HEDIS/QARR 2017 Quick Reference Guide ALL MEASURES

Transcription

1 2017 HEDIS s

2 HEDIS/QARR 2017 Quick Reference Guide ALL MEASURES Measure Age Band Denominator Event Numerator Requirement Line of Business AAB Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Adults Access to Preventive/ Ambulatory Health Services Adults are identified for the eligible population: Diagnosed with acute bronchitis through outpatient or ED visit between January 1 and December 24 of the measurement year. 20+ Entire eligible population. Antibiotics should not be prescribed for adults with a diagnosis of acute bronchitis. Adults ages 20 years and older should have at least one ambulatory or preventive care visit. Medicaid HARP QHP EP Medicaid Medicare HARP EP ABA Adult BMI Assessment Adults who had an outpatient visit during the measurement year or the year prior to the measurement year. Adults years old should have a BMI documented at least once per year: Members 20 years of age or older on the date of service should have a BMI value during the measurement year or the year prior to the measurement year. Members younger than 20 years of age on the date of service should have a BMI percentile during the measurement year or the year prior to the measurement year. Medicaid Medicare QHP EP Follow-Up Care for Children Prescribed 6 12 Children with newly prescribed medication for attention-deficit/ hyperactivity disorder (ADHD). At least three follow-up care visits within a 10-month period, one of which should be within 30 days of when the first ADHD medication was dispensed. Two rates are reported: 1. : Children with an ambulatory prescription dispensed for ADHD medication should have one follow-up visit with a practitioner with prescribing authority during the 30-day. 2. Continuation and Maintenance Phase: Children with an ambulatory prescription dispensed for ADHD medication who remained on the medication for at least 210 days should have two or more followup visits with a practitioner from 31 to 300 days after the ADHD medication was newly prescribed. Medicaid HARP QHP EP ADL Adolescent Preventive Care Entire eligible population. Adolescents years old should have the following documented during measurement year: 1. Assessment/Counseling/Education on risk behaviors and preventive actions associated with Sexual Activity. 2. Assessment/Counseling/Education for Depression. 3. Assessment/Counseling/Education about the risk factors of Tobacco Usage. 4. Assessment/Counseling/Education about the risk factors of Substance Abuse (including alcohol, excluding tobacco). Medicaid Medicare EP ADV Annual Dental Visit 2 20 Entire eligible population. Children 2 20 years old should have an annual preventive dental visit with a dental practitioner. All Dental claims MUST be submitted to DentaQuest. Medicaid HARP QHP 2 Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies.

3 HEDIS/QARR 2017 Quick Reference Guide ALL MEASURES Measure Age Band Denominator Event Numerator Requirement Line of Business AMM AMR APC APM APP ART Antidepressant Medication Management Asthma Medication Ratio Use of Multiple Concurrent Antipsychotics in Children and Adolescents Metabolic Monitoring for Children and Adolescents on Antipsychotics Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis Adults who were treated with antidepressant medication and had a diagnosis of major depression and remained on an antidepressant medication treatment. Children and adults with at least one of the following criteria during both the measurement year and the year prior to the measurement year: 1. At least one ED visit, with a principal diagnosis of asthma. 2. At least one acute inpatient encounter, with a principal diagnosis of asthma. 3. 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. Visit type need not be the same for the four visits. 4. At least four asthma medication dispensing events. Children and adolescents with 90 days of continuous antipsychotic medication treatment during the measurement year. Children and adolescents who were on two or more antipsychotic prescriptions. Children and adolescents who had a new prescription for an antipsychotic medication during the measurement year. Adults are identified for the eligible population by any two of the following events on different dates of service between January 1 and November 30 of the measurement year: 1. Outpatient visit with any diagnosis of rheumatoid arthritis, or 2. Nonacute inpatient discharge with any diagnosis of rheumatoid arthritis. Two rates are reported: 1. Effective Acute Phase Treatment The percentage of members who remained on an antidepressant medication for at least 84 days. 2. Effective Continuation Phase Treatment The percentage of members who remained on an antidepressant medication for at least 180 days. Children and adults ages 5 85 diagnosed with persistent asthma should have a ratio of controller medications to total asthma medications of 0.50 or greater. Children and adolescents on two or more concurrent antipsychotic medications for at least 90 consecutive days during the measurement year. *LOWER RATE IS BETTER Children and adolescents on two or more antipsychotic medications should have both of the following during the measurement year: 1. At least one test for blood glucose or HbA1c. 2. At least one test for LDL-C or cholesterol. Children and adolescents who had a new prescription dispensed for an antipsychotic medication should have documentation of psychosocial care in the 121-day period from 90 days prior to the earliest antipsychotic medication dispensing event through 30 days after the earliest antipsychotic medication dispensing event. Adults 18 years and older diagnosed with Rheumatoid Arthritis should be dispensed at least one prescription for a disease modifying anti-rheumatic drug (DMARD). DO NOT use Rheumatoid Arthritis diagnosis codes when Ruling Out the disease. Medicaid Medicare HARP QHP EP Medicaid Medicare HARP EP Medicaid HARP EP Medicaid HARP EP Medicaid HARP EP Medicaid Medicare HARP EP Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies. 3

4 HEDIS/QARR 2017 Quick Reference Guide ALL MEASURES Measure Age Band Denominator Event Numerator Requirement Line of Business AWC Adolescent Well-Care Entire eligible population. BCS CAP Breast Cancer Screening Children s and Adolescents Access to Primary Care Practitioners Adolescents should have at least one comprehensive well-care visit annually with a PCP or an OB/GYN practitioner Entire eligible population. Women years old should have a mammogram every two years. 12 months 19 years old Entire eligible population. Children 12 months 19 years old should have an annual visit with their PCP. Medicaid HARP EP Medicaid Medicare HARP QHP EP Medicaid HARP EP CBP Controlling High Blood Pressure Adults are identified as hypertensive by: One outpatient visit with a diagnosis of hypertension during the first six months of the measurement year. Adults years old should have their Blood Pressure documented at least once per year: Members Goal: <140/90mm Hg (most recent reading) Members with a diagnosis of diabetes Goal: <140/90mm Hg (most recent reading) Members without a diagnosis of diabetes Goal: <150/90mm Hg (most recent reading) Medicaid Medicare QHP EP CCS Cervical Cancer Screening Entire eligible population. Women years old should be screened for cervical cancer using either of the following: years old cervical cytology every 1 3 years years old cervical cytology with HPV co-testing every 1 5 years. Medicaid QHP EP CDC Comprehensive Diabetes Care Adults are indentified as having diabetes by claim/encounter data during the measurement year or year prior: 1. At least two outpatient visits, observation, ED visits, or nonacute inpatient encounters, or 2. At least one acute inpatient encounter with a diagnosis of diabetes. 3. Pharmacy data: Members who were dispensed insulin or hypoglycemics/ antihyperglycemics on an ambulatory basis. Adults years old diagnosed with diabetes (type 1 and 2) should have each of the following at least annually: 1. HbA1c testing Goal: <7.0% (most recent in measurement year). 2. Blood Pressure Goal: <140/90mm HG (most recent in measurement year). 3. Medical Attention for Nephropathy: Urine Protein test, or ACE/ARB prescription or Evidence of treatment for nephropathy. 4. Dilated or retinal eye exam by an eye care professional (annually) or negative for retinopathy in the year prior to the measurement year. Medicaid Medicare QHP EP CHL Chlamydia Screening in Women Women identified as sexually active. Women years old identified as sexually active should be screened annually for Chlamydia. Medicaid HARP QHP EP 4 Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies.

5 HEDIS/QARR 2017 Quick Reference Guide ALL MEASURES Measure Age Band Denominator Event Numerator Requirement Line of Business CIS Childhood Immunizations Status Birth 2 yrs Children who turn two years old during the measurement year. COA Care for Older Adults 66+ Entire eligible population Medicare SNP. COL CWP DAE DDE Colorectal Cancer Screening Appropriate Testing for Children with Pharyngitis Use of High-Risk Medications in the Elderly Potentially Harmful Drug-Disease Interactions in the Elderly Entire eligible population Children with a diagnosis of pharyngitis who were dispensed an antibiotic. 66+ Entire eligible population. 65+ Entire eligible population. Children should have complete Immunizations on or before their 2 nd birthday (events must be at least 14 days apart): 4 - DTaP 3 - IPV 3 - Hep B 2 - Influenza 3 - Hib 4 - PCV 2 or 3 - Rotavirus 1 - Hep A 1 - VZV 1 - MMR Adults 66 years and older should have the following documented at least annually: 1. Advance Care Planning. 2. Medication List and Review. 3. Functional Status Assessment. 4. Pain Assessment. Adults aged should be screened for colorectal cancer by one of the following: 1. Fecal occult blood test (FOBT, gfobt, ifobt) every year, or 2. Flexible sigmoidoscopy during the measurement year or 4 years prior, or 3. Colonoscopy during the measurement year or 9 years prior, or 4. CT colonography during the measurement year or 4 years prior 5. FIT-DNA test during the measurement year or 2 years prior. Children 3 18 years old should receive a strep test (rapid strep test and/ or throat culture) on or between 3 days prior to 3 days after an antibiotic is dispensed for a pharyngitis diagnosis. Adults aged 66+ years old should be screened for use of high-risk medications in the elderly. Two rates are reported: 1. Members who received at least one dispensing event for a high-risk medication during the measurement year. 2. Members who received at least two dispensing events for the same high-risk medication during the measurement year. *LOWER RATES ARE BETTER Adults aged 65+ years old who have evidence of an underlying disease, condition, or health concern and who were dispensed an ambulatory prescription for a potentially harmful medication, concurrent with or after the diagnosis. *LOWER RATE IS BETTER Medicaid QHP EP Medicare Medicaid Medicare QHP EP Medicaid HARP QHP EP Medicare Medicare FPC Frequency of (FPC) n/a Live births Deliveries on or between November 6 of the year prior to the measurement year and November 5 of the measurement year. Expected prenatal visits is determined by member enrollment date and gestational age by using ACOG recommended scheduled visits. Frequency of Prenatal Care: The percentage of deliveries that received the following number of prenatal visits: 21% of expected visits 21 40% of expected visits 41 60% of expected visits 61 80% of expected >81% of expected visits The number of expected prenatal care visits is adjusted for the month of pregnancy at time of enrollment and gestational age. Medicaid QHP EP Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies. 5

6 HEDIS/QARR 2017 Quick Reference Guide ALL MEASURES Measure Age Band Denominator Event Numerator Requirement Line of Business FUH Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence Follow-Up After Hospitalization for Children and adults with emergency department (ED) visits with a prinicipal diagnosis of alcohol or other drug (AOD) dependence. The denominator for this measure is based on ED visits, not members. If members have more than one ED visit for AOD, all ED visits on or between January 1 and December 1 (no more than one visit per 31-day period) in the measurement year will be included. Children and adults who were hospitalized for treatment of selected mental illness diagnoses. Children and adults who have emergency department (ED) visits with a principal diagnosis of alcohol or other drug (AOD) dependence who had a follow-up visit for AOD. Two rates are reported: 1. The percentage of ED visitors who received follow-up within 30 days of the ED visit. 2. The percentage of ED visitors who received follow-up within 7 days of the ED visit. Children and adults should have a follow-up outpatient visit, intensive outpatient encounter, or partial hospitalization with a mental health practitioner after discharge. Two rates are reported: 1. The percentage of members who received follow-up within 7 days of discharge. 2. The percentage of members who received follow-up within 30 days of discharge. Medicaid Medicare HARP EP Medicaid Medicare HARP QHP EP Follow-Up After Emergency Department Visit for 6+ Children and adults with emergency department (ED) visits with a prinicipal diagnosis of mental illness. The denominator for this measure is based on ED visits, not members. If members have more than one ED visit for mental illness, all ED visits on or between January 1 and December 1 (no more than one visit per 31-day period) in the measurement year will be included. Children and adults who have emergency department (ED) visits with a principal diagnosis of mental illness who had a follow-up visit for mental illness. Two rates are reported: 1. The percentage of ED visitors who received follow-up within 30 days of the ED visit. 2. The percentage of ED visitors who received follow-up within 7 days of the ED visit. Medicaid Medicare HARP EP Initiation and Engagement of Alcohol and Other Drug Dependence Treatment 13+ Adolescent and adult members with a new episode of alcohol or other drug (AOD) dependence between January 1 and November 15 of the measurement year. Adolescent and adult members with a new episode of AOD dependence should initiate treatment within 14 days of the diagnosis and should receive two or more additional services within 30 days of the initiation visit. Two rates are reported: 1. Initiation of AOD Treatment: the percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of the diagnosis. 2. Engagement of AOD Treatment: the percentage of members who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit. Medicaid Medicare HARP QHP EP IMA Immunizations for Adolescents 13 Adolescents who turn 13 years old during the measurement year. Adolescents should have the following immunizations on or before their 13 th birthday: 1. Meningococcal on or between 11 th and 13 th birthdays 2. Tdap on or between 10 th and 13 th birthdays 3. HPV vaccines on or between 9 th and 13 th birthdays Medicaid QHP EP 6 Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies.

7 HEDIS/QARR 2017 Quick Reference Guide ALL MEASURES Measure Age Band Denominator Event Numerator Requirement Line of Business LBP Use of Imaging Studies for Lower Back Pain Adults are identified for the eligible population from an outpatient or ED visit with a primary diagnosis of lower back pain during the measurement year. Adults years with a primary diagnosis of lower back pain who did not have an imaging study (plain x-ray, MRI, CT scan) within 28 days of diagnosis unless clinically indicated. *LOWER RATE IS BETTER Medicare HARP QHP EP LCS Lead Screening in Children Birth to 2 yrs Children who turn two years old during the measurement year. Children should have at least one lead capillary or venous blood test on or before their second birthday. Medicaid EP MMA Medication Management for People with Asthma 5 85 Children and adults are identified for the eligible population by one of the following criteria during both the measurement year and the year prior to the measurement year: 1. At least one ED visit, with a principal diagnosis of asthma. 2. At least one acute inpatient encounter, with a principal diagnosis of asthma. 3. 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. Visit type need not be the same for the four visits. 4. At least four asthma medication dispensing events. Children and adults ages 5 85 who were identified as having persistent asthma and were dispensed appropriate medications must remain on an asthma controller for at least 75% of the treatment period. Two rates are reported: 1. The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period. 2. The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period. Medicaid Medicare HARP QHP EP Annual Monitoring for Patients on Persistent Medications 18+ Adults who received at least 180 treatment days of the following medication therapy during the measurement year: 1. ACE inhibitors or ARBs 2. Digoxin 3. Diuretic Adults 18 years and older who received at least 180 days of ambulatory medication therapy for select therapeutic agents should have at least one therapeutic monitoring event annually: 1. ACE/ARB and Diuretics lab panel; or one serum potassium and a serum creatinine. 2. Digoxin lab panel and a serum digoxin; or one serum potassium and a serum creatinine and a serum digoxin. Medicaid Medicare HARP QHP EP MRP Medication Reconciliation Post-Discharge 18+ Adults are identified for the eligible population by an acute or nonacute inpatient discharge on or between January 1 and December 1 of the measurement year. The denominator for this measure is based on discharges, not members. If members have more than one discharge, all discharges on or between January 1 and December 1 in the measurement year will be included. Adults 18 years and older should have medications reconciled by outpatient provider within 30 days of discharge. Medicare Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies. 7

8 HEDIS/QARR 2017 Quick Reference Guide ALL MEASURES Measure Age Band Denominator Event Numerator Requirement Line of Business NCS OMW PBH PCE PPC PPC PSA Non-Recommended Cervical Cancer Screening in Adolescent Females Osteoporosis Management in Women Who Had a Fracture Persistence of Beta- Blocker Treatment After a Heart Attack Pharmacotherapy Management of COPD Exacerbation Prenatal Timeliness of First Visit (PPC-T) Postpartum Care (PPC-P) Non-Recommended Prostate-Specific Antigen (PSA) Screening in Older Men Entire eligible population n/a n/a Women are identified for the eligible population by claims/encounter data: 1. An outpatient, ED, or observation visit for a fracture. 2. Acute or nonacute inpatient discharges with a diagnosis of a fracture between July 1 of the year prior to the measurement year and June 30 of the measurement year. Adults are indentified for the eligible population by a hospitalization and discharge with a diagnosis of AMI, from July 1 of the year prior to the measurement year and June 30 of the measurement year. A COPD exacerbation is identified by claims/encounter data: 1. An acute inpatient discharge, or 2. ED encounter with a principal diagnosis of COPD during January 1 thru November 30 of the measurement year. The eligible population for this measure is based on acute inpatient discharges and ED visits, not members. It is possible for the denominator to include multiple events for the same individual. Live births Deliveries on or between November 6 of the year prior to the measurement year and November 5 of the measurement year. Live births Deliveries on or between November 6 of the year prior to the measurement year and November 5 of the measurement year. 70+ Entire eligible population. Adolescent females years old should not be screened for cervical cancer. *LOWER RATE IS BETTER Women years of age who suffered a fracture should have a bone mineral density test or be dispensed a drug to treat or prevent osteoporosis within six months after the fracture. Adults 18 years and older who were hospitalized and discharged with a diagnosis of AMI should be dispensed persistent beta-blocker treatment for six months after discharge. Adults 40 years and older who had an acute inpatient discharge or ED encounter for COPD exacerbation should be dispensed the following medications: 1. A systemic corticosteroid within 14 days of discharge. 2. A bronchodilator within 30 days of discharge. Timeliness of Prenatal Care: initial prenatal visit must be within first trimester or within 42 days of enrollment with health plan. Postpartum Care visit must occur between 21 and 56 days after delivery. Men 70 years and older should not receive PSA-based screening, unless clinically appropriate. *LOWER RATE IS BETTER Medicaid HARP EP Medicare Medicaid Medicare HARP EP Medicaid Medicare HARP EP Medicaid QHP EP Medicaid QHP EP Medicare 8 Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies.

9 HEDIS/QARR 2017 Quick Reference Guide ALL MEASURES Measure Age Band Denominator Event Numerator Requirement Line of Business SAA Adherence to Antipsychotic Medications for Individuals With Schizophrenia Adults with schizophrenia who were dispensed an antipsychotic medication. Adults with schizophrenia who were dispensed an antipsychotic medication should remain on an antipsychotic medication for at least 80% of their treatment period. Medicaid HARP SMC Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia Adults with schizophrenia and cardiovascular disease. Adults with schizophrenia and cardiovascular disease should have a LDL-C test during the measurement year. Medicaid HARP SMD Diabetes Monitoring for People With Diabetes and Schizophrenia Adults with schizophrenia and diabetes. Adults with schizophrenia and diabetes should have the following tests during the measurement year: 1. LDL-C test 2. HbA1c test Medicaid HARP SPC Statin Therapy for Patients With Cardiovascular Disease Males years of age and females years of age during the measurement year who were identified as having clinical atherosclerotic cardiovascular diesease (ASCVD). Males and females with ASCVD should meet the following: 1. Received Statin Therapy: At least one dispensing event for a high- or moderate-intensity statin medication during the measurement year. 2. Statin Adherence: Remained on a high- or moderate-intensity statin medication for at least 80% of the treatment period. Medicaid Medicare HARP EP SPD Statin Therapy for Patients With Diabetes Adults years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD). Adults with diabetes who do not have ASCVD should meet the following: 1. Received Statin Therapy: At least one dispensing event for a high- or moderate-intensity statin medication during the measurement year. 2. Statin Adherence: Remained on a high- or moderate-intensity statin medication for at least 80% of the treatment period. Medicaid Medicare HARP EP SPR Use of Spirometry Testing in the Assessment and of COPD 40+ Adults are identified for the eligible population by an outpatient, ED, or acute inpatient visit with a diagnosis of COPD between July 1 of the year prior to the measurement year and June 30 of the measurement year. Adults 40 years and older with a new diagnosis of COPD or newly active COPD should have appropriate spirometry testing between two years prior through six months after diagnosis. Medicaid Medicare HARP EP SSD Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications Adults with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication. Adults with schizophrenia or bipolar disease who were dispensed an antipsychotic should have a glucose screening test or an HbA1c screening test during the measurement year. Medicaid HARP Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies. 9

10 HEDIS/QARR 2017 Quick Reference Guide ALL MEASURES Measure Age Band Denominator Event Numerator Requirement Line of Business URI W15 Appropriate Testing for Children with Upper Respiratory Infection Well-Child 0 15 Months 3 months 18 years old 0 15 months W34 Well-Child WCC Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents 3 17 Children and adolescents are identified for the eligible population: diagnosed with upper respiratory infection with no comorbid or competing conditions. Thru outpatient or ED visit between July 1 of the year prior to the measurement year and June 30 of the measurement year. Children who turn 15 months of age during the measurement year. Children who are 3 to 6 years of age during the measurement year. Children and adolescents 3 17 with a PCP or OB/GYN outpatient visit during the measurement year. Antibiotics should not be prescribed for children ages 3 months 18 years old with a diagnosis of URI. Children who turn 15 months of age should have six or more well-child visits from birth through 15 months old (visits must be at least 14 days apart). Children 3 6 years old ahould have one well-child visit annually. Children and adolescents 3 17 years old should have the following documented during measurement year: 1. BMI Percentile only 2. Counseling for Nutrition 3. Counseling for Physical Activity Medicaid HARP QHP EP Medicaid HARP QHP EP Medicaid HARP QHP EP Medicaid QHP EP 10 Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies.

11 Measure Measure Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Value Set Definition Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Back to 2017 HEDIS s Quick Links 11

12 Measure Measure Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Value Set Definition Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory G0402 Ambulatory G0438 Ambulatory G0439 Ambulatory G0463 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment (G0402) 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) Hospital outpatient clinic visit for assessment and management of a patient (G0463) 12 Back to 2017 HEDIS s Quick Links

13 Measure Measure Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Value Set Definition Ambulatory T1015 Clinic visit/encounter, all-inclusive (T1015) [Z00.00] Encounter for general adult medical examination without abnormal Ambulatory Z00.00 findings Ambulatory Z00.01 [Z00.01] Encounter for general adult medical examination with abnormal findings [Z00.121] Encounter for routine child health examination with abnormal Ambulatory Z findings [Z00.129] Encounter for routine child health examination without abnormal Ambulatory Z findings Ambulatory Z00.5 [Z00.5] Encounter for examination of potential donor of organ and tissue Ambulatory Z00.8 [Z00.8] Encounter for other general examination Ambulatory Z02.0 [Z02.0] Encounter for examination for admission to educational institution Ambulatory Z02.1 [Z02.1] Encounter for pre-employment examination Ambulatory Z02.2 [Z02.2] Encounter for examination for admission to residential institution Ambulatory Z02.3 [Z02.3] Encounter for examination for recruitment to armed forces Ambulatory Z02.4 [Z02.4] Encounter for examination for driving license Ambulatory Z02.5 [Z02.5] Encounter for examination for participation in sport Ambulatory Z02.6 [Z02.6] Encounter for examination for insurance purposes Ambulatory Z02.71 [Z02.71] Encounter for disability determination Ambulatory Z02.79 [Z02.79] Encounter for issue of other medical certificate Ambulatory Z02.81 [Z02.81] Encounter for paternity testing Ambulatory Z02.82 [Z02.82] Encounter for adoption services Ambulatory Z02.83 [Z02.83] Encounter for blood-alcohol and blood-drug test Ambulatory Z02.89 [Z02.89] Encounter for other administrative examinations Ambulatory Z02.9 [Z02.9] Encounter for administrative examinations, unspecified Ambulatory V20.2 Routine child health exam ICD9CM Ambulatory V70.0 Routine medical exam ICD9CM Ambulatory V70.3 Med exam NEC admin purp ICD9CM Ambulatory V70.5 Health exam group survey ICD9CM Back to 2017 HEDIS s Quick Links 13

14 Measure Measure 14 Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Value Set Definition Back to 2017 HEDIS s Quick Links Ambulatory V70.6 Health exam pop survey ICD9CM Ambulatory V70.8 General medical exam NEC ICD9CM Ambulatory V70.9 General medical exam NOS ICD9CM Ambulatory 0510 Ambulatory 0511 Ambulatory 0512 Ambulatory 0513 Ambulatory 0514 Ambulatory 0515 Ambulatory 0516 Ambulatory 0517 Ambulatory 0519 Ambulatory 0520 Ambulatory 0521 Ambulatory 0522 Ambulatory 0523 Ambulatory 0526 Ambulatory 0527 Ambulatory 0528 Ambulatory 0529 Ambulatory 0982 Ambulatory 0983 Other Ambulatory Other Ambulatory Other Ambulatory UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV

15 Measure Measure Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Health Services () Value Set Definition Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory S0620 Other Ambulatory S0621 Other Ambulatory 0524 Other Ambulatory 0525 Routine ophthalmological examination including refraction; new patient (S0620) Routine ophthalmological examination including refraction; established patient (S0621) UBREV UBREV Back to 2017 HEDIS s Quick Links 15

16 Measure Measure Value Set Definition ABA Adult BMI Assessment BMI Z68.1 [Z68.1] Body mass index (BMI) 19 or less, adult ABA Adult BMI Assessment BMI Z68.20 [Z68.20] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.21 [Z68.21] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.22 [Z68.22] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.23 [Z68.23] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.24 [Z68.24] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.25 [Z68.25] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.26 [Z68.26] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.27 [Z68.27] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.28 [Z68.28] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.29 [Z68.29] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.30 [Z68.30] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.31 [Z68.31] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.32 [Z68.32] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.33 [Z68.33] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.34 [Z68.34] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.35 [Z68.35] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.36 [Z68.36] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.37 [Z68.37] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.38 [Z68.38] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.39 [Z68.39] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.41 [Z68.41] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.42 [Z68.42] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.43 [Z68.43] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.44 [Z68.44] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.45 [Z68.45] Body mass index (BMI) 70 or greater, adult ABA Adult BMI Assessment BMI V85.0 BMI less than 19, adult ICD9CM ABA Adult BMI Assessment BMI V85.1 BMI between 19-24, adult ICD9CM ABA Adult BMI Assessment BMI V85.21 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.22 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.23 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.24 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.25 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.30 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.31 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.32 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.33 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.34 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.35 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.36 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.37 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.38 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.39 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.41 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.42 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.43 BMI , adult ICD9CM 16 Back to 2017 HEDIS s Quick Links

17 Measure Measure Value Set Definition ABA Adult BMI Assessment BMI V85.44 BMI , adult ICD9CM ABA Adult BMI Assessment BMI V85.45 BMI 70 and over, adult ICD9CM ABA Adult BMI Assessment BMI Percentile Z68.51 [Z68.51] Body mass index (BMI) pediatric, less than 5th percentile for age ABA Adult BMI Assessment BMI Percentile Z68.52 [Z68.52] Body mass index (BMI) pediatric, 5th percentile to less than 85th percentile for age ABA Adult BMI Assessment BMI Percentile Z68.53 [Z68.53] Body mass index (BMI) pediatric, 85th percentile to less than 95th percentile for age ABA Adult BMI Assessment BMI Percentile Z68.54 [Z68.54] Body mass index (BMI) pediatric, greater than or equal to 95th percentile for age ABA Adult BMI Assessment BMI Percentile V85.51 BMI, pediatric <5% ICD9CM ABA Adult BMI Assessment BMI Percentile V85.52 BMI, pediatric 5% <85% ICD9CM ABA Adult BMI Assessment BMI Percentile V85.53 BMI, pediatric 85% <95% ICD9CM ABA Adult BMI Assessment BMI Percentile V85.54 BMI, pediatric 95% ICD9CM Back to 2017 HEDIS s Quick Links 17

18 Measure Measure Value Set Definition Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Back to 2017 HEDIS s Quick Links

19 Measure Measure Value Set Definition Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Back to 2017 HEDIS s Quick Links 19

20 Measure Measure Value Set Definition Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone G0155 Services of clinical social worker in home health or hospice settings, each 15 minutes (G0155) Activity therapy, such as music, dance, art, or play therapies not for G0176 recreation, related to the care and treatment of patient s disabling mental health problems, per session (45 minutes or more) (G0176) Training and educational services related to the care and treatment of G0177 patient s disabling mental health problems per session (45 minutes or more) (G0177) Social work and psychological services, directly relating to and/or G0409 furthering the patient s rehabilitation goals, each 15 minutes, face-toface; individual (services provided by a corf-qualified social worker or psychologist in a corf) (G0409) G0410 Group psychotherapy other than of a multiple-family group, in a partial hospitalization setting, approximately 45 to 50 minutes (G0410) G0411 Interactive group psychotherapy, in a partial hospitalization setting, approximately 45 to 50 minutes (G0411) G0463 Hospital outpatient clinic visit for assessment and management of a patient (G0463) H0002 Behavioral health screening to determine eligibility for admission to treatment program (H0002) H0004 Behavioral health counseling and therapy, per 15 minutes (H0004) H0031 Mental health assessment, by non-physician (H0031) H0034 Medication training and support, per 15 minutes (H0034) H0035 H0036 H0037 Mental health partial hospitalization, treatment, less than 24 hours (H0035) Community psychiatric supportive treatment, face-to-face, per 15 minutes (H0036) Community psychiatric supportive treatment program, per diem (H0037) H0039 Assertive community treatment, face-to-face, per 15 minutes (H0039) H0040 Assertive community treatment program, per diem (H0040) H2000 Comprehensive multidisciplinary evaluation (H2000) H2001 Rehabilitation program, per 1/2 day (H2001) H2010 Comprehensive medication services, per 15 minutes (H2010) H2011 Crisis intervention service, per 15 minutes (H2011) H2012 Behavioral health day treatment, per hour (H2012) 20 Back to 2017 HEDIS s Quick Links

21 Measure Measure Value Set Definition Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone Stand Alone H2013 Psychiatric health facility service, per diem (H2013) H2014 Skills training and development, per 15 minutes (H2014) H2015 Comprehensive community support services, per 15 minutes (H2015) H2016 Comprehensive community support services, per diem (H2016) H2017 Psychosocial rehabilitation services, per 15 minutes (H2017) H2018 Psychosocial rehabilitation services, per diem (H2018) H2019 Therapeutic behavioral services, per 15 minutes (H2019) H2020 Therapeutic behavioral services, per diem (H2020) M0064 Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders (M0064) S0201 Partial hospitalization services, less than 24 hours, per diem (S0201) S9480 Intensive outpatient psychiatric services, per diem (S9480) S9484 Crisis intervention mental health services, per hour (S9484) S9485 Crisis intervention mental health services, per diem (S9485) T1015 Clinic visit/encounter, all-inclusive (T1015) 0510 UBREV 0513 UBREV 0515 UBREV 0516 UBREV 0517 UBREV 0519 UBREV 0520 UBREV 0521 UBREV 0522 UBREV 0523 UBREV 0526 UBREV Back to 2017 HEDIS s Quick Links 21

22 Measure 22 Measure Value Set Definition Stand Alone 0527 UBREV Stand Alone 0528 UBREV Stand Alone 0529 UBREV Stand Alone 0900 UBREV Stand Alone 0902 UBREV Stand Alone 0903 UBREV Stand Alone 0904 UBREV Stand Alone 0905 UBREV Stand Alone 0907 UBREV Stand Alone 0911 UBREV Stand Alone 0912 UBREV Stand Alone 0913 UBREV Stand Alone 0914 UBREV Stand Alone 0915 UBREV Stand Alone 0916 UBREV Stand Alone 0917 UBREV Stand Alone 0919 UBREV Stand Alone 0982 UBREV Stand Alone 0983 UBREV POS Group 1 03 School POS POS Group 1 05 Indian Health Service Free-standing Facility POS POS Group 1 07 Tribal 638 Free-standing Facility POS POS Group 1 09 Prison/Correctional Facility POS POS Group 1 11 Office POS POS Group 1 12 Home POS Back to 2017 HEDIS s Quick Links

23 Measure Measure Value Set Definition POS Group 1 13 Assisted Living Facility POS POS Group 1 14 Group Home POS POS Group 1 15 Mobile Unit POS POS Group 1 16 Temporary Lodging POS POS Group 1 17 Walk-in Retail Health Clinic POS POS Group 1 18 Place of Employment-Worksite POS POS Group 1 19 Off Campus-Outpatient Hospital POS POS Group 1 20 Urgent Care Facility POS POS Group 1 22 On Campus-Outpatient Hospital POS POS Group 1 33 Custodial Care Facility POS POS Group 1 49 Independent Clinic POS POS Group 1 50 Federally Qualified Health Center POS POS Group 1 52 Psychiatric Facility-Partial Hospitalization POS POS Group 1 53 Community Center POS POS Group 1 71 Public Health Clinic POS POS Group 1 72 Rural Health Clinic POS Group Group Group Group Group Group Group Group Group Back to 2017 HEDIS s Quick Links 23

24 Measure 24 Measure Value Set Definition Group Group Group Group Group Group Group POS Group 2 52 Psychiatric Facility-Partial Hospitalization POS POS Group 2 53 Community Center POS Group Group Group Group Group Group Group Group Group Group Group Group Group Continuation and Telephone Maintenance Continuation and Telephone Maintenance Continuation and Telephone Maintenance Back to 2017 HEDIS s Quick Links

25 Measure Measure Value Set Definition Continuation and Telephone Maintenance Continuation and Telephone Maintenance Continuation and Telephone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Back to 2017 HEDIS s Quick Links 25

26 Measure 26 Measure Value Set Definition Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Back to 2017 HEDIS s Quick Links

27 Measure Measure Value Set Definition Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Services of clinical social worker in home health or hospice settings, G0155 Maintenance each 15 minutes (G0155) Activity therapy, such as music, dance, art, or play therapies not for Continuation and Stand Alone G0176 recreation, related to the care and treatment of patient s disabling Maintenance mental health problems, per session (45 minutes or more) (G0176) Continuation and Maintenance Continuation and Maintenance Stand Alone Stand Alone Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance Continuation and Stand Alone Maintenance G0177 G0409 Training and educational services related to the care and treatment of patient s disabling mental health problems per session (45 minutes or more) (G0177) Social work and psychological services, directly relating to and/or furthering the patient s rehabilitation goals, each 15 minutes, face-toface; individual (services provided by a corf-qualified social worker or psychologist in a corf) (G0409) G0410 Group psychotherapy other than of a multiple-family group, in a partial hospitalization setting, approximately 45 to 50 minutes (G0410) G0411 Interactive group psychotherapy, in a partial hospitalization setting, approximately 45 to 50 minutes (G0411) G0463 Hospital outpatient clinic visit for assessment and management of a patient (G0463) H0002 Behavioral health screening to determine eligibility for admission to treatment program (H0002) H0004 Behavioral health counseling and therapy, per 15 minutes (H0004) H0031 Mental health assessment, by non-physician (H0031) H0034 Medication training and support, per 15 minutes (H0034) H0035 H0036 H0037 Mental health partial hospitalization, treatment, less than 24 hours (H0035) Community psychiatric supportive treatment, face-to-face, per 15 minutes (H0036) Community psychiatric supportive treatment program, per diem (H0037) H0039 Assertive community treatment, face-to-face, per 15 minutes (H0039) H0040 Assertive community treatment program, per diem (H0040) H2000 Comprehensive multidisciplinary evaluation (H2000) H2001 Rehabilitation program, per 1/2 day (H2001) Back to 2017 HEDIS s Quick Links 27