CHILDHOOD IMMUNIZATIONS

Transcription

1 CHILDHOOD IMMUNIZATIONS APPLICATIONS OBJECTIVE Purpose of Measure: ELIGIBLE POPULATION Which members are included? STANDARD OF CARE What immunizations should be administered? NCQA ACCEPTED CODES DOCUMENTATION REQUIREMENTS What documentation should be submitted? HEDIS (Hybrid) NCQA Accreditation NCQA Rating EPSDT* To identify children due for an immunization Children who turn two (2) years of age as of December 31st of the measurement year. By their second (2 nd ) birthday, children should receive all of the following: 4 diptheria, tetanus, and acellular pertussis (DTaP) 3 polio (IVP) 1 measles, mumps, and rubella (MMR) 3 H influenza type B (HiB) 3 hepatitis B (Hep B) 1 chicken pox (VZV) 4 pneumococcal conjugate (PCV) 1 hepatitis A (Hep A) 2 or 3 rotavirus (RV) 2 influenza (flu) Note: The member must have all of the recommended doses of each vaccine prior to their second birthday in order to be compliant with HEDIS. Rates are calculated on individual vaccines and in combinations as outlined in NCQA s HEDIS Technical Specifications. Please see code table. For each immunization given: A note indicating the name of the immunization and date given, or A certificate of immunization prepared by an authorized health care provider or agency that includes the type of immunization and date administered. State immunization certificates should be

2 signed and dated. For Hepatitis B, notations that the first dose was administered at birth or in the hospital are acceptable. For Rotavirus, the documentation should indicate whether the two- or three-dose schedule was administered. If the documentation does not clearly indicate if the two-or three-dose vaccine was given, it will be assumed the three-dose was used. Flumist is not acceptable for either dose of the required influenza vaccines. Documentation of parental refusal of vaccines(s) is not compliant under HEDIS specifications. REFERENCES For each immunization not given: Documentation of a contraindication to the vaccine or its components, (such as anaphylactic reaction). DTaP: diagnosis of encephalopathy IVP: anaphylactic reaction to streptomycin, polymyxin B, or neomycin MMR, VZV, and influenza: immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, leukemia, or anaphylactic reaction to neomycin Hepatitis B: anaphylactic reaction to common baker s yeast A documented history of the illness or a seropositive test result. Note must indicate date of the event, which must have occurred prior to the member s second (2 nd ) birthday. For more information, please refer to Passport Health Plan s Preventive Health Clinical Practice Guideline including current immunization schedules, KY EPSDT Manual, and the AAP Bright Futures Provider Toolkit.

3 The criteria above are based on standards established under NCQA s HEDIS 2016 Technical Specifications. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). *The Early and Periodic Screening Diagnosis and Treatment (EPSDT) program is designed to provide a comprehensive preventive health care package to members from birth to age 21. For billing and or other questions/concerns please contact your Provider Network Account Manager or Provider Services at (800)

4 DTaP Code System Code CPT CPT CPT CPT Inactivated Polio Vaccine (IPV) Code System Code CPT CPT CPT MMR Code System Code Measles, Mumps and Rubella Vaccine CPT CPT Measles/Rubella Vaccine CPT Measles Vaccine CPT Mumps Vaccine CPT Rubella Vaccine CPT CHILDHOOD IMMUNIZATION STATUS Meet Screening Criteria Measles ICD10CM B05.0 [B05.0] Measles complicated by encephalitis ICD10CM B05.1 [B05.1] Measles complicated by meningitis ICD10CM B05.2 [B05.2] Measles complicated by pneumonia ICD10CM B05.3 [B05.3] Measles complicated by otitis media ICD10CM B05.4 [B05.4] Measles with intestinal complications ICD10CM B05.81 [B05.81] Measles keratitis and keratoconjunctivitis ICD10CM B05.89 [B05.89] Other measles complications ICD10CM B05.9 [B05.9] Measles without complication ICD9CM Postmeasles encephalitis ICD9CM Postmeasles pneumonia ICD9CM Postmeasles otitis media ICD9CM Measles keratoconjunctivitis ICD9CM Measles with other specified complications

5 ICD9CM Measles with unspecified complication ICD9CM Measles without mention of complication Mumps ICD10CM B26.0 [B26.0] Mumps orchitis ICD10CM B26.1 [B26.1] Mumps meningitis ICD10CM B26.2 [B26.2] Mumps encephalitis ICD10CM B26.3 [B26.3] Mumps pancreatitis ICD10CM B26.81 [B26.81] Mumps hepatitis ICD10CM B26.82 [B26.82] Mumps myocarditis ICD10CM B26.83 [B26.83] Mumps nephritis ICD10CM B26.84 [B26.84] Mumps polyneuropathy ICD10CM B26.85 [B26.85] Mumps arthritis ICD10CM B26.89 [B26.89] Other mumps complications ICD10CM B26.9 [B26.9] Mumps without complication ICD9CM Mumps orchitis ICD9CM Mumps meningitis ICD9CM Mumps encephalitis ICD9CM Mumps pancreatitis ICD9CM Mumps hepatitis ICD9CM Mumps polyneuropathy ICD9CM Other mumps with other specified complications ICD9CM Mumps with unspecified complication ICD9CM Mumps without mention of complication Rubella ICD10CM B06.00 [B06.00] Rubella with neurological complication, unspecified ICD10CM B06.01 [B06.01] Rubella encephalitis ICD10CM B06.02 [B06.02] Rubella meningitis ICD10CM B06.09 [B06.09] Other neurological complications of rubella ICD10CM B06.81 [B06.81] Rubella pneumonia ICD10CM B06.82 [B06.82] Rubella arthritis ICD10CM B06.89 [B06.89] Other rubella complications ICD10CM B06.9 [B06.9] Rubella without complication ICD9CM Rubella with unspecified neurological complication ICD9CM Encephalomyelitis due to rubella ICD9CM Rubella with other neurological complications ICD9CM Arthritis due to rubella ICD9CM Rubella with other specified complications ICD9CM Rubella with unspecified complications ICD9CM Rubella without mention of complication HiB Code System Code CPT CPT 90646

6 CPT CPT CPT CPT CPT CPT Hepatitis B CPT CPT CPT CPT CPT HCPCS G0010 Administration of hepatitis b vaccine (G0010) ICD10PCS 3E0234Z [3E0234Z] Introduction of Serum, Toxoid and Vaccine into Muscle, Percutaneous Approach ICD9PCS Prophylactic administration of vaccine against other diseases ICD10CM B16.0 [B16.0] Acute hepatitis B with delta-agent with hepatic coma ICD10CM B16.1 [B16.1] Acute hepatitis B with delta-agent without hepatic coma ICD10CM B16.2 [B16.2] Acute hepatitis B without delta-agent with hepatic coma ICD10CM B16.9 [B16.9] Acute hepatitis B without delta-agent and without hepatic coma ICD10CM B17.0 [B17.0] Acute delta-(super) infection of hepatitis B carrier ICD10CM B18.0 [B18.0] Chronic viral hepatitis B with delta-agent ICD10CM B18.1 [B18.1] Chronic viral hepatitis B without delta-agent ICD10CM B19.10 [B19.10] Unspecified viral hepatitis B without hepatic coma ICD10CM B19.11 [B19.11] Unspecified viral hepatitis B with hepatic coma ICD10CM Z22.51 [Z22.51] Carrier of viral hepatitis B ICD9CM Viral hepatitis B with hepatic coma, acute or unspecified, without mention of hepatitis delta ICD9CM Viral hepatitis B with hepatic coma, acute or unspecified, with hepatitis delta ICD9CM Chronic viral hepatitis B with hepatic coma without hepatitis delta ICD9CM Chronic viral hepatitis B with hepatic coma with hepatitis delta ICD9CM Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta ICD9CM Viral hepatitis B without mention of hepatic coma, acute or unspecified, with hepatitis delta ICD9CM Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta ICD9CM Chronic viral hepatitis B without mention of hepatic coma with hepatitis delta ICD9CM V02.61 Hepatitis B carrier Varicella Zoster (VZV) CPT CPT 90716

7 ICD10CM B01.0 [B01.0] Varicella meningitis ICD10CM B01.11 [B01.11] Varicella encephalitis and encephalomyelitis ICD10CM B01.12 [B01.12] Varicella myelitis ICD10CM B01.2 [B01.2] Varicella pneumonia ICD10CM B01.81 [B01.81] Varicella keratitis ICD10CM B01.89 [B01.89] Other varicella complications ICD10CM B01.9 [B01.9] Varicella without complication ICD10CM B02.0 [B02.0] Zoster encephalitis ICD10CM B02.1 [B02.1] Zoster meningitis ICD10CM B02.21 [B02.21] Postherpetic geniculate ganglionitis ICD10CM B02.22 [B02.22] Postherpetic trigeminal neuralgia ICD10CM B02.23 [B02.23] Postherpetic polyneuropathy ICD10CM B02.24 [B02.24] Postherpetic myelitis ICD10CM B02.29 [B02.29] Other postherpetic nervous system involvement ICD10CM B02.30 [B02.30] Zoster ocular disease, unspecified ICD10CM B02.31 [B02.31] Zoster conjunctivitis ICD10CM B02.32 [B02.32] Zoster iridocyclitis ICD10CM B02.33 [B02.33] Zoster keratitis ICD10CM B02.34 [B02.34] Zoster scleritis ICD10CM B02.39 [B02.39] Other herpes zoster eye disease ICD10CM B02.7 [B02.7] Disseminated zoster ICD10CM B02.8 [B02.8] Zoster with other complications ICD10CM B02.9 [B02.9] Zoster without complications ICD9CM Postvaricella encephalitis ICD9CM Varicella (hemorrhagic) pneumonitis ICD9CM Postvaricella myelitis ICD9CM Chickenpox with other specified complications ICD9CM Chickenpox with unspecified complication ICD9CM Varicella without mention of complication ICD9CM Herpes zoster with meningitis ICD9CM Herpes zoster with unspecified nervous system complication ICD9CM Geniculate herpes zoster ICD9CM Postherpetic trigeminal neuralgia ICD9CM Postherpetic polyneuropathy ICD9CM Herpes zoster myelitis ICD9CM Herpes zoster with other nervous system complications ICD9CM Herpes zoster dermatitis of eyelid ICD9CM Herpes zoster keratoconjunctivitis ICD9CM Herpes zoster iridocyclitis ICD9CM Herpes zoster with other ophthalmic complications ICD9CM Otitis externa due to herpes zoster ICD9CM Herpes zoster with other specified complications ICD9CM Herpes zoster with unspecified complication

8 ICD9CM Herpes zoster without mention of complication Pneumococcal Conjugate CPT CPT HCPCS G0009 Administration of pneumococcal vaccine (G0009) Hepatitis A CPT ICD10CM B15.0 [B15.0] Hepatitis A with hepatic coma ICD10CM B15.9 [B15.9] Hepatitis A without hepatic coma ICD9CM Viral hepatitis A with hepatic coma ICD9CM Viral hepatitis A without mention of hepatic coma Rotavirus CPT Dose Schedule CPT Dose Schedule Influenza CPT CPT CPT CPT CPT CPT HCPCS G0008 Administration of influenza virus vaccine (G0008) Exclusions Any Particular Vaccine Anaphylactic reaction to the vaccine or its components DTaP Encephalopathy with a vaccine adverse-effect code MMR, VZV and Influenza Immunodeficiency HIV Lymphoreticular cancer, multiple myeloma or leukemia Anaphylactic reaction to neomycin IPV Anaphylactic reaction to streptomycin, polymyxin B or neomycin Hepatitis B Anaphylactic reaction to common baker s yeast