HEDIS QUICK REFERENCE GUIDE: DOCUMENTATION TIPS FOR ADULT MEASURES

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1 HEDIS QUICK REFERENCE GUIDE: DOCUMENTATION TIPS FOR ADULT MEASURES For Health Care Providers January 2018 Helping you improve your scores, as you improve the health of your patients. Healthcare Effectiveness Data and Information Set (HEDIS ) scores are not only important for you as a provider, they also help guide your patients to quality care. As your trusted partner with the mutual goal of helping people lead healthier lives, we are committed to providing support in every way we can. Utilizing complete and accurate codes can significantly reduce the number of medical records we may request from you for HEDIS. This quick reference guide outlines what documentation is required to make a record compliant, including up-to-date codes that will help you maintain, and even improve, your HEDIS scores. * HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

2 Adult BMI Assessment (ABA) Patients years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year. Indicate in the medical record the weight and BMI value dated during the measurement year or year prior to the measurement year. For patients 20 years or older, the BMI value and weight from the measurement year or year prior must be documented. For patients younger than 20 years old: - BMI percentile documented as a value (e.g., 85th percentile) or, - BMI percentile plotted on an age growth chart - Height - Weight Exclusions: Patients with diagnosis of pregnancy during the measurement year or year prior. Common billing codes accepted by HEDIS Diagnosis codes , , , , , , , , 99411, 99412, 99429, 99455, ICD-10: Z68.1, Z68.20-Z68.29, Z68.30-Z68.39, Z Z68.45, Z68.51-Z , , , 0982, 0983 Breast Cancer Screening (BCS) Women years of age with one or more mammograms within last two years. Note: Digital breast tomosynthesis has been added as a screening method for this measure. No documentation required (administrative only) Diagnostic screenings do not qualify for the measure, including biopsies, ultrasounds, magnetic resonance imaging (MRI), or 3D tomography , , Digital Breast Tomosynthesis: 77061, G0202, G0204,G0206 Current Procedural Terminology (CPT) Health Care Common Procedural Coding System (HCPCS) International Classification of Diseases 10 th Revision (ICD-10)

3 Cervical Cancer Screening (CCS) The percentage of women years of age who were screened for cervical cancer using either of the following criteria: Women age who had cervical cytology performed every three years. Women age who had cervical cytology and human papillomavirus (HPV) co-testing performed every five years. A lab report or result documented in the medical record. The following do not qualify: Lab results that indicate inadequate sample or no cervical cells Referral to OB/GYN alone Biopsies (are considered diagnostic, rather than screening) Two-year look-back includes Pap tests given at age 21. Exclusions: Acquired absence of both cervix and uterus. Documentation of total, complete or radical abdominal or vaginal hysterectomy. Partial hysterectomy can only be used if absence of cervix is documented. Common billing codes accepted by HEDIS Cervical Cytology , 88147, 88148, 88150, , , 88174, HPV: , G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001 HPV Test: G0476 UB REV: Cervical Cytology 0923 Chlamydia (CHL) Screening in Women Women years of age who are identified as sexually active with a chlamydia test annually. No documentation required (administrative only) Exclusions: Patients who had a pregnancy test during the measurement year followed within seven days (inclusive) by either a prescription for isotretinoin (i.e., Accutane) or X-ray. Pregnancy test alone does not exclude patient , 87270, 87320, , 87810

4 Controlling High Blood Pressure (CBP) The percentage of patients years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria: years of age whose BP was <140/90 mm Hg years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg. Documentation of diagnosis of HTN prior to June 30 of the measurement year, and BP was adequately controlled during the measurement year. Diagnosis and documented BP ideally would come from the same provider, but it is not limited to that provider. The representative BP from the most recent provider seen by the patient should be used. This measure is medical record review only. Identify the most recent BP reading noted during the measurement year. The reading must occur after the date when the diagnosis of hypertension was confirmed. BP readings at the following types of visits do not count: An acute inpatient stay or an emergency department (ED) visit. An outpatient visit which was for the sole purpose of having a diagnostic test or surgical procedure performed (e.g., sigmoidoscopy, removal of a mole). Obtained the same day as a major diagnostic or surgical procedure (e.g., stress test, administration of IV contrast for a radiology procedure, endoscopy). Reported by or taken by the patient. Note: If initial BP is high, and multiple blood pressure readings are taken, the lowest reading will be abstracted during medical record review. Exclusions: Patients with evident end-stage renal disease (ESRD), or with diagnosis of pregnancy during the measurement year Patients with a non-acute inpatient stay Patients who have had a kidney transplant or dialysis Common billing codes accepted by HEDIS ICD-10 Diagnosis code: I10 Blood Pressure procedure codes: Systolic BP < 140: 3074F, 3075F Diastolic BP: 3078F, 3079F

5 Comprehensive Diabetes Care (CDC) Hemoglobin A1c Patients years of age with a diagnosis of diabetes who had Hemoglobin A1c (HbA1c) testing. Comprehensive Diabetes Care (CDC) Diabetic Retinal Eye Exam (DRE) Patients years of age with a diagnosis of diabetes who had a retinal eye exam performed. An HbA1c test performed during the measurement year, as identified by administrative data or medical record review. This can be a copy of the HbA1c test result or, at a minimum, documentation in the medical record of a note indicating the date when the HbA1c test was performed and the result. An optometrist/ophthalmologist dilated eye exam annually for patients with diabetic retinopathy, or every two years for patients without retinopathy. At a minimum, documentation in the medical record must include one of the following: A letter prepared by an optometrist, ophthalmologist, PCP, or other health care provider indicating that an ophthalmoscope exam was completed, the date when the procedure was performed, and the results. A chart or photograph of retinal abnormalities indicating the date when the fundus photography was performed, and evidence that an eye care professional reviewed the results. Alternatively, results may be read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist. A negative retinal or dilated exam by an eye care professional in the year prior to the measurement year where results indicate retinopathy was not present (e.g., documentation of normal findings for a dilated or retinal eye exam performed by an eye care professional meets criteria). Bilateral eye enucleation any time during the patient s history through December 31 of the measurement year. Provider specialty: Ophthalmologist, optometrist Common billing codes accepted by HEDIS HbA1c: 83036, HbA1c level < 7.0: 3044F HbA1c level : 3045F HbA1c level > 9.0: 3046 DRE: 67228, 67030, 67031, 67036, ,67101, 67105, 67107, 67108, , 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019,92134, , 92230, 92235, 92240, 92250, 92260, , , CPT II: 2022F, 2024F, 2026F, 3072F Eye Enucleation: 65091,65093, 65101, 65105, 65110, 65112, S0620, S0621, S3000

6 Comprehensive Diabetes Care (CDC) Medical Attention for Nephropathy Patients years of age with diabetes (type 1 or type 2) who had medical attention for nephropathy. A nephropathy screening test, medical attention for nephropathy, a visit to a nephrologist or treatment with angiotensin II receptor blocker (ARB), or angiotensin-converting enzyme (ACE) inhibitor medications during the measurement year as documented through either administrative data or medical record review. Any of the following meet criteria for a nephropathy screening or monitoring test or evidence of nephropathy. (At a minimum, documentation must include a note indicating the date when a urine test was performed, and the result or finding). 24-hour urine for albumin or protein Timed urine for albumin or protein Spot urine for albumin or protein. Urine for albumin/creatinine ratio 24-hour urine for total protein Random urine for protein/creatinine ratio Documentation of: A visit to a nephrologist Medical attention for any of the following (no restriction on provider type): Diabetic nephropathy, ESRD, chronic renal failure (CRF), chronic kidney disease (CKD), renal insufficiency, proteinuria, albuminuria, renal dysfunction, acute renal failure (ARF), dialysis, and hemodialysis or peritoneal dialysis A renal transplant Treatment with ACE/ARB medication Common billing codes accepted by HEDIS Nephropathy Screening Test: 82042, 82043, 82044, Urine Macroalbumin Test: , CPT CAT II: ACE/ARB: 4009F CPT CAT II: 3060F (nephropathy screening test) 3061F (nephropathy screening test) 3066F (treatment for nephropathy) 4010F (treatment for nephropathy 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, I12.0, I12.9, I13.0, I13.10, I13.11, I13.2, I15.0, I15.1, N00.0-N08.0, N14.0- N14.4, N17.0-N17.2, N17.8, N17.9, N18.1-N18.6, N18.9, N19, N25.0, N25.1, N25.81, N25.89, N25.9, N26.1,N26.2, N26.9, Q60.0-Q60.6, Q Q61.02, Q61.11, Q61.19, Q61.2-Q61.5, Q61.8, Q61.9, R80.0, R80.1, R80.2, R80.3, R80.8, R80.9 UB REV: , 0809, , 0829, , 0839, , 0849, , 0859, , 0889

7 Comprehensive Diabetes Care (CDC) Blood Pressure Patients years of age with diabetes (type 1 or type 2) who had BP control < 140/90 mm Hg. Prenatal Care (PC) Percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. For these women, the measure assesses the percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization. The patient is not compliant if the BP reading is 140/90, if there is no BP reading during the measurement year, or if the reading is incomplete (e.g., the systolic or diastolic level is missing). If initial reading is high, a second reading can be taken later in the same visit. The lowest diastolic and lowest systolic reading is used, not necessarily from the same reading. Basic physical OB exam (FHR, fundus height, or pelvic exam with OB observations), or notation of LMP or EDD with either: prenatal risk assessment and counseling/education, or complete obstetrical history Documentation of the visit on a prenatal flow sheet or American College of Obstetricians and Gynecologists (ACOG) form. Evidence that a prenatal care procedure was performed, such as: Screening test in the form of an obstetric panel. Must include all of the following: hematocrit, differential white blood count (WBC) count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, red blood cell (RBC) antibody screen, Rh and ABO blood typing) TORCH antibody panel alone, or a rubella antibody test/titer with an Rh incompatibility (ABO/Rh) blood typing Echography of a pregnant uterus Provider specialty: Prenatal care provider, primary care provider (services provided by an RN do not count) Common billing codes accepted by HEDIS CPT Blood Pressure: Systolic: 3074F: < 140 mm Hg 3075F: mm Hg 3077F: > 140mm Hg Diastolic: 3078F: < F: 80-89mm Hg: 3080F: > 90 mm Hg Prenatal Bundle Service: 59400, 59425, 59426, 59510, 59610, Prenatal Visits: , , Stand Alone Prenatal Visits: CPT Cat II: 0500F, 0501F, 0502F Prenatal: H1005

8 Postpartum Care (PPC) The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. For these women, the measure assesses the percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. A visit that occurs on or between days after delivery. Components of a postpartum exam visit note: Pelvic exam, or Weight, BP, and breasts and abdominal evaluation, or Postpartum check, postpartum care, six-week check notation, or completed pre-printed postpartum care form Provider specialty: Prenatal care provider, primary care provider (services provided by an RN do not count) Common billing codes accepted by HEDIS 59400, 59410, 59510, 59515, 59610, 59614, 59618, Postpartum Visits: 57170, 58300, 59430, CPT II: 0503F Postpartum Visits: G0101 ICD-10: Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2