTATIONAL_DIABETES ICDDx: 6488* Medical record documentation of gestational diabetes in prior years. POLYCYSTIC OVARIES Diphtheria/Tetanus/Pertussis Vaccine (DTaP) DTAP_VACCINATION_13: ICDPx: 9939 CPTPx: 90968, 90700, 90721, Provider reported DTaP via GIC worksheets. Medical Record documentation of DTaP vaccination ENCEPHALOPATHY_FOLLOWING_IMM ICDDx: 32351* Event Cholesterol Test (CAD) LDL_C_SCREENING CPTPx:3048F-3050F, 80061, , 83704, LOINC: , , , , , , , , , Provider reported screening via GIC worksheets. IVD_INPATIENT_VISIT [ICDDx: 411*, 413*, 4140*, 4142*, 4148*, 4149*, 4292*, 433*, 434*, 4401*, 4402*, 4404*, 444*, 445* CPTPx: , , , 99291] [ICDDx: 411*, 413*, 4140*, 4142*, 4148*, 4149*, 4292*, 433*, 434*, 4401*, 4402*, 4404*, 444*, 445* UBRevenueCode: , , , , , , , , 0987] IVD_OUTPATIENT_VISIT [ICDDx: 411*, 413*, 4140*, 4142*, 4148*, 4149*, 4292*, 433*, 434*, 4401*, 4402*, 4404*, 444*, 445* CPTPx: , , , , , , , , , 99411, 99412, 99420, 99429, ] [ICDDx: 411*, 413*, 4140*, 4142*, 4148*, 4149*, 4292*, 433*, 434*, 4401*, 4402*, 4404*, 444*, 445* UBRevenueCode: , , , ] PTCA_PROCEDURE CPTPx: 92980, 92982, ICDPx: 0066*, 3606*, 3607* HCPCSPx: G0290 ACUTE_DISCHARGE_ANY_DIAGNOSIS [POS:IA RoomBoardFlag:Y] NON_ACUTE_DISCHARGE_ANY_DIAGNOSIS [POS:IN RoomBoardFlag:Y] AMI_CABG_INPATIENT_DIAGNOSIS [POS: IA, IN ICDDx: with digit 5=1] CABG_PROCEDURE [HCPCS: S2205-S2209 POS: IA, IN] [CPTPx: , , , POS: IA, IN] [ICDDxPri: 361*, 362* POS: IA, IN] DECEASED DischgStatus: 20, 22-29, or Med records indicating deceased CAD_ PROVIDER REPTED EXCLUSION Provider reported CAD exclusion via GIC worksheet. Page 8 of 13

9 Glaucoma Screening in Older Adults GLAUCOMA_SCREENING ProviderType: VC 92002, 92004, 92014, , 92100, 92120, 92130, 92140, , , GLAUCOMA_DIAGNOSIS ICDDx: 3650*-3659*, GLAUCOMA_PROVIDER REPTED EXCLUSION Provider reported glaucoma exclusion via GIC worksheet Provider reported glaucoma screening via GIC worksheet H Influenza Type B Vaccine HIB_VACCINATION CPTPx: 90645, 90646, 90647, 90648, 90698, 90721, Provider reported HiB vaccination via GIC worksheets. Medical record documentation of HIB vaccination Medical record documentation of anaphylactic reaction in prior years. Hepatitis B Vaccine HEPATITIS_B_VACCINATION CPTPx: 90723, 90740, 90744, 90747, HCPCSPx: G0010 Provider reported HepB vaccination via GIC worksheets. HEPATITIS B HISTY ICDDx: 0702, 0703, V0261 Medical record documentation of Hep B history in prior years Medical record documentation of anaphylactic reaction in prior years. HEPATITIS_B_HISTY ICDDx: 0702*, 0703*, V0261 Medical record documentation of Hep B history in prior years LDL Lowering Drug Therapy (CAD) LIPID_LOWERING_DRUG NDC: Large, manually entered NDC listing. CPTPx: 4013F with CPTMod 1P, 2P or 3P INDICATION_OF_CAD CPTPx: 33140, , , , , , 92984, ICDDx: , 4140*, 4148*, 4149*, V4581, V4582 ADVERSE_EFFECT_CODES ICDDx:9950*, 9951*, 99527, ICDDx: E9422* LIPID_THERAPY_EXCLUSION [LOINC: , , , , , , , Result between 1.00 and ] [CPTPx: 80061, 83700, 83701, 83704, 83721] Result between 1.00 and ] CPTPx: 3048F, 3049F [CPTPx: 4013F with CPTMod 1P, 2P 3P] Page 9 of 13

10 Lead Screening in Children LEAD_SCREENING_14 CPTPx: LOINC: , , , , , , , , GIC_LEAD_SCREEN Provider reported lead screening via GIC worksheets. MR_LEAD_SCREENING_PRI_YEARS Medical Record evidence of lead screening Lipid Test (CDC) - for Diabetes LDL_C_SCREENING CPTPx: 80061, , 83704, 83721, 3048F, 3049F, 3050F LOINC: , , , , , , , , , Provider reported lipid screening via GIC worksheets. AMBULATY_NON_ACUTE_DIABETIC_VISIT [CPTPx: , , , , , , 99318, , , , , , , , , 99420, 99429, ICDDx: 250*, 3572*, 3620*, 36641, 6480] [UBRevCode: 0118, 0128, 0138, 0148, 0158, , , , , , , , CDDx: 250*, 3572*, 3620*, 36641, 6480] ACUTE_ER_DIABETIC_VISIT [UBRevCode: , , 0119, , 0129, , 0139, , AMBULATY_INSULIN_HYPOGLYCEMIC_RX NDC: RxCategory DIABETES13 EXCLUDE SupplyFlag=Y STEROID_INDUCED_DIABETES ICDDx: 249*, 2518*, 9620* GESTATIONAL_DIABETES ICDDx: 6488* Medical record documentation of gestational diabetes in prior years. POLYCYSTIC_OVARIES ICDDx: 2564* Medical record documentation of polycystic ovary disease in prior years. GIC_CDC_EXCLUSION Provider reported exclusion on GIC worksheet Lipid Test (CMC) - for Coronary Artery Disease LIPID_PROFILE_CHOLESTEROL CPTPx: LOINC: , , , Provider reported lipid screening via GIC worksheets. LIPID_PROFILE_FULL CPTPx: 3011F, LOINC: , , , LIPID_PROFILE_HDL CPTPx: LOINC: , LIPID_PROFILE_TRIG CPTPx: LOINC: , , , , , LIPID_PROFILE_LDL CPTPx: 83700, 83701, 83704, LOINC: , , , , , , , INDICATION_OF_CAD_GIC CPTPx: 33140, , , , , , 92984, ICDDx: , 4140*, 4148*, 4149*, V4581, V4582 CAD_PROVIDER REPTED EXCLUSION_ Provider reported CAD exclusion via GIC worksheets LVF Assessment (HF) LVF_ASSESSMENT CPTPx: 78414, 78452, 78468, 78472, 78473, 78481, 78483, 78492, 78494, 93303, 93304, 93306, 93307, 93308, 93312, 93314, 93315, 93317, 93350, Provider reported LVF assessment via GIC worksheets. LVF RESULT CPTPx: 3020F DIAGNOSIS_HEART_FAILURE ICDDx: Begins with 402 with digit 4=0,1,9 and digit 5=1 Begins with 404 with digit 4=0,1,9 and digit 5=1,3 Begins with 428 with digit 4=0,1,9 Begins with 428 with digit 4=2,3,4 and digit 5=0,1,2,3 GIC_HF_EXCLUSION Provider reported exclusion on worksheet (HomegrownPx=GIC_HF_EXCLUSION Page 10 of 13

11 Measles Mumps Rubella Vaccine MEASLES_VACCINATION ICDPx: 9945, 9948 CPTPx: 90705, 90707, 90708, Medical record documentation in prior years Provider reported MMR vacc via GIC worksheets. MEASLES_HISTY ICDDx: 055* Medical record documentation in prior years MUMPS_VACCINATION ICDDx: 9946, 9948 CPTPx: 90704, 90707, Medical record documentation in prior years MUMPS_HISTY ICDDx: 072* Medical record documentation in prior years RUBELLA_VACCINATION ICDPx: 9947, 9948 CPTPx: , Medical record documentation in prior years Medical record documentation of anaphylactic reaction in prior years. HIV_INFECTED HIV_HOUSEHOLD ICDDx: 042*, V08* Medical record documentation of HIV-infected patient or household in prior years. IMMUNODEFICIENCY_INCL_GENETIC ICDDx: 279* Medical record documentation of immunodeficiency in prior years. LEUKEMIA ICDDx: 204*-208* Medical record documentation of leukemia in prior years. LYMPHETICULAR_HISTIOCYTIC_CANCER ICDDx: 200*-202* Medical record documentation of lymphoma/cancer history in prior years. MULTIPLE_MYELOMA ICDDx: 203* Medical record documentation of myeloma history in prior years. MR_CHICKEN_POX_HISTY_PRI_YEARS: Medical record documentation of chicken pox n in prior years. REACTION_TO_NEOMYCIN Medical record documentation of reaction to neomycin in prior years. MUMPS _HISTY ICDDx: 072* Medical record documentation of mumps in prior years RUBELLA HISTY FRACTURE ((ICDPx: Begins with 79 with digit 3 in {0,1,2,3,6} and digit 4 in {1,2,3,5,6,7}) (ICDPx: )) ICDDx: 7331*, , 805*-806*, 8070*-8074*, 808*-815*, 818*-825*, 827*-828* ED_VISIT_OMW CPTPx: UBRevCode: 045*, 0981* BONE_MINERAL_DENSITY_TEST CPTPx: 76977, , 78350, ICDPx:8898 HCPCSPx: G0130 OSTEOPOSIS_MEDICATION_PRESCRIPTION_ NDC: RxCategory OSTEO13 HCPCSPx: J0630, J0897, J1000, J1740, J3110, J3487, J3488 OSTEOPOSIS_PROVIDER REPTED EXCLUSION Prvoider reported exclusion via GIC worksheet Osteoporosis Management in Women Who Have Had a Fracture BONE_MINERAL_DENSITY_TEST CPTPx: 76977, , 78350, ICDPx:8898 HCPCSPx: G0130 OSTEOPOSIS_MEDICATION_PRESCRIPTION NDC: RxCategory OSTEO13 HCPCSPx: J0630, J0897, J1000, J1740, J3110, J3487, J3488 Provider reported osteoporosis treatment via GIC worksheet CPTPx: 21800, 21805, 21810, 21825, 22305, 22310, 22318, 22319, 22520, 22521, 22523, 22524, 23500, 23505, , 23570, 23575, 23585, 23600, 23605, 23615, 23616, 23620, 23625, 23630, 23665, 23670, 23675, 23680, 24500, 24505, 24515, 24516, 24530, 54535, 24538, 24545, 24546, 24560, 24565, 24566, , 24579, 24582, 24620, 24635, 24650, 24655, 24665, 24666, 24670, 24675, 24685, 25500, 25505, 25515, 25520, 25525, 25526, 25530, 25535, 25545, 25560, 25565, 25574, 25575, 25600, , 25622, 25624, 25628, 25630, 25635, 25645, 25650, 25651, 25652, 25680, 25685, 26600, 26605, 26607, 26608, 26615, 27193, 27194, 27200,27202, , 27220, 27222, , 27230, 27232, 27235, 27236, 27238, 27240, 27244, 27245, 27246, 27248, 27254, , , , 27513, 27514,27520, 27524, 27530, 27532, 27535, 27536, 27538, 27540, 27750, 27752, 27756, , 27762, , 27780, 27781, 27784, 27786, 27788, 27792, 27808, 27810, 27814, 27816, 27818, , 28400, 28405, 28406, 28415, 28420, 28430, 28435, 28436, 28445, 28450, 28455, 28456, 28465, 28470, 28475, 28476, 28485, 29850, 29851, HCPCSPx: S2360 INPATIENT_VISIT_OMW CPTPx: , , 99238, 99239, , 99291, , 99315, 99316, 99318, , UBRevCode: 010*, , , , , 0148, 0154, , 016*, 019*, 020*, 021*, , 055*, 066*, 072*, 0987* OUTPATIENT_VISIT_OMW CPTPx: , , , , , , 99387, 99397, , 99411, 99412, 99420, 99429, 99455, UBRevCode: 051*, 0520*-0523*, 0526*-0529*, 057*-059*, 0982*-0983* ANY_INPATIENT_EPISODE RoomBoardFlag: Y POS: BC, IA, IN Pneumococcal Conjugate Vaccine PNEUMOCOCCAL_CONJUGATE_VACCINATION CPTPx: 90669, HCPCS: G0009 Provider reported PCV vacc via GIC worksheets. Medical record documentation of PCV in reporting year Medical record documentation of PCV in prior years Medical record documentation of anaphylactic reaction in prior years. Page 11 of 13

12 Polio Vaccine POLIO_VACCINATION ICDPx: 9941 CPTPx: 90698, 90713, Provider reported Polio vacc via GIC worksheets. Medical record documentation of Polio in reporting year Medical record documentation of Polio in prior years Medical record documentation of anaphylactic reaction in prior years.. STREPTOMYCIN_POLYMYXINB_REACTION Medical record documentation of streptomycin reaction in prior years. Primary Care Visit 1 to 2 years PCP_VISIT CPTPx: , , , , , , , , , 99420, and Provider Type=NPCP or PCP CPTPx (addnl): , , , , , , , , , 99420, and PCPFlag=Y ICDDx: V202, V70 and Provider Type=NPCP or PCP ICDDx (addnl): V202, V70 and PCPFlag=Y HCPCSPx: G0438, G0439 and PCPFlag=Y HCPCSPx (addnl): G0438, G0439 and Provider Type=NPCP or PCP Provider reported PCP visit via our GIC worksheets. Well Child Visit 3 to 6 Years WELL_CHILD_VISIT ((CPTPx:99382, 99383, 99392, 99393) (PCPFlag=Y) (EXCLUDE POS ER, IA, IN)) ((ICDDx: V202, V700, V703, V705, V706, V708) (PCPFlag=Y) (EXCLUDE POS: ER, IA, IN)) ((CPTPx (addnl): CPTPx:99382, 99383, 99392, 99393) (EXCLUDE POS ER, IA, IN ) (ProvType=NPCP, PCP)) ((ICDDx (addnl): V202, V700, V703, V705, V706, V708, V709) (EXCLUDE POS: ER, IA, IN) (ProvType=NPCP, PCP)) ((HCPCSPx: G0438, G0439) (EXCLUDE POS: ER, IA, IN) (ProvType=NPCP, PCP)) ((HCPCSPx (addnl): G0438 G0439) (EXCLUDE POS: ER IA IN) Page 12 of 13

13 WELL_CHILD_VISIT_711_13: ((CPTPx: 99383, 99393) (PCPFlag=Y) (EXCLUDE POS=ER, IA, IN) ((CPTPx (addnl): 99383, 99393) (ProvType=NPCP, PCP) (EXCLUDE POS: ER, IA, IN)) ((ICDDx: V202, V700, V703, V705, V706, V708, V709) (PCPFlag=Y) (EXCLUDE POS: ER, IA, IN)) Well Child Visit 7 to 11 Years ((ICDDx (addnl): V202, V700, V703, V705, V706, V708, V709) (PCPFlag=Y) (EXCLUDE POS: ER, IA, IN) (ProvType=NPCP, PCP)) ((HCPCSPx: G0438, G0439) (EXCLUDE POS: ER, IA, IN) (ProvType=NPCP, PCP)) ((HCPCSPx (addnl): G0438, G0439) (EXCLUDE POS: ER, IA, IN) (PCPFlag=Y) Provider reported Well Visit via our GIC worksheets. Page 13 of 13