GLOBAL P4P. Pay for Performance (P4P) Program Guide

Transcription

1 GLOBAL P4P Pay for Performance (P4P) Program Guide Contact: Published: March 28, 2018

2 PROGRAM OVERVIEW This program guide provides an overview of the 2018 Global Quality Pay for Performance (GQ P4P) Program for Independent Physician Associations (IPAs). In this third year of the program, IEHP has made program enhancements based on feedback from Providers in an effort to continually improve effectiveness. The IEHP GQ P4P program for IPAs is designed to reward IPAs for high performance and year-over-year improvement in key quality performance measures. This program overview is designed for IPAs and their staff as an easy guide to help maximize GQ P4P. This year s GQ P4P Program continues to provide financial rewards to IPAs for improving healthcare quality across multiple domains and measures. The 2018 GQ P4P program focuses on performance-based incentives to IPAs for services rendered in If you would like to get more information about IEHP s GQ P4P Program or best practices to help improve quality scores and outcomes, visit our Secure Provider Portal at the Quality Team at QualityPrograms@iehp.org or call the IEHP Provider Relations Team at What s New? Two measures were retired Annual Monitoring for Patients on Persistent Medications - Total Childhood Immunizations - Combo 3 Three measures were added to the Clinical Quality Domain Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Concurrent Use of Opioids and Benzodiazepines (monitoring only) New Tier 1 and Tier 2 goal methodology includes a practical significance standard The budget was reduced from $30 million to $20 million, with removal of the condition to pass through percent of the funding to Primary Care Providers (PCPs), which was in place for previous program years. 1

3 Eligibility and Participation To be eligible for incentive payments in the 2018 GQ P4P Program, IPAs must meet the following criteria: Have at least 5,000 IEHP Medi-Cal Members assigned as of January 2018 Have at least 30 Members in the denominator as of December 2018 for each quality measure to qualify Submit a GQ P4P Quality Work Plan to IEHP by March 1, 2018 in order to enroll in the program (see Work Plan details in Appendix 5) Meet minimum Encounter Data Gates in order to qualify for incentive payments Minimum Data Requirements Encounter Data Encounter data is foundational to performance scoring and is essential to success in the GQ P4P Program. Complete, timely and accurate encounter data should be submitted through normal reporting channels for all services rendered to IEHP Members. Please use the codes listed in Appendix 2 to help with proper coding to meet measure requirements. Lab Results Data from lab results is also foundational to Program performance scoring. Providers should ensure they submit complete lab results data for services rendered to IEHP Members. IPAs should work with their network Providers to ensure they are using the appropriate lab vendors for IEHP Members, and submitting complete lab results data to IEHP. Lab results that are performed in the office (e.g., point of care HbA1c testing, urine tests, etc.) should be coded and submitted through Providers encounter data. Immunizations To maximize performance in immunization-based measures, IEHP strongly encourages all Providers to report all immunizations via the California Immunization Registry (CAIR2). For more information on how to register for CAIR2, please visit IEHP is working closely with CAIR to establish a data sharing arrangement to be used in Global Quality P4P reporting. 2

4 Supplemental Data What is Supplemental Data? When services are not captured in traditional encounter data systems, other Supplemental Data sources may be used to collect information about services rendered to Members to support Quality Reporting. When Supplemental Data may be needed For services that were provided prior to eligibility When a Provider has proof-of-service for a noted gap in care (e.g. cervical cancer screening, immunizations rendered by another provider) When Provider has proof-of-service for an eligible-population exclusion (e.g. total hysterectomy, bilateral mastectomy) How to use Supplemental Data to support Global Quality P4P Create an electronic log that includes minimum required data elements. See Appendix 6 for file layout requirements. Below is a listing of minimum data elements needed in a supplemental data log. Member ID Date of Service Provider Identification Provider Specialty Diagnosis Code(s) if applicable Procedure Code(s) Lab Results if applicable Requirements for using Supplemental Data in Global Quality P4P Reporting The IPA must have clearly defined policies and procedures (in writing) that describe how Supplemental Data is collected, validated and used for P4P reporting Policies/procedures must be shared with IEHP and must be in place to validate quality / accuracy of Supplemental Data The IPA must collect proof-of-service documentation to confirm all services that are reported in the Supplemental Data log The IPA must receive approval from IEHP s Quality Team to use Supplemental Data in Global Quality Reporting (deadline for approval is October 31, 2018) The IPA must complete a P4P Roadmap no later than December 1, 2018 The IPA must complete IPA data validation activities prior to submitting Supplemental Data to IEHP The IPA must submit a final Supplemental Data log to IEHP via SFTP no later than February 1,

5 Data Validation Requirements for Supplemental Data in Global Quality P4P Reporting To be counted in final IPA Global Quality P4P rates, Supplemental Data file must pass IEHP s independent HEDIS audit process The IPA must present proof-of-service documents within required timeframes when requested by IEHP s auditors An auditor review will compare proof-of-service documents to submitted data Supplemental Data records must pass 100 percent validation to be included in the final P4P reporting Financial Overview Providers are eligible to receive financial rewards for performance excellence and for performance improvement. Financial rewards are based on a tiered system, providing increasing financial rewards for reaching higher tiered level performance. The 2018 GQ P4P Program incentive pool is $20 million for the IPA Program. Incentive dollars for the 2018 performance period will be distributed monthly via a new monthly per Member per month (PMPM) Quality Payment beginning in July 2019 and continuing through June IPA Encounter Data Gates IPA encounter data submissions must meet minimum adequacy requirements in order to receive GQ P4P Program incentive dollars. IPA encounter data performance is based on all professional encounters submitted by the IPA for services rendered during the measurement year (e.g., 2018 dates of service). IPA encounter data volume will be compared to established encounter data benchmarks for Seniors and Persons with Disabilities (SPD) and Non-SPD Members. IPA performance will be calculated against each IPA s proportion of SPD and Non-SPD Members. Encounter data benchmarks have been established and correspond to an Encounter Data Gate, reflecting higher encounter data volumes. As IPAs reach higher levels of encounter data performance, they become eligible for a larger percentage of the total possible GQ P4P incentive. Encounter rates are expressed as the number of encounters per Member per year (PMPY). An encounter is defined as a unique visit per Member per Provider per day. The table below describes the Encounter Data Gates, performance levels, and their impact to IPA GQ P4P Program incentive payments. PERCENT OF POSSIBLE INCENTIVE PAYMENT ENCOUNTER DATA GATE NON-SPD PMPY SPD PMPY 50% Gate % Gate % Gate

6 The Encounter Data Gating methodology only applies to the IPA methodology. Encounter data must be submitted to IEHP in a timely way and must adhere to the reporting timeframes delineated in IEHP s Provider Policy and Procedure Manual - Policy 21A. Performance Measures Appendix 1 provides a list of the 23 measures included in the 2018 GQ P4P Program and includes the thresholds and benchmarks associated with respective tier goals. These measures have been categorized into four domains: Clinical Quality; Behavioral Health Integration; Patient Experience; Encounter Data. Most measures included in the Clinical Quality Domain primarily use standard Healthcare Effectiveness Data and Information Set (HEDIS ) process and outcomes measures that are based on the specifications published by the National Committee for Quality Assurance (NCQA). Non-HEDIS measures that are included in the Clinical Quality Domain come from the California Department of Health Care Services (DHCS) Medi-Cal Managed Care Quality Program and the Pharmacy Quality Alliance (PQA). Clinical Quality Domain Measures: Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (New) Breast Cancer Childhood Immunizations Combo 10 Comprehensive Diabetes Care Eye Exam Comprehensive Diabetes Care HbA1c Control < 8 Concurrent Use of Opioids and Benzodiazepines (New) Immunizations for Adolescents Combo 2 Initial Health Assessment Medication Management for People with Asthma 75% rate Timely Postpartum Care Timely Prenatal Care Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (New) - Counseling for Physical Activity - Counseling for Nutrition - BMI Percentile Well-Child 3-6 Years of Life IEHP s HEDIS 2019 data set (measurement year 2018) will be used to evaluate Providers year-end performance. This measure set undergoes an independent audit review prior to rate finalization. 5

7 The Initial Health Assessment (IHA) measure follows IEHP s IHA internal compliance monitoring methodology and is not a HEDIS measure. The Concurrent Use of Opioids and Benzodiazepines measure specification is developed and maintained by the PQA. This measure will not be used for incentive calculations but will be collected to establish a baseline rate for See Appendix 2 for measure details. Behavioral Health Integration Domain Measures: The Behavioral Health Integration Domain includes two measures derived from the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) measure set.1 for Clinical Depression in Primary Care Positive Depression with Follow-Up Plan Patient Experience Domain Measures: Patient Experience Domain measures include Member Satisfaction Survey questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey that is published by the Agency for Healthcare Research and Quality (AHRQ). IEHP conducts a Member Satisfaction Survey that is a modified CAHPS survey and is the sole data source supporting the performance scoring methodology for this measure domain. The IEHP Member Satisfaction Survey is conducted between June and December of each year. Surveys received from the 2018 Member Satisfaction Survey will be used to calculate the Patient Experience Domain measures. A copy of the current Member Satisfaction Survey is included in Appendix 4. Access to Care Needed Right Away Access to Routine Care Coordination of Care Encounter Data Domain Measures: The fourth measure domain is Encounter Data. IPAs eligible for the GQ P4P Program become eligible to receive payment dollars once they have met the minimum encounter data gate. Higher encounter gate performance qualifies an IPA to receive a higher percentage of incentive dollars. See the IPA Encounter Data Gates section of this program guide for additional details on this methodology. 1 For information on the PQRS measure set: Assessment-Instruments/PQRS/index.html. 6

8 2018 IPA Global Quality P4P Scoring and Payment Flowchart PROGRAM ELIGIBILITY REQUIREMENTS Membership will be determined as of 01/2018 IPAs with 5,000 or more assigned Members SCORING METHOD Incentive eligible IPAs will receive a Quality Score for each Measure IPAs must have 30 or more Members in each measure to be eligible for a Quality Score The Quality Score is averaged to determine the Global Quality Performance Score At least three measures are required to determine the Global Quality Performance Score IPA PAYMENT CALCULATION [Global Quality Performance Score] x [# Medi-Cal average Member months] = Member Points [Member Points] x [payment amount per Member pint] = Max Payment Amount [Max Payment Amount] x [Encounter Gate %] = Final Payment Amount 7

9 Scoring Methodology Payment will be awarded to IPAs based on individual performance in reaching established Quality Goals (e.g., Tier Goals for each measure). In the Clinical Quality Domain, HEDIS measure results are based on each measure s total eligible population assigned to the IPA. The eligible population is defined as the set of Members that meet the denominator criteria specified in the current year s HEDIS Technical Specifications (Volume 2) published by NCQA. Members in the eligible population are attributed to the assigned PCP on the anchor date of each measure, as defined within the HEDIS measure. Members contribute to a IPA s HEDIS measure denominator if continuous enrollment criteria are met at the health plan level. For each measure, the HEDIS score reflects the proportion of the eligible population that is in compliance with the numerator criteria, as defined in the current HEDIS technical specifications (Volume 2). In the Clinical Quality Domain, Non-HEDIS measure results (i.e., Initial Health Assessment) are based on new health plan Members who are assigned to the IPA during the measurement year and who remain enrolled with IEHP and the IPA through the 120 day post enrollment period. See Appendix 2 for measure details. In the Patient Experience Domain, monthly Member Satisfaction Survey measures are based on Members who meet eligibility criteria to receive a mailed survey between June and December of the measurement year. Members eligible to receive a Member Satisfaction Survey must have been continuously enrolled with IEHP for at least six months in the measurement year (2018) and must have had an office visit in the prior six months, based on encounter data submitted to IEHP. Members who meet the survey eligibility criteria are randomly sampled to receive a survey. Survey measure results are attributed to the Member s assigned IPA based on the most recent encounter that qualified the Member for the survey. A Member is eligible to receive only one survey per calendar year. For IPAs, the Encounter Data Domain measures assess the volume of IPA encounters received for all assigned IPA Members. The denominator is all assigned Medi-Cal Members each month of the measurement year (2018). All monthly assigned Members are summed to create the denominator (i.e., Member months). The numerator is the sum of all unique encounters (e.g., unique Member, Provider, date of service) in the measurement year for all assigned Members in the denominator. A Per Member Per Year (PMPY) rate is calculated following this formula: (Total Unique Encounters / Total Member Months) x 12 = PMPY 8

10 Payment Methodology IPA performance for each quality measure will be given a point value (i.e., a Quality Score). Points are assigned based on the Tier Goal achieved (e.g., Tier 1 = one point, Tier 2 = two points, Tier 3 = three points) for each measure. IPAs that have at least three quality measures which meet the minimum denominator size (n = 30) will be considered for payment calculations. An average of all eligible Quality Scores will determine the overall GQ Performance Score. GQ P4P Program payments will be awarded according to the following formula: [Global Quality Performance Score] x [# Medi-Cal Average Member Months] = Member Points [Member Points] x [Payment Amount per Member Point] = Incentive Payout Total The payment amount per Member point is dependent on the total incentive money available for IPAs. IPA PMPM Quality Payment Methodology From July 2019 June 2020, IPAs will receive a monthly PMPM (per member per month) quality payment based on 2018 GQ P4P performance using the following formula: 2018 Global Quality P4P Payments Total Medi-Cal Member Months Quality PMPM Payment Amount IPA payment example: IPA with monthly average of 120,000 Members (1,440,000 Member Months), 2.0 GQ Quality Score and Encounter Data Gate 2 met (A) Global P4P Payments: $2,656,800 Total Member Months: 1,440,000 Quality PMPM Payment Amount: $1.85 ~ $221,400 monthly payment * ~$2,656,800 annual payment * *assuming stable membership volume 9

11 Quality Incentive Payout Timeline: Provider Communication Timeline Interim 2017 GQ P4P payment (PCP & IPA) Final 2017 GQ P4P payment (PCP & IPA) Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018 Jul 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 End of Traditional PCP P4P Program Monthly Quality PMPM payments based on 2017 GQ P4P Performance year results (PCP only) Monthly Quality PMPM payments based on 2017 GQ P4P Performance year results (PCP only) Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Getting Help Monthly Quality PMPM payments based on 2018 GQ P4P Performance year results (PCP & IPA) Please direct questions and/or comments related to this program to IEHP s Provider Call Center at or to IEHP s Quality Department at QualityPrograms@iehp.org. Program Terms and Conditions Participation in IEHP s GQ P4P Program, as well as acceptance of incentive payments, does not in any way modify or supersede any terms or conditions of any agreement between IEHP and Providers or IPAs, whether that agreement is entered into, prior to or subsequent to, the date of this communication. There is no guarantee of future funding for, or payment under, any IEHP Provider incentive program. The IEHP GQ P4P Program and/or its terms and conditions may be modified or terminated at any time, with or without notice, at IEHP s sole discretion. Criteria for calculating incentive payments are subject to change at any time, with or without notice, at IEHP s sole discretion. In consideration of IEHP s offering of the IEHP GQ P4P Program, participants agree to fully and forever release and discharge IEHP from any and all claims, demands, causes of action, and suits, of any nature, pertaining to or arising from the offering by IEHP of the IEHP GQ P4P Program. The determination of IEHP regarding performance scoring and payments under the IEHP GQ P4P Program is final. As a condition of receiving payment under the IEHP GQ P4P Program, Providers and IPAs must be active and contracted with IEHP and have active assigned Members at the time of payment. 10

12 APPENDIX 1: 2018 IPA Global Quality P4P Program Measures 2018 GQ P4P PROGRAM MEASURE LIST Domain Measure Name Population Tier 1 Tier 2 Tier 32 Clinical Quality Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 1 Adult 39.0% Improvement Improvement Clinical Quality Comprehensive Diabetes Care - HbA1c demonstrated demonstrated Control <8 Adult 58.0% by meeting the by meeting the following following Clinical Quality Comprehensive Diabetes Care - Eye Exam Adult 2 conditions: 2 conditions: 68.0% Clinical Quality Behavioral Health Integration Medication Management for People with Asthma - 75% for Clinical Depression in Primary Care Adult 10% 20% 48.0% reduction reduction Adult and in noncomplianccompliance in non- Adolescent 50.0% Behavioral Health Integration Positive Depression with Follow-Up Plan Adult and Adolescent AND AND 90.0% Clinical Quality Breast Cancer Women Improvement Improvement 71.0% of at least 2.0 of at least 3.0 Clinical Quality Women percentage percentage 70.0% Clinical Quality Timeliness of Prenatal Care Women points points 91.0% Clinical Quality Postpartum Care Women 74.0% Clinical Quality Childhood Immunizations - Combo 10 Child 46.0% Improvement Improvement Clinical Quality Immunizations for Adolescents - Combo 2 Child demonstrated demonstrated 32.3% by meeting by meeting Clinical Quality Well-Child Visits 3-6 Years of Life Child 83.0% Clinical Quality Clinical Quality Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents - Counseling for Physical Activity 1 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents - Counseling for Nutrition 1 the following 2 conditions: the following 2 conditions: Child Child 10% reduction in noncompliance AND 20% reduction in noncompliance AND 72.0% 80.0% Weight Assessment and Counseling Improvement Improvement Clinical Quality for Nutrition and Physical Activity of at least 2.0 of at least 3.0 for Children and Adolescents - BMI Child 86.0% percentage percentage Percentile 1 points points Clinical Quality Initial Health Assessment All 50.0% Clinical Quality Concurrent Use of Opioids and Benzodiazepines 1 ** All Baseline Reporting Year Patient Experience Patient Experience Patient Experience Member Satisfaction Survey - Access to Care Needed Right Away Member Satisfaction Survey - Coordination of Care Member Satisfaction Survey Access to Routine Care All 84.00% 86.00% 88.0% All 82.00% 84.00% 86.0% All 82.00% 85.00% 86.0% Encounter Data Encounter Data for PCPs PMPY SPD*** All Encounter Data Encounter Data for PCPs PMPY - Non- SPD*** All New Measure for Tier 3 goals set at the 90th percentile as published in the NCQA 2017 Mid-year Benchmarks and Thresholds and 2016 HEDIS and Exclusion Audit Means, Percentiles source files ** Reporting Only Measure. Not eligible for incentive dollars *** Encounter Data measure benchmarks are gates not tiers 11

13 APPENDIX 2: Measures Overview Population: Adult Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAB) Methodology: HEDIS Measure Description: The percentage of adults years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription on or three days after the Index Episode Start Date (IESD). Episode Date is the date of service for any outpatient or emergency department (ED) visit during the Intake Period (January 1, 2018-December 24, 2018) with a diagnosis of acute bronchitis IESD: the earliest Episode Date during the Intake Period with a diagnosis of acute bronchitis that meets all of the following criteria: 1. Episode Date is the date of service for any outpatient or ED visit during the Intake Period with a diagnosis of acute bronchitis. 2. A 30-day Negative Medication History prior to the Episode Date. 3. A 12-month Negative Comorbid Condition History prior to and including the Episode Date. 4. A Negative Competing Diagnosis during the 38-day period from 30 days prior to the Episode Date through seven days after the Episode Date. 5. The member was continuously enrolled one year prior to the Episode Date through seven days after the Episode Date. The measure is reported as an inverted rate [1 (numerator/eligible population)]. A higher rate indicates appropriate treatment of adults with acute bronchitis (i.e., the proportion for whom antibiotics were not prescribed). Members in hospice are excluded from the eligible population. Exclude denied claims when assessing numerator criteria. Do not include ED visits or observation visits that result in an inpatient stay. When an ED or observation visit and an inpatient stay are billed on separate claims, the visit results in an inpatient stay when the admission date for the inpatient stay occurs on the ED/ observation date of service or one calendar day after. An ED or observation visit billed on the same claim as an inpatient stay is considered a visit that resulted in an inpatient stay. 12

14 Denominator: Members years of age, who had an outpatient visit, an observation visit or an ED visit between January 1 December 24 of the measurement year (2018) with a diagnosis of acute bronchitis. Numerator: Dispensed prescription for an antibiotic medication on or three days after IESD for the Members in denominator. Description AAB ANTIBIOTIC MEDICATIONS Prescription Aminoglycosides Amikacin Tobramycin Gentamicin Streptomycin Aminopenicillins Amoxicillin Ampicillin Beta-lactamase inhibitors Amoxicillin-clavulanate Piperacillin-tazobactam Ticarcillin-clavulanate Ampicillin-sulbactam First-generation Cefadroxil Cefazolin Cephalexin cephalosporins Fourth-generation cephalosporins Cefepime Ketolides Telithromycin Lincomycin derivatives Clindamycin Lincomycin Azithromycin Erythromycin Erythromycin Macrolides Clarithromycin Erythromycin lactobionate ethylsuccinate Erythromycin stearate Aztreonam Daptomycin Metronidazole Miscellaneous antibiotics Chloramphenicol Erythromycin- Vancomycin Dalfopristin-quinupristin sulfisoxazole Linezolid Penicillin G benzathine- Penicillin G procaine Penicillin V potassium Natural penicillins procaine Penicillin G sodium Penicillin G Penicillin G potassium benzathine Penicillinase resistant Dicloxacillin Nafcillin Oxacillin penicillins Quinolones Ciprofloxacin Levofloxacin Norfloxacin Gemifloxacin Moxifloxacin Ofloxacin Rifamycin derivatives Rifampin Second-generation cephalosporin Cefaclor Cefoxitin Cefuroxime Cefotetan Cefprozil Sulfonamides Sulfadiazine Sulfamethoxazole-trimethoprim Tetracyclines Doxycycline Minocycline Tetracycline Cefdinir Cefotaxime Ceftibuten Third-generation Cefditoren Cefpodoxime Ceftriaxone cephalosporins Cefixime Ceftazidime Fosfomycin Nitrofurantoin macrocrystals-monohydrate Urinary anti-infectives Nitrofurantoin Nitrofurantoin macrocrystals Trimethoprim 13

15 Comprehensive Diabetes Care (CDC) HbA1c Control (<8.0) Methodology: HEDIS Measure Description: The percentage of Members years of age with diabetes (type 1 and type 2) who had the following: HbA1c Control (<8.0%) This includes diabetics whose most recent HbA1c test during the measurement year (2018) has a value <8.0%. - The Member is not numerator compliant if the result for the most recent HbA1c test is 8.0% or is missing a result, or if an HbA1c test was not done during the measurement year (2018). The eligible population in this measure meets all of the following criteria: 1. Members who are years old as of December 31 of the measurement year (2018). 2. Continuous enrollment in the measurement year (2018) with no more than one gap of up to 45 days during the measurement year. 3. Members who meet any of the following criteria during the measurement year (2018) or the year prior to the measurement year (2017). Count services that occur over both years: At least two outpatient visits, observation visits, ED visits or nonacute inpatient encounters on different dates of service, with a diagnosis of diabetes. Visit type need not be the same for the two visits. At least one acute inpatient encounter with a diagnosis of diabetes. Members who were dispensed insulin or hypoglycemics/ antihyperglycemics on an ambulatory basis during the measurement year (2018) or the year prior to the measurement year (2017). 14

16 CODES TO IDENTIFY HbA1c TESTS Service Code Type Code Code Description HbA1c Test (<7.0%) CPT-CAT-II 3044F Hg A1c Level Lt 7.0% HbA1c Test CPT Hemoglobin Glycated HbA1c Test CPT Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use HbA1c Test CPT-CAT-II 3044F Most recent hemoglobin A1c (HbA1c) level < 7.0% HbA1c Test CPT-CAT-II 3045F Most recent hemoglobin A1c (HbA1c) level % HbA1c Test CPT-CAT-II 3046F Most recent hemoglobin A1c (HbA1c) level > 9.0% HbA1c Test LOINC Hemoglobin A1c/hemoglobin.total In Blood By Hplc HbA1c Test LOINC Hemoglobin A1c/hemoglobin.total In Blood HbA1c Test LOINC Hemoglobin A1c/hemoglobin.total In Blood By Electrophoresis Members who meet any of the following criteria are excluded: 1. Members in hospice 2. Members who did not have a diagnosis of diabetes, in any setting, during the measurement year (2018) or the year prior to the measurement year (2017) and who had a diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year (2018) or the year prior to the measurement year (2017) Denominator: Members years of age who meet all the criteria for eligible population. Numerator: Members in the denominator who had the most recent HbA1c level <8 during the measurement year (2018). 15

17 Comprehensive Diabetes Care (CDC) Eye Exam Methodology: HEDIS Measure Description: The percentage of Members years of age with diabetes (type 1 and type 2) who had the following: Eye Exam (retinal) performed This includes diabetics who had one of the following: - A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year (2018) - A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year (2018) The eligible population in this measure meets all of the following criteria: 1. Members who were years old as of December 31 of the measurement year (2018). 2. Continuous enrollment in the measurement year (2018) with no more than one gap of up to 45 days during the measurement year. 3. Members who meet any of the following criteria during the measurement year (2018) or the year prior to the measurement year (2017). Count services that occur over both years: At least two outpatient visits, observation visits, ED visits or nonacute inpatient encounters on different dates of service, with a diagnosis of diabetes. Visit type need not be the same for the two visits. At least one acute inpatient encounter with a diagnosis of diabetes. Members who were dispensed insulin or hypoglycemics/ antihyperglycemics on an ambulatory basis during the measurement year (2018) or the year prior to the measurement year (2017). 16

18 Service Code Type CODES TO IDENTIFY EYE EXAMS Code Code Description CPT Intravitreal Injection Of A Pharmacologic Agent (separate Procedure) CPT Discission Of Vitreous Strands (without Removal) Pars Plana Approach CPT Severing Of Vitreous Strands Vitreous Face Adhesions Sheets Membranes Or Opacities Laser Surgery (one Or More Stages) CPT Vitrectomy Mechanical Pars Plana Approach CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT Vitrectomy Mechanical Pars Plana Approach With Focal Endolaser Photocoagulation Vitrectomy Mechanical Pars Plana Approach With Endolaser Panre Tinal Photocoagulation Vitrectomy Mechanical Pars Plana Approach With Removal Of Preretinal Cellular Membrane (eg Macular Pucker) Vitrectomy Mechanical Pars Plana Approach With Removal Of Internal Limiting Membrane Of Retina (eg For Repair Of Macular Hole Vitrectomy mechanical pars plana approach, with removal of subretinal membrane (eg, Choroidal Neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) Repair Retinal Detachment, Incld Drainage Of Subretinal Fluid When Performed; Cryotherapy Repair Retinal Detachment, Incld Drainage Of Subretinal Fluid When Performed; Photocoagulation Repair Of retinal detachment scleral buckling (such as lamellar scleral dissection, Imbrication or encircling procedure), including, when performed, implant, cryotherapy, photocoagulation, and drainage of subretinal fluid Repair Of Retinal Detachment With Vitrectomy Any Method With OR Without Air Or Gas Tamponade Focal Endolaser Photocoagulation Repair Of Retinal Detachment By Injection Of Air Or Other Gas (e G Pneumatic Retinopexy) Repair Of Retinal Detachment By Scleral Buckling Or Vitrectomy On Patient Having Previous Ipsilateral Retinal Detachment Repair Repair Of Complex Retinal Detachment (eg, Proliferative Vitreoretinopathy Stage C-1 or greater, diabetic Traction Retinal Detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, including, when performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens CPT Removal Of Implanted Material Posterior Segment Intraocular 17

19 Service Code Type CODES TO IDENTIFY EYE EXAMS Code CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT Code Description Prophylaxis Of Retinal Detachment (eg, retinal break lattice degeneration) without drainage, 1 or more sessions; cryotherapy, diathermy Prophylaxis Of Retinal Detachment (eg, retinal break lattice degeneration) without drainage, 1 or more sessions; photocoagulation (laser or xenon arc) Destruction Of Localized Lesion Of Retina (eg Macular Edema Tumors) One Or More Sessions Cryotherapy Diathermy Destruction Of Localized Lesion Of Retina (eg Macular Edema Tumors) One Or More Sessions Photocoagulation Destruction Of Localized Lesion Of Retina (eg Macular Edema Tumors) One Or More Sessions Radiation By Implantation Of Source Destruction Of Localized Lesion Of Choroid (eg Choroidal Neovasc Ularization) Photocoagulation (eg Laser) One Or More Sessions Destruction Of Localized Lesion Of Choroid (eg Choroidal Neovasc Ularization) Photodynamic Therapy (includes Intravenous Infusion Destruction Of Extensive Or Progressive Retinopathy (eg Diabetic Retinopathy) One Or More Sessions Cryotherapy Diathermy Destruction of extensive or progressive retinopathy (eg, Diabetic Retinopathy), 1 or more sessions; Photocoagulation Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; Intermediate, new patient Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits Ophthalmological services: medical examination and evaluation with initiation or continuation of diagnostic and treatment program; intermediate, established patient Ophthalmological services: medical examination and evaluation with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits Ophthalmological examination and evaluation under general anesthesia with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete Ophthalmological examination and evaluation under general anesthesia with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; limited Scanning computerized ophthalmic diagnostic imaging posterior segment, with interpretation and report, unilateral or bilateral: optic nerve Ophthalmoscopy extended with retinal drawing (eg, for retinal detachment melanoma), with Interpretation and report; initial 18

20 Service Code Type CODES TO IDENTIFY EYE EXAMS Code CPT CPT CPT Code Description Ophthalmoscopy Extended With Retinal Drawing (eg For Retinal Detachment Melanoma) With Interpretation And Report Subsequent Remote imaging for detection of retinal disease (eg, Retinopathy in a patient with diabetes) with analysis and report under Physician supervision, unilateral or bilateral Remote imaging for monitoring and management of active retinal disease (eg, Diabetic Retinopathy) with Physician review, interpretation and report, unilateral or bilateral CPT Fluorescein Angioscopy With Interpretation And Report CPT CPT Fluorescein Angiography (includes Multiframe Imaging) With Interpretation And Report (unilateral Or Bilateral) Indocyanine-green Angiography (includes Multiframe Imaging) With Interpretation And Report (unilateral Or Bilateral) CPT Fundus Photography With Interpretation And Report CPT Ophthalmodynamometry CPT CPT CPT CPT CPT CPT Office or other patient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history: A detailed exam: Medical decision making of low complexity. Office or other patient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history: A comprehensive exam: Medical decision making of moderate complexity. Office or other patient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history: A comprehensive exam: Medical decision making of high complexity. Office or other patient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components: An expanded problem focused history: An expanded problem focused examination: Medical decision making of low complexity. Office or other patient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components: A detailed history: A detailed exam: Medical decision making of moderate complexity. Office or other patient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components: A comprehensive history: A comprehensive exam: Medical decision making of high complexity. 19

21 Service Code Type CODES TO IDENTIFY EYE EXAMS Code CPT CPT CPT CPT HCPCS HCPCS S0620 S0621 Code Description Office consultation for a new or established patient which requires these 3 key components: An expanded problem focused history: An expanded problem focused examination: and, Straightforward medical decision making. Office consultation for a new or established patient which requires these 3 key components: A detailed history: A detailed exam: and, Medical decision making of low complexity. Office consultation for a new or established patient which requires these 3 key components: A comprehensive history: A comprehensive examination: and, Medical decision making of moderate complexity. Office consultation for a new or established patient which requires these 3 key components: A comprehensive history: A comprehensive examination: and, Medical decision making of high complexity. Routine Ophthalmological Examination Including Refraction; New Patient (s0620) Routine Ophthalmological Examination Including Refraction; Established Patient (s0621) HCPCS S3000 Diabetic Indicator; Retinal Eye Exam, Dilated, Bilateral (s3000) Members who meet any of the following criteria are excluded: 1. Members in hospice 2. Members who did not have a diagnosis of diabetes, in any setting, during the measurement year (2018) or the year prior to the measurement year (2017) and who had a diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year Denominator: Members years of age who meet all the criteria for eligible population. Numerator: Members in the denominator who had an eye exam during the measurement year (2018). 20

22 Medication Management for People with Asthma 75% rate (MMA) Methodology: HEDIS Measure Description: The percentage of Members 5 64 years of age during the measurement year (2018) who were identified as having persistent asthma and were dispensed appropriate medications which they remained on for at least 75 percent of their treatment period. (Treatment Period: The period of time beginning on the Index Prescription Start Date through December 31, 2018.) Eligible population in this measure meets all of the following criteria: 1. Age 5-64 as of December 31 of the measurement year (2018). 2. Continuous enrollment during the measurement year (2018) and the year prior to the measurement year (2017) with no more than one gap in enrollment of up to 45 days during each year of continuous enrollment. 3. Members had a) At least one ED visit with a principal diagnosis of asthma, OR b) At least one acute inpatient encounter with a principal diagnosis of asthma, OR c) 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 for any controller medication or reliever medication. Visit type need not be the same for the four visits, OR d) At least four asthma medication dispensing events for any controller medication or reliever medication. Description ASTHMA CONTROLLER MEDICATIONS: Prescription Antiasthmatic Dyphylline-guaifenesin Guaifenesin-theophylline combinations Antibody inhibitors Omalizumab Anti-interleukin-5 Mepolizumab Reslizumab Inhaled steroid Budesonide-formoterol Fluticasone-vilanterol combinations Fluticasone-salmeterol Mometasone-formoterol Beclomethasone Flunisolide Inhaled corticosteroids Budesonide Fluticasone CFC free Ciclesonide Mometasone Leukotriene modifiers Montelukast Zafirlukast Zileuton Mast cell stabilizers Cromolyn Methylxanthines Dyphylline Theophylline ASTHMA RELIEVER MEDICATIONS Description Prescriptions Short-acting, inhaled beta-2 agonists Albuterol Levalbuterol Pirbuterol 21

23 Members who meet any of the following criteria are excluded: 1. Members who had no asthma controller medications dispensed during the measurement year (2018). 2. Members in hospice are excluded. 3. Members with the following diagnosis any time during the Member s history through December 31 of the measurement year (2018) are excluded: COPD, Acute Respiratory Failure, Cystic Fibrosis, Chronic respiratory conditions and Emphysema. Denominator: Members 5 64 years of age during the measurement year (2018) who were identified as having persistent asthma and were dispensed appropriate medications which they remained on during the treatment period. Numerator: Members in denominator who remained on an asthma controller medication for at least 75 percent of their treatment period. 22

24 Population: Adult and Adolescent for Clinical Depression in Primary Care Methodology: IEHP-defined Quality Metric Modified from PQRS measure (NQF 0418) Measure Description: The percentage of Members aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool during the measurement year (2018). Denominator: All Members aged 12 years and older with a PCP visit in the measurement year (2018). Member counted only once in the denominator. Service for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care PRIMARY CARE PROVIDER VISIT CODES: Code Code Code Description Type CPT CPT CPT CPT Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Typically, 10 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Typically, 20 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: A detailed history; A detailed examination; Medical decision making of low complexity. Typically, 30 minutes are spent face-to- face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Typically, 45 minutes are spent face-to-face with the patient and/or family. 23

25 Service for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care PRIMARY CARE PROVIDER VISIT CODES: Code Type Code CPT CPT CPT CPT CPT HCPCS HCPCS HCPCS HCPCS G0101 G0402 G0438 G0439 Code Description Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Typically, 60 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Typically, 10 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Typically, 15 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Typically, 25 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Typically, 40 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Typically, 40 minutes are spent face-to-face with the patient and/or family. Initial preventive physical examination face-to-face visits services limited to new beneficiary during the first 12 months Annual wellness visit includes a personalized prevention plan of service (pps) initial visit Annual wellness visit includes a personalized prevention plan of service (pps) subsequent visit 24

26 Service for Clinical Depression in Primary Care for Clinical Depression in Primary Care PRIMARY CARE PROVIDER VISIT CODES: Code Type Code Code Description HCPCS G0444 Annual depression screening 15 minutes CPT Occupational therapy evaluation Numerator: Members screened for clinical depression on the date of the encounter using an age appropriate standardized tool during the measurement year (2018). CODES TO IDENTIFY SCREENING FOR CLINICAL DEPRESSION Service Code Type Code Code Description for Clinical Depression in Primary Care CPT 1220F Patient screened for depression (sud) for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care for Clinical Depression in Primary Care CPT CPT CPT CPT 3351F 3352F 3353F 3354F Negative screen for depressive symptoms as categorized by using a standardized depression screening/ assessment tool (mdd) No significant depressive symptoms as categorized by using a stan dardized depression assessment tool (mdd) Mild to moderate depressive symptoms as categorized by using a standardized depression screening/ assessment tool (mdd) Clinically significant depressive symptoms as categorized by usin g a standardized depression screening/assessment tool (mdd) CPT 3725F for depression performed (dem) HCPCS G0444 Annual depression screening 15 minutes HCPCS HCPCS HCPCS HCPCS HCPCS G8431 G8433 G8510 G8511 G8940 Positive screen for clinical depression using a standardized tool and a follow-up plan documented for clinical depression using a standardized tool not documented patient not eligible/appropriate Negative screen for clinical depression using a standardized tool patient not eligible/appropriate for follow-up plan documented Screen for clinical depression using a standardize tool documented follow up plan not documented reason not specified for clinical depression documented follow-up plan not documented patient not eligible/ appropriate 25

27 Definitions: Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms. Standardized Depression Tool A normalized and validated depression screening tool developed for the Member population in which it is being utilized. The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. Examples of depression screening tools include but are not limited to: Adolescent Tools (12-17 years): Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire (MFQ), Center for Epidemiologic Studies Depression Scale (CES-D), and PRIME MD-PHQ2 Adult Tools (18 years and older): Patient Health Questionnaire (PHQ-9 or PHQ-2), Beck Depression Inventory (BDI or BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke Anxiety-Depression Scale (DADS), Geriatric Depression Scale (GDS), Cornell Scale, and PRIME MD-PHQ2 26

28 Positive Depression with Follow Up Plan Methodology: IEHP-defined Quality Metric Modified from PQRS measure (NQF 0418) Measure Description: The percentage of Members aged 12 years and older who screened positive for clinical depression using an age appropriate standardized depression screening tool who also have a follow-up plan documented during the measurement year (2018). Denominator: All Members aged 12 years and older with a PCP visit with a positive depression screening in the measurement year (2018). Member counted only once in the denominator. CODES TO IDENTIFY POSITIVE DEPRESSION SCREENING DURING A PRIMARY CARE PROVIDER VISIT: Service Code Type Code Code Description Positive Depression with Follow Up Plan Positive Depression with Follow Up Plan Positive Depression with Follow Up Plan Positive Depression with Follow Up Plan Positive Depression with Follow Up Plan CPT CPT HCPCS HCPCS HCPCS 3353F 3354F G8431 G8511 G8940 Mild to moderate depressive symptoms as categorized by using a standardized depression screening/assessment tool (mdd) Clinically significant depressive symptoms as categorized by using a standardized depression screening/assessment tool (mdd) Positive screen for clinical depression using a standardized tool and a follow-up plan documented Screen for clinical depression using a standardize tool documented follow up plan not documented reason not specified for clinical depression documented follow-up plan not documented patient not eligible/ appropriate Numerator: Members screened positive for clinical depression with a follow-up plan documented during the measurement year (2018). 27

29 CODES TO IDENTIFY POSITIVE DEPRESSION SCREENING WITH FOLLOW-UP PLAN Service Code Type Code Code Description Positive Depression Plan for follow-up care for major depressive disorder CPT 0545F with Follow Up Plan documented (mdd adol) Positive Depression Positive screen for clinical depression using a HCPCS G8431 with Follow Up Plan standardized tool and a follow-up plan documented Positive Depression with Follow Up Plan HCPCS G8940 for clinical depression documented follow-up plan not documented patient not eligible/ appropriate Definitions: Follow-Up Plan Documented follow-up for a positive depression screening must include one or more of the following: Additional evaluation for depression Suicide Risk Assessment Referral to a practitioner who is qualified to diagnose and treat depression Pharmacological interventions Other interventions or follow-up for the diagnosis or treatment of depression 28

30 Population: Women Breast Cancer (BCS) Methodology: HEDIS Measure Description: The percentage of women years of age who had a mammogram to screen for breast cancer any time on or between October 1 two years prior to the measurement year (2016) and December 31 of the measurement year (2018). The eligible population in the measure meets all of the following criteria: 1. Women years as of December 31 of the measurement year (2018). 2. Continuous enrollment from October 1 two years prior to the measurement year (2016) through December 31 of the measurement year (2018) with no more than one gap in enrollment of up to 45 days for each calendar year of continuous enrolment. No gaps in enrollment are allowed from October 1 two years prior to the measurement year (2016) through December 31 two years prior to the measurement year (2016). CODES USED TO IDENTIFY MAMMOGRAPHY: Service Code Type Code Code Description Breast Cancer CPT Mammography Unilateral Breast Cancer CPT Mammography Bilateral Breast Cancer CPT Mammography Bilateral (2-view Film Study Of Each Breast) Breast Cancer CPT Digital Breast Tomosynthesis Unilateral Breast Cancer CPT Digital Breast Tomosynthesis Bilateral Breast Cancer CPT Digital Breast Tomosynthesis Bilateral (list Separately In Addition To Code For Primary Procedure) Breast Cancer CPT Diagnostic Mammography W/computer-aided Detection; Unilateral Breast Cancer CPT Diagnostic Mammography W/computer-aided Detection; Bilateral Breast Cancer CPT Mammography Bilateral (2-view Film Study Of Each Breast Including Computer-aided Detection (cad) Breast Cancer HCPCS G0202 Mammography, Bilateral (2-view Study Of Each Breast), Including Computer-aided Detection (cad) When Performed (g0202) Breast Cancer HCPCS G0204 Diagnostic Mammography, Including Computer-aided Detection (cad) When Performed; Bilateral (g0204) Breast Cancer HCPCS G0206 Diagnostic Mammography, Including Computer-aided Detection (cad) When Performed; Unilateral (g0206) 29

31 Members who meet any of the following criteria are excluded: 1. Members who have had a bilateral mastectomy anytime during their history through December 31, 2018 may be excluded. To exclude Members who meet the exclusion criteria, please complete Member Historical Data Form and fax to IEHP s Quality Informatics Team at: A copy of the Historical Data Form is available in Appendix Members in hospice are excluded. Denominator: Women years of age who met the criteria for eligible population. Numerator: Members in denominator who had one or more mammograms any time on or between October 1 two years prior to the measurement year (2016) and December 31 of the measurement year (2018). (CCS) Methodology: HEDIS Measure Description: 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 3 years. Women age who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years. The eligible population in the measure meets all of the following criteria: 1. Women years as of December 31 of the measurement year (2018). 2. Continuous enrollment during the measurement year (2018) with no more than one gap in enrollment of up to 45 days. CODES TO IDENTIFY CERVICAL CYTOLOGY: Service Code Type Code Code Description CPT CPT Cytopathology Cervical Or Vaginal (any Reporting System) Requiring Interpretation By Physician (List separately In addition to code for technical service.) Cytopathology Cervical Or Vaginal (any Reporting System) Collected In Preservative Fluid Automated Thin Layer Preparation Manual screening Under Physician Supervision 30

32 CODES TO IDENTIFY CERVICAL CYTOLOGY: Service Code Type Code Code Description CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT HCPCS HCPCS G0123 G0124 Cytopathology Cervical Or Vaginal (any Reporting System) Collec Ted In Preservative Fluid Automated Thin Layer Preparation; manual screening Under Physician Supervision: With manual screening and rescreening Under Physician Supervision Cytopathology Smears Cervical Or Vaginal By Automated System Under Physician Supervision Cytopathology Smears Cervical Or Vaginal By Automated System With Manual Rescreening Under Physician Supervision Cytopathology Slides Cervical Or Vaginal Manual Under Physician Supervision Cytopathology Slides Cervical Or Vaginal With Manual And Computer-assisted Rescreening Under Physician Supervision Cytopathology Slides Cervical Or Vaginal With Manual And Rescreening Under Physician Supervision Cytopathology Slides Cervical Or Vaginal With Manual And Computer-assisted Rescreening Using Cell Selection And Review Under Physician Supervision Cytopathology Slides Cervical Or Vaginal (the Bethesda System) Manual Under Physician Supervision Cytopathology Slides Cervical Or Vaginal (the Bethesda System) With Manual And Rescreening Under Physician Supervision Cytopathology Slides Cervical Or Vaginal (the Bethesda System) With Manual And Computer-assisted Rescreening Under Physician Supervision Cytopathology Slides Cervical Or Vaginal (the Bethesda System) With Manual And Computer-assisted Rescreening Using cell selection and review Under Physician Supervision Cytopathology Cervical Or Vaginal (any Reporting System) Collected In Preservative Fluid Automated Thin Layer Preparation Cytopathology Cervical Or Vaginal (any Reporting System) Collected In Preservative Fluid Automated By System Cytopathology, Cervical Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, By Cytotechnologist Under Physician Supervision (g0123) Cytopathology, Cervical Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, Requiring Interpretation By Physician (g0124) 31

33 CODES TO IDENTIFY CERVICAL CYTOLOGY: Service Code Type Code Code Description HCPCS HCPCS HCPCS HCPCS HCPCS HCPCS HCPCS HCPCS HCPCS LOINC LOINC LOINC LOINC LOINC LOINC LOINC G0141 G0143 G0144 G0145 G0147 G0148 P3000 P3001 Q0091 Cytopathology Smears, Cervical Or Vaginal, Performed By Automated System, With Manual Rescreening, Requiring Interpretation By Physician (g0141) Cytopathology, Cervical Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, With Manual And Rescreening By Cytotechnologist Under Physician Supervision (g0143) Cytopathology, Cervical Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, With By Automated System, Under Physician Supervision (g0144) Cytopathology, Cervical Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, With By Automated System And Manual Rescreening Under Physician Supervision (g0145) Cytopathology Smears, Cervical Or Vaginal, Performed By Automated System Under Physician Supervision (g0147) Cytopathology Smears, Cervical Or Vaginal, Performed By Automated System With Manual Rescreening (g0148) Papanicolaou Smear, Cervical Or Vaginal, Up To Three Smears, By Technician Under Physician Supervision (p3000) Papanicolaou Smear, Cervical Or Vaginal, Up To Three Smears, Requiring Interpretation By Physician (p3001) Papanicolaou Smear; Obtaining, Preparing And Conveyance Of Cervical Or Vaginal Smear To Laboratory (q0091) Microscopic Observation [identifier] In Cervix By Cyto Stain Microscopic Observation [identifier] In Cervix By Cyto Stain Thinprep General Categories [interpretation] Of Cervical Or Vaginal Smear Or Scraping By Cyto Stain Statement Of Adequacy [interpretation] Of Cervical Or Vaginal Smear Or Scraping By Cyto Stain Microscopic Observation [identifier] In Cervical Or Vaginal Smear Or Scraping By Cyto Stain Microscopic Observation [identifier] In Cervical Or Vaginal Smear Or Scraping By Cyto Stain Narrative Cytology Study Comment Cervical Or Vaginal Smear Or Scraping Cyto Stain 32

34 CODES TO IDENTIFY CERVICAL CYTOLOGY: Service Code Type Code Code Description LOINC Cytology Cervical Or Vaginal Smear Or Scraping Study Cytology Report Of Cervical Or Vaginal Smear Or Scraping Cyto LOINC Stain.thin Prep Cytology Report Of Cervical Or Vaginal Smear Or Scraping Cyto LOINC Stain CODES TO IDENTIFY HPV TESTS: Service Code Type Code Code Description Infectious Agent Detection By Nucleic Acid (dna Or Rna) CPT Papillom Avirus Human Direct Probe Technique Infectious Agent Detection By Nucleic Acid (dna Or Rna) CPT Papillom Avirus Human Amplified Probe Technique Infectious Agent Detection By Nucleic Acid (dna Or Rna) CPT Papillom Avirus Human Quantification Infectious Agent Detection By Nucleic Acid (dna Or Rna) CPT Human Pap Illomavirus (hpv) High-risk Types (eg ) CPT HCPCS LOINC G LOINC LOINC LOINC LOINC LOINC LOINC Infectious Agent Detection By Nucleic Acid (dna Or Rna) Human Pap Illomavirus (hpv) Types 16 And 18 Only Includes Type 45, If Performed Infectious Agent Detection By Nucleic Acid (dna Or Rna); Human Papillomavirus (hpv), High-risk Types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) For, Must Be Performed In Addition To Pap Test (g0476) Human Papilloma Virus Dna [presence] In Cervix By Dna Probe Human Papilloma Virus Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus 16 Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus 18 Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus E6+e7 Mrna [presence] In Cervix By Probe And Target Amplification Method 33

35 CODES TO IDENTIFY HPV TESTS: Service Code Type Code Code Description LOINC LOINC LOINC LOINC LOINC LOINC LOINC LOINC Human Papilloma Virus Dna [presence] In Cervix By Probe And Target Amplification Method Human Papilloma Virus E6+e7 Mrna [presence] In Cervix By Probe And Target Amplification Method Human Papiloma Virus 16 And 18 And Dna [interpretation] In Cervix Human Papilloma Virus 16 Dna [presence] In Cervix By Probe And Target Amplification Method Human Papilloma Virus 18 Dna [presence] In Cervix By Probe And Target Amplification Method Human Papilloma Virus 16 And E6+e7 Mrna [identifier] In Cervix By Probe And Target Amplification Method Human Papilloma Virus 16 E6+e7 Mrna [presence] In Cervix By Probe And Target Amplification Method Human Papilloma Virus Dna [presence] In Cervix By Probe And Target Amplification Method Members who meet any of the following criteria are excluded: 1. Members who have had a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix any time during their history through December 31, 2018 may be excluded. To exclude Members who meet the exclusion criteria, please complete the Member Historical Data Form and fax to IEHP s Quality Informatics Team at: A copy of the Historical Data Form is available in Appendix Members in hospice are excluded. Denominator: Women years of age who met the criteria for eligible population. Numerator: Women in the denominator who received a timely screen for cervical cancer. 34

36 Timeliness of Prenatal Care (PPC) Methodology: HEDIS Measure Description: The percentage of deliveries of live births on or between November 6, 2017 and November 5, 2018 that received a prenatal care visit as a Member of the organization in the first trimester, on the enrollment start date or within 42 days of enrollment in the organization. The eligible population in this measure meets all of the following criteria: 1. Continuous enrollment 43 days prior to delivery through 56 days after delivery with no allowable gap. 2. Members who delivered a live birth on or between November 6 of the year prior to the measurement year (2017) and November 5 of the measurement year (2018). This includes women who delivered in any setting. Women who had two separate deliveries (different dates of service) between November 6 of the year prior to the measurement year (2017) and November 5 of the measurement year (2018) count twice. Women who had multiple live births during one pregnancy count once. CODES TO IDENTIFY STAND ALONE PRENATAL VISITS: Service Code Type Code Code Description Prenatal Visit CPT 0500F Initial Prenatal Care Visit Prenatal Visit CPT 0501F Prenatal Flow Sheet Prenatal Visit CPT 0502F Subsequent Prenatal Care Visit Prenatal Visit CPT Home Visit Prenatal Prenatal Visit HCPCS H1000 Prenatal Care, At-risk Assessment Prenatal Visit HCPCS H1001 Prenatal Care, At-risk Enhanced Service; Antepartum Management Prenatal Visit HCPCS H1002 Prenatal Care, At Risk Enhanced Service; Care Coordination Prenatal Visit HCPCS H1003 Prenatal Care, At-risk Enhanced Service; Education Prenatal Visit HCPCS H1004 Prenatal Care, At-risk Enhanced Service; Follow-up Home Visit Prenatal Visit HCPCS Z1032 Initial Antepartum Office Visit Prenatal Visit HCPCS Z1034 Antepartum Follow-Up Visit Prenatal care visit to an OB/GYN or other prenatal care practitioner or PCP. For visits to a PCP, a diagnosis of pregnancy must be present. Documentation in the medical record must include a note indicating the date when the prenatal care visit occurred, and evidence of one of the following. A basic physical obstetrical examination that includes auscultation for fetal heart tone, or pelvic exam with obstetric observations, or measurement of fundus height (a standardized prenatal flow sheet may be used). 35

37 Evidence that a prenatal care procedure was performed, such as: test in the form of an obstetric panel (must include all of the following: hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO blood typing), OR TORCH antibody panel alone, OR A rubella antibody test/titer with an Rh incompatibility (ABO/Rh) blood typing, OR Echography of a pregnant uterus. Documentation of LMP or EDD in conjunction with either of the following. Prenatal risk assessment and counseling/education. Complete obstetrical history. Members in hospice are excluded. Denominator: Members who delivered a live birth on or between November 6 of the year prior to the measurement year (2017) and November 5 of the measurement year (2018). Numerator: Members in the denominator who had a prenatal care visit as a member of the organization in the first trimester, on the enrollment start date or within 42 days of enrollment in the organization. Postpartum Care (PPC) Methodology: HEDIS Measure Description: The percentage of deliveries of live births on or between November 6, 2017 and November 5, 2018 that had a postpartum visit on or between 21 and 56 days after delivery. The eligible population in this measure meets all of the following criteria: 1. Continuous enrollment 43 days prior to delivery through 56 days after delivery with no allowable gap. 2. Members who delivered a live birth on or between November 6 of the year prior to the measurement year (2017) and November 5 of the measurement year (2018). This includes women who delivered in any setting. Women who had two separate deliveries (different dates of service) between November 6 of the year prior to the measurement year (2017) and November 5 of the measurement year (2018) count twice. Women who had multiple live births during one pregnancy count once. 36

38 CODES TO IDENTIFY POSTPARTUM CARE: Service Code Type Code Code Description Postpartum Care Postpartum Care Postpartum Care Postpartum Care Postpartum Care Postpartum Care Postpartum Care Postpartum Care Postpartum Care Postpartum Care Postpartum Care Postpartum Care Postpartum Care CPT Diaphragm Or Cervical Cap Fitting With Instructions CPT Insertion Of Intrauterine Device (iud) CPT Postpartum Care Only (separate Procedure) CPT Home Visit Postnatal CPT-CAT-II 0503F Postpartum Care Visit HCPCS G0101 ICD10CM Z ICD10CM Z ICD10CM Z01.42 ICD10CM Z Cervical Or Vaginal Cancer ; Pelvic And Clinical Breast Examination (g0101) [z01.411] Encounter For Gynecological Examination (general) (routine) With Abnormal Findings [z01.419] Encounter For Gynecological Examination (general) (routine) Without Abnormal Findings [z01.42] Encounter For Cervical Smear To Confirm Findings Of Recent Normal Smear Following Initial Abnormal Smear [z30.430] Encounter For Insertion Of Intrauterine Contraceptive Device ICD10CM Z39.1 [z39.1] Encounter For Care And Examination Of Lactating Mother ICD10CM Z39.2 [z39.2] Encounter For Routine Postpartum Follow-up HCPCS Z1038 Postpartum Follow-Up Office Visit Members in hospice are excluded. Denominator: Members who delivered a live birth on or between November 6 of the year prior to the measurement year (2017) and November 5 of the measurement year (2018). Numerator: Members in the denominator who had a postpartum visit on or between 21 and 56 days after delivery. 37

39 Population: Child Childhood Immunizations (CIS) Combo 10 Methodology: HEDIS Measure Description: The percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and one combination rate. Combo 10 includes the timely completion of the following antigens: - DTaP; IPV; MMR; HiB; HepB; VZV; PCV; HepA; Rotavirus; Flu The eligible population in this measure meets all of the following criteria: 1. Children who turn 2 years of age during the measurement year (2018). 2. Continuous enrollment 12 months prior to the child s second birthday with no more than one gap in enrollment of up to 45 days during the 12 months prior to the child s second birthday. CHILDHOOD IMMUNIZATION CODE SET: Antigen Code Type Code Code Description DTaP CPT Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And Hemophilus Influenza B Vaccine And Activated Poliovirus Vaccine, (DTaP-IPV/Hib), For Intramuscular Use DTaP CPT Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine (dta P) For Intramuscular Use DTaP CPT Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And Hemophilus Influenza B Vaccine (dtap-hib) For Intramuscular Use DTaP CPT Diphtheria Tetanus Toxoids Acellular Pertussis Vaccine Hepatitis B, and Inactivated poliovirus vaccine (dtap-hepb-ipv), For Intramuscular Use IPV CPT Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And Hemophilus Influenza B Vaccine and activated poliovirus vaccine, (DTaP- IPV/Hib), For Intramuscular Use IPV CPT Poliovirus Vaccine Inactivated (ipv) For Subcutaneous Use IPV CPT MMR CPT Diphtheria Tetanus Toxoids Acellular Pertussis Vaccine Hepatitis B, and Inactivated poliovirus vaccine (dtap-hepb-ipv), For Intramuscular Use Measles Mumps And Rubella Virus Vaccine (mmr) Live For Subcuta Neous Use 38

40 CHILDHOOD IMMUNIZATION CODE SET: Antigen Code Type Code Code Description MMR CPT Measles Mumps Rubella And Varicella Vaccine (mmrv) Live For Subcutaneous Use HiB CPT Meningococcal Conjugate Vaccine, Serogroups C & Y And Hemophilus Influenzae Type B Vaccine (hib-mency), 4 dose schedule, When Administered to children 6 wks to 18 mos of age, For Intramuscular Use HiB CPT Hemophilus Influenza B Vaccine (hib) Hboc Conjugate (4 Dose Schedule) For Intramuscular Use HiB CPT Hemophilus Influenza B Vaccine (hib) Prp-d Conjugate For Booster Use Only Intramuscular Use HiB CPT Hemophilus Influenza B Vaccine (hib) Prp-omp Conjugate (3 Dose S Chedule) For Intramuscular Use HiB CPT Hemophilus Influenza B Vaccine (hib)prp-t Conjugate (4 Dose Sche Dule) For Intramuscular Use HiB CPT Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And Hemophilus Influenza B Vaccine and activated poliovirus vaccine, (DTaP-IPV/Hib), For Intramuscular Use HiB CPT Diphtheria Tetanus Toxoids And Acellular Pertussis Vaccine And Hemophilus Influenza B Vaccine (dtap-hib) For Intramuscular Use HiB CPT Hepatitis B And Hemophilus Influenza B Vaccine (hepb-hib) For Intramuscular Use HepB CPT Diphtheria Tetanus Toxoids Acellular Pertussis Vaccine Hepatitis B, and Inactivated poliovirus vaccine (dtap-hepb-ipv), For Intramuscular Use HepB CPT Hepatitis B Vaccine Dialysis Or Immunosuppressed Patient Dosage (3 Dose Schedule) For Intramuscular Use HepB CPT Hepatitis B Vaccine Pediatric/adolescent Dosage (3 Dose Schedule ) For Intramuscular Use HepB CPT Hepatitis B Vaccine Dialysis Or Immunosuppressed Patient Dosage (4 Dose Schedule) For Intramuscular Use HepB CPT Hepatitis B And Hemophilus Influenza B Vaccine (hepb-hib) For Intramuscular Use HepB HCPCS G0010 Administration Of Hepatitis B Vaccine (g0010) VZV CPT Measles Mumps Rubella And Varicella Vaccine (mmrv) Live For Subcutaneous Use VZV CPT Varicella Virus Vaccine Live For Subcutaneous Use PCV CPT Pneumococcal Conjugate Vaccine Polyvalent For Children Under Five Years For Intramuscular Use PCV CPT Pneumococcal Conjucate Vaccine 13 Valent For Intramuscular Use PCV HCPCS G0009 Administration Of Pneumococcal Vaccine (g0009) HepA CPT Hepatitis A Vaccine Pediatric/adolescent Dosage-2 Dose Schedule For Intramuscular Use Rotavirus - 2 Dose CPT Rotavirus Vaccine Human Attenuated 2 Dose Schedule Live For Oral Use. 39

41 CHILDHOOD IMMUNIZATION CODE SET: Antigen Code Type Code Code Description Rotavirus - 3 Dose CPT Rotavirus Vaccine Tetravalent Live For Oral Use Flu CPT Flu Virus Vaccine, Trivalent (iiv3), Split Virus, Preservative Free, 0.25ml Dosage, For Intramuscular Use Flu CPT Influenza Virus Vaccine Split Virus For Children 6-35 Months Of Age For Intramuscular Use Flu CPT Influenza Virus Vaccine Derived From Cell Cultures Subunit Preservative And Antibiotic Free For Intramuscular Use Flu CPT Influenza Virus Vaccine Split Virus Preservative Free Enhanced Immunogenicity Via Increased Antigen Content, For Intramuscular Use Flu CPT Influenza Virus Vaccine Trivalent Derived From Recombinant Dna (r Iv3) Hemagglutinin (ha) Protein Only Preservative And Antibiotic Flu CPT Influenza Virus Vaccine Quadrivalent (II4V) Split Virus preservative free, 0.25 ml dosage, For Intramuscular Use Flu CPT Influenza Virus Vaccine Quadrivalent (II4V) Split Virus preservative free, 0.5 ml dosage, For Intramuscular Use Flu CPT Influenza Virus Vaccine Quadrivalent (II4V) Split Virus, 0.25 ml dosage, For Intramuscular Use Flu CPT Influenza Virus Vaccine Quadrivalent (II4V) Split Virus, 0.5 ml dosage, For Intramuscular Use Flu HCPCS G0008 Administration Of Influenza Virus Vaccine (g0008) Members who meet any of the following criteria are excluded: 1. Members in hospice are excluded. 2. Children who had a contraindication for a specific vaccine are excluded from the denominator for all antigen rates and the combination rates. Denominator: Children 2 years of age in the eligible population. Numerator: Members in denominator who show timely completion of all antigens in combo10. 40

42 Immunizations for Adolescents (IMA) Combo 2 Methodology: HEDIS Measure Description: The percentage of adolescents 13 years of age who had one dose of meningococcal conjugate; vaccine, one tetanus, diphtheria toxoids and acellular pertussis (Tdap); vaccine and two or three doses of the human papillomavirus (HPV) vaccine on or before their 13th birthday. The measure calculates a rate for each vaccine and a combination rate. At least one dose of meningococcal conjugate vaccine on or between the Member s 11th and 13th birthdays. At least one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine on or between the Member s 10th and 13th birthdays. At least two HPV vaccines, with different dates of service on or between the Member s 9th and 13th birthdays. There must be at least 146 days between the first and second dose of the HPV vaccine. For example, if the service date for the first vaccine was March 1, then the service date for the second vaccine must be after July 25. OR At least three HPV vaccines, with different dates of service on or between the Member s 9th and 13th birthdays. The eligible population in this measure meets all of the following criteria: 1. Adolescents who turn 13 years of age during the measurement year (2018). 2. Continuous enrollment 12 months prior to the member s 13th birthday with no more than one gap in enrollment of up to 45 days during the 12 months prior to the 13th birthday. CODES TO IDENTIFY MENINGOCOCAL: Antigen Code Type Code Code Description Meningococcal conjugate CPT Meningococcal Conjugate Vaccine Serogroups A, C, Y and W-135, quadrivalent (MCV4 or MenACWY), For Intramuscular Use CODES TO IDENTIFY TDAP: Antigen Code Type Code Code Description Tdap CPT Tetanus Diphtheria Toxoids And Acellular Pertussis Vaccine (Tdap) When Administered To Individuals 7 Years Or Older For Intramuscular Use 41

43 CODES TO IDENTIFY HPV: Antigen Code Type Code Code Description HPV CPT HPV CPT HPV CPT Human Papilloma Virus (hpv) Vaccine Types Quadrivalent (4vHPV), 2 or 3 Dose Schedule, For Intramuscular Use Human Papilloma Virus (hpv) Vaccine Types 16, 18 bivalent (2vHPV) 2 or 3 Dose Schedule, For Intramuscular Use Human Papilloma Virus Vaccine , nonavalent (9vHPV) 2 or 3 Dose Schedule, For Intramuscular Use Members who meet any of the following criteria are excluded: 1. Members in hospice are excluded. 2. Adolescents who had a contraindication for a specific vaccine are excluded from the denominator for all antigen rates and the combination rates. Denominator: Adolescents 13 years of age who meet all the criteria for eligible population. Numerator: Members in the denominator who had one dose of meningococcal conjugate vaccine, one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday during the measurement year (2018). 42

44 Well-Child 3-6 Years of life (W34) Methodology: HEDIS Measure Description: The percentage of Members 3 6 years of age who had one or more well-child visits with a PCP during the measurement year (2018). The eligible population in this measure meets all of the following criteria: 1. Age 3-6 years as of December 31 of the measurement year (2018). 2. Continuous enrollment in the measurement year (2018) with no more than one gap in enrollment of up to 45 days. CODES TO IDENTIFY WELL-CHILD: (NOTE: These codes must be provided by a Primary Care Provider in an office setting.) Service Code Type Code Code Description Well-Child 3-6 Years of Life Well-Child 3-6 Years of Life Well-Child 3-6 Years of Life Well-Child 3-6 Years of Life Well-Child 3-6 Years of Life Well-Child 3-6 Years of Life Well-Child 3-6 Years of Life Well-Child 3-6 Years of Life Well-Child 3-6 Years of Life CPT CPT CPT CPT HCPCS HCPCS G0438 G0439 ICD10CM Z ICD10CM Z Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient: early childhood (age 1 through 4 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient: late childhood (age 5 through 11 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) 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) Encounter For Routine Child Health Examination With Abnormal Findings Encounter For Routine Child Health Examination Without Abnormal Findings ICD10CM Z00.5 Encounter For Examination Of Potential Donor Of Organ And Tissue 43

45 CODES TO IDENTIFY WELL-CHILD: (NOTE: These codes must be provided by a Primary Care Provider in an office setting.) Service Code Type Code Code Description Well-Child 3-6 Years of Life ICD10CM Z00.8 Encounter For Other General Examination Well-Child 3-6 Years of Life ICD10CM Z02.0 Encounter For Examination For Admission To Educational Institution Well-Child 3-6 Years of Life ICD10CM Z02.1 Encounter For Pre-employment Examination Well-Child 3-6 Years of Life ICD10CM Z02.2 Encounter For Examination For Admission To Residential Institution Well-Child 3-6 Years of Life ICD10CM Z02.5 Encounter For Examination For Participation In Sport Well-Child 3-6 Years of Life ICD10CM Z02.6 Encounter For Examination For Insurance Purposes Well-Child 3-6 Years of Life ICD10CM Z02.71 Encounter For Disability Determination Well-Child 3-6 Years of Life ICD10CM Z02.79 Encounter For Issue Of Other Medical Certificate Well-Child 3-6 Years of Life ICD10CM Z02.81 Encounter For Paternity Testing Well-Child 3-6 Years of Life ICD10CM Z02.82 Encounter For Adoption Services Well-Child 3-6 Years of Life ICD10CM Z02.83 Encounter For Blood-alcohol And Blood-drug Test Well-Child 3-6 Years of Life ICD10CM Z02.89 Encounter For Other Administrative Examinations Well-Child 3-6 Years of Life ICD10CM Z02.9 Encounter For Administrative Examinations, Unspecified Members in hospice are excluded. Denominator: Members 3-6 years of age who meet all the criteria for eligible population. Numerator: Members in the denominator who had at least one well-child visit with a PCP during the measurement year (2018). The Well-Child visit must occur with a PCP, but the PCP does not have to be the practitioner assigned to the child. 44

46 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (WCC) Methodology: HEDIS Measure Description: The percentage of Members 3 17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of the following during the measurement year (2018). Report each of the three indicators below. BMI percentile documentation* Counseling for nutrition Counseling for physical activity The eligible population in this measure meets all of the following criteria: 1. Members who are 3-17 years of age as of December 31 of the measurement year (2018). 2. Continuous enrollment in the measurement year (2018) with no more than one gap up to 45 days. 3. An outpatient visit with a PCP or an OB/GYN during the measurement year (2018). * Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value. CODES TO IDENTIFY BMI PERCENTILE: Code Code Type Description Z68.51 ICD10 Body Mass Index (BMI) Pediatric, Less Than 5th Percentile For Age Z68.52 ICD10 Body Mass Index (BMI) Pediatric, 5th Percentile To Less Than 85th Percentile For Age Z68.53 ICD10 Body Mass Index (BMI) Pediatric, 85th Percentile To Less Than 95th Percentile For Age Z68.54 ICD10 Body Mass Index (BMI) Pediatric, Greater Than Or Equal To 95th Percentile For Age CODES TO IDENTIFY COUNSELING FOR PHYSICAL ACTIVITY: Code Code Type Description G0447 HCPCS Face-to-face Behavioral Counseling For Obesity, 15 Minutes S9451 HCPCS Exercise Classes, Non-Physician Provider, Per Session Z02.5 ICD10 Encounter For Examination For Participation In Sport Z71.82 ICD10 Exercise Counseling 45

47 CODES TO IDENTIFY COUNSELING FOR NUTRITION: Code Code Type Description CPT Medical Nutrition Therapy Initial Assessment And Intervention Individual Face-toface With The Patient Each 15 Minutes CPT Medical Nutrition Therapy Re-assessment And Intervention Individual Face-to-face With The Patient Each 15 Minutes CPT Medical Nutrition Therapy Group (2 Or More Individual(s)) Each 30 Minutes G0270 HCPCS Medical Nutrition Therapy; Reassessment And Subsequent Intervention(s) Following Second Referral In Same Year For Change In Diagnosis, Medical Condition Or Treatment Regimen (including Additional Hours Needed For Renal Disease), Individual, Face To Face G0271 HCPCS Medical Nutrition Therapy, Reassessment And Subsequent Intervention(s) Following Second Referral In Same Year For Change In Diagnosis, Medical Condition, Or Treatment Regimen (including Additional Hours Needed For Renal Disease), Group (2 Or More Individuals) G0447 HCPCS Face-to-face Behavioral Counseling For Obesity, 15 Minutes (G0447) S9449 HCPCS Weight Management Classes, Non-Physician Provider, Per Session (S9449) S9452 HCPCS Nutrition Classes, Non-Physician Provider, Per Session (S9452) S9470 HCPCS Nutritional Counseling, Dietitian Visit (S9470) Z71.3 ICD10 Dietary Counseling And Surveillance Members who meet any of the following criteria are excluded: 1. Members in hospice are excluded. 2. Female Members who have a diagnosis of pregnancy during the measurement year (2018) are excluded. A diagnosis of pregnancy will be determined using claims and encounter data only. Denominator: Members 3-17 years of age who meet all the criteria for eligible population. Numerator: Members in the denominator who had evidence of BMI, counseling of nutrition or physical activity during the measurement year (2018). 46

48 Population: All Initial Health Assessment (IHA) Methodology: IEHP-Defined Compliance Metric Measure Description: The IHA is a comprehensive assessment that is completed during the Member s initial encounter with a PCP, appropriate medical specialist, or Non-Physician medical Provider and must be documented in the Member s medical record. The IHA enables the Member s PCP to assess and manage the acute, chronic and preventive health needs of the Member. IEHP provides PCPs a monthly detailed Member roster on the IEHP Secure Provider Portal for all newly enrolled IEHP Members who are due for an IHA after 120 days of enrollment. The eligible population is newly assigned Members with an IEHP effective enrollment date of January 1, 2018 through December 31, The IHA must be provided within 120 days of enrollment (e.g., Member enrolled in December 2018 must be seen by April 2019 and PCP must submit encounter by May 2019) IHA visits completed during the 11 months prior to enrollment with IEHP count towards numerator compliance. CODES TO IDENTIFY IHA VISITS: Code Code Type Description CPT Office/Outpt E&M New Minor CPT Office/Outpt E&M New Low-Mod CPT Office/Outpt E&M New Mod Seve CPT Office/Outpt E&M New Mod-Hi CPT Office/Outpt E&M New Mod-Hi CPT Office/Outpt E&M Estab 5 Min CPT Office/Outpt E&M Estab Minor CPT Office/Outpt E&M Estab Low-Mo CPT Office/Outpt E&M Estab Mod-Hi CPT Office/Outpt E&M Estab Mod-Hi CPT Office Cons New/Estab Minor CPT Office Cons New/Est Lo Sever CPT Office Cons New/Estab Mod CPT Office Cons New/Estab Mod-Hi CPT Office Cons New/Estab Mod-Hi CPT Nursing Facility Care Init CPT Nursing Facility Care Init CPT Nursing Facility Care Init CPT Nursing Fac Care Subseq 47

49 CODES TO IDENTIFY IHA VISITS: Code Code Type Description CPT Nursing Fac Care Subseq CPT Nursing Fac Care Subseq CPT Nursing Fac Care Subseq CPT Nurs Facil D/C Da Mgmt; 30 M CPT Nurs Facil D/C Da Mgmt; > CPT Annual Nursing Fac Assessmnt CPT Domicil/R-Home Visit New Pat CPT Domicil/R-Home Visit New Pat CPT Domicil/R-Home Visit New Pat CPT Domicil/R-Home Visit New Pat CPT Domicil/R-Home Visit New Pat CPT Domicil/R-Home Visit Est Pat CPT Domicil/R-Home Visit Est Pat CPT Domicil/R-Home Visit Est Pat CPT Domicil/R-Home Visit Est Pat CPT Home Visit E&M New Pt Lo Sev CPT Home Visit E&M New Pt Mod Se CPT Home Visit E&M New Pt Mod-Hi CPT Home Visit E&M New Pt Hi Sev CPT Home Visit E&M New Pt Unstbl CPT Home Visit E&M Estab Minor CPT Home Visit E&M Estab Low-Mod CPT Home Visit E&M Estab Mod-Hi CPT Home Visit E&M Estab Mod-Hi CPT Prolong Md Serv Outpt W/Pt; CPT Prolong Md Serv Outpt W/Pt; CPT Init Preven Meds E&M New Pt; CPT Init Preven Meds E&M New Pt; CPT Init Preven Meds E&M New Pt; CPT Init Preven Meds E&M New Pt; CPT Init Preven Meds E&M New Pt; CPT Init Preven Meds E&M New Pt; CPT Init Preven Meds E&M New Pt; CPT Preven Meds E&M Estab Pt; In CPT Preven Meds E&M Estab Pt; CPT Preven Meds E&M Estab Pt; CPT Preven Meds E&M Estab Pt; CPT Preven Meds E&M Estab Pt; CPT Preven Meds E&M Estab Pt; CPT Preven Meds E&M Estab Pt; 65 48

50 CODES TO IDENTIFY IHA VISITS: Code Code Type Description CPT Preven Med Counsl (Sep Pro); CPT Preven Med Counsl (Sep Pro); CPT Preven Med Counsl (Sep Pro); CPT Preven Med Counsl (Sep Pro); CPT Preven Med Counsl Grp (Sep P CPT Preven Med Counsl Grp (Sep P CPT Admin/Intrpt Health Risk Ass CPT Unlisted Preven Meds Serv CPT Online E/M By Phys CPT Interprof Phone/Online CPT Interprof Phone/Online CPT Interprof Phone/Online CPT Interprof Phone/Online 31/> CPT Basic Life &/Or Disability E CPT Work Relat/Disabl Exam-Treat CPT Work Relat/Disabl Exam-Not T G0402 HCPCS Initial Preventive Exam G0438 HCPCS Ppps Initial Visit G0439 HCPCS Ppps Subseq Visit G0463 HCPCS Hospital Outpt Clinic Visit T1015 HCPCS Clinic Service Z00.00 ICD10CM Encounter for general adult medical examination without abnormal findings Z00.01 ICD10CM Encounter for general adult medical examination with abnormal findings Z ICD10CM Encounter for routine child health examination with abnormal findings Z ICD10CM Encounter for routine child health examination without abnormal findings Z00.5 ICD10CM Encounter for examination of potential donor of organ and tissue Z00.8 ICD10CM Encounter for other general examination Z02.0 ICD10CM Encounter for examination for admission to educational institution Z02.1 ICD10CM Encounter for pre-employment examination Z02.2 ICD10CM Encounter for examination for admission to residential institution Z02.3 ICD10CM Encounter for examination for recruitment to armed forces Z02.4 ICD10CM Encounter for examination for driving license Z02.5 ICD10CM Encounter for examination for participation in sport Z02.6 ICD10CM Encounter for examination for insurance purposes Z02.71 ICD10CM Encounter for disability determination Z02.79 ICD10CM Encounter for issue of other medical certificate Z02.81 ICD10CM Encounter for paternity testing Z02.82 ICD10CM Encounter for adoption services Z02.83 ICD10CM Encounter for blood-alcohol and blood-drug test Z02.89 ICD10CM Encounter for other administrative examinations Z02.9 ICD10CM Encounter for administrative examinations, unspecified 49

51 Concurrent Use of Opioids and Benzodiazepines Methodology: IEHP-Defined Compliance Metric Measure Description: The Concurrent Use of Opioids and Benzodiazepines measure specification is developed and maintained by the Pharmacy Quality Alliance (PQA). This measure examines the percentage of individuals 18 years and older with concurrent use of prescription opioids and benzodiazepines. The denominator includes individuals 18 years and older by the first day of the measurement year with two or more prescription claims for opioids filled on two or more separate days, for which the sum of the days supply is 15 or more days during the measurement period. The numerator includes individuals from the denominator with two or more prescription claims for benzodiazepines filled on two or more separate days, and concurrent use of opioids and benzodiazepines for 30 or more cumulative days. Exclusion: Patients in hospice care and those with a cancer diagnosis are excluded. Access to Care Needed Right Away Methodology: Monthly Member Satisfaction Survey. Measure Description: In the last six months, when you needed care right away, how often did you get care as soon as you needed it? Valid response: never, sometimes, usually, always Target response: usually, always Measure Support: To help identify opportunities to improve customer service, IEHP conducts a monthly Member Satisfaction Survey between June-December annually. Member survey responses are analyzed and shared at the PCP level. 50

52 Coordination of Care Methodology: Monthly Member Satisfaction Survey Measure Description: In the last six months, how often did your Personal Doctor seem informed and up-to-date about the care you got from these doctors or other health providers? Valid response: never, sometimes, usually, always Target response: usually, always Measure Support: To help identify opportunities to improve customer service, IEHP conducts a monthly Member Satisfaction Survey between June-December annually. Member Survey responses are analyzed and shared at the PCP level. Rating of Access to Routine Care Methodology: Monthly Member Satisfaction Survey Measure Description: In the last six months, how often did you get an appointment for a check-up or routine care at a Doctor s office or clinic as soon as you needed it? Valid response: never, sometimes, usually, always Target response: usually, always Measure Support: To help identify opportunities to improve customer service, IEHP conducts a monthly Member Satisfaction Survey between June-December annually. Member Survey responses are analyzed and shared at the IPA level. 51

53 APPENDIX 3: Historical Data Form 52

54 APPENDIX 4: Member Satisfaction Survey 53

55 APPENDIX 4: Member Satisfaction Survey (continued...) 54