HEDIS 2014 & CMS Star Ratings: Provider Quick Reference Guide HEDIS 2014

Transcription

1 Breast Cancer Screening (BCS) (Administrative- Claims Data Only) STAR RATING: Percentage of female plan members aged who had a mammogram during the past 2 years. Test Performed by: October 1, December 31, 2013 HEDIS: Percentage of women years of age as of December 31 who had a mammogram to screen for breast cancer during the measurement year or the year prior to the measurement year. Exclusions: Women who had a bilateral mastectomy. Continuous Enrollment: October 1, December 31, 2013 Allowable Gap: no more than 45 days <43 >43 to <64 >64 to <74 >74 to <83 > CPT HCPCS ICD-9 CM Procedure G0202, G0204, G , Mammogram NOTE: The Purpose of this measure is to evaluate primary screening. Do not count biopsies, breast ultrasounds or MRIs for this measure because they are not appropriate methods for primary breast cancer screening. Colorectal Cancer Screening (COL) STAR RATING: Percentage of plan members aged who had appropriate screening for colon cancer. Test Performed by: Jan 01- Dec 31 of CY or Colonoscopy during past 10 years <35 >35 to to <58 58 to <67 67 HEDIS: Percentage of members years of age who had appropriate screening for colorectal cancer. Exclusions: Members with a diagnosis of colorectal cancer or total colectomy. Continuous Enrollment: Measurement year and year prior, Allowable Gap: no more than 45 days Description CPT HCPCS ICD 9-CM Procedure FOBT 82270,82274 G0328, Flexible , , G0104 Sigmoidoscopy Colonoscopy ,44397,45355, G0105, 45.22, 45.23, 45.25, , 45391, G , of 3 depending of the FOBT test used. 1. Fecal occult blood test (FOBT) during the measurement year. Regardless of FOBT type, guaiac (gfobt) or immunochemical (ifobt), assume that the required number of samples was returned. 2. Flexible Sigmoidoscopy during the measurement year or the four years prior to the measurement year 3. Colonoscopy during the measurement year or the nine years prior to the measurement year Documentation must be provided of previously performed colorectal screening test including result and date of service. 1

2 Preferred billing code for this measure 2

3 Cholesterol Management for Patients with Cardiovascular Conditions (CMC) STAR RATING: Percentage of plan members age with ischemic vascular disease, AMI, coronary bypass Graft (CABG) or percutaneous trans luminal coronary angioplasty (PTCA) who had LDL-C test performed during the measurement year. Test Performed by: Jan 01- Dec 31 of 2013 HEDIS: Percentage of members years of age who were discharge alive for AMI, coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) from January 1- December 31 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year. Continuous Enrollment: Measurement year and year prior, Allowable Gap: no more than 45 days <66 66 to <80 80 to <87 87 to <89 89 CPT CPT Category II LOINC 80061, 83700, 83701, 83704, F, 3049F, 3050F , , , , , , , , LDL C Screening test performed during the measurement year, as identified by claim/encounter or automated laboratory data <100mg/DL Glaucoma Testing in Older Adults (GSO) STAR RATING: Percent of senior plan members who got a glaucoma eye exam for early detection Test Performed by: Jan 01- Dec 31 of current or previous year <54 54 to <62 62 to <70 70 to <74 74 (Administrative- Claims Data Only) HEDIS: The percentage of Medicare members 65 years and older, without a prior diagnosis of glaucoma or glaucoma suspect, who received a glaucoma eye exam by an eye care professional for early identification of glaucomatous conditions. Exclusions: Members who had a prior diagnosis of glaucoma or glaucoma suspect. Continuous Enrollment: Measurement year and year prior, Allowable Gap: no more than 45 days CPT 92002, 92004, 92012, 92014, ,92100, 92140, , , Optometrist and/or Ophthalmologist referral in order to conduct eye exams for glaucoma during the measurement year. HCPCS G0117, G0118, S0620, S0621 ICD 9-CM Diagnosis ICD 9-CM Procedure Preferred billing code for this measure 3

4 Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) STAR RATING: Percent of plan members with Rheumatoid Arthritis who got 1 or more prescription(s) for an anti-rheumatic drug. Prescribed once in: Jan 01- Dec 31 of CY <49 49 to <66 66 to <78 78 to <86 86 (Administrative Claim/Encounter) HEDIS: The percentage of members who were diagnosed with rheumatoid arthritis and were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD). Exclusions: Members diagnosed with HIV or who are pregnant Description ICD -9-CM Diagnosis Rheumatoid arthritis 714.0, 714.1, 714.2, Outpatient Visit Type CPT , , , , , , , , 99411,99412, 99420, 99429, 99455, NONE NOTE: In order to be compliant for this measure the member has to have at least one prescription, during the year, for any of the following anti-rheumatic drugs: First Line Therapy Medications -Azathioprine -Cyclophosphamide -Gold Sodium Thiomalate -Hydroxychloroquine -Leflunomide -Methotrexate -Minocycline -Sulfasalazine. -Cyclosporine 4

5 Comprehensive Diabetes Care (CDC) Cholesterol Screening STAR RATING: Percentage of plan members with diabetes who had a test for bad (LDL) cholesterol. Test Performed by: Jan 01- Dec 31 of CY <69 69 to <81 81 to <85 85 to <90 90 HEDIS: The percentage of members years of age with diabetes (type 1 and type 2) who had LDL C Screening during the measurement year, as identified by claim/encounter or automated laboratory data. CPT CPT Category II LOINC 80061, 83700, 83701, 83704, F, 3049F, 3050F , , , , , , , , , LDL C Screening test performed during the measurement year, as identified by claim/encounter or automated laboratory data. Comprehensive Diabetes Care (CDC) Cholesterol Controlled / LDL control < 100 mg/dl STAR RATING: Percentage of plan members with diabetes who had a cholesterol test during the year that showed an acceptable level of bad (LDL) cholesterol. Test Performed by: Jan 01- Dec 31 of CY <34 34 to <48 48 to to <60 60 HEDIS: The percentage of members years of age with diabetes (type 1 and type 2) who had the most recent LDL-C test during the measurement year and the level is < 100mg/dL. Description CPT Category II Numerator compliant (LDL-C < 100mg/dL 3048F Weighted Value- 3 Not numerator compliant (LDL-C 100 mg/dl) 3049F, 3050F LDL C Screening test performed during the measurement year with level outcome of <100mg/dL, as identified by claim/encounter or automated laboratory data Comprehensive Diabetes Care (CDC) Blood Sugar Controlled / HbA1c Controlled STAR RATING: Percentage of plan members with diabetes who had an A1c lab test during the year that showed their average blood sugar is under control (<9%). Test Performed by: Jan 01- Dec 31 of CY <41 41 to <68 68to <80 80 to <88 88 Weighted Value- 3 HEDIS: The percentage of members years of age with diabetes (type 1 and type 2) who had a Hemoglobin A1c screening and the most recent A1c test during the measurement year is < 8%. Description CPT / CPT Category II HbA1c Test 83036, / 3044F, 3045F, 3046F Numerator compliant (HbA1c < 8%) 3044F Not numerator compliant (HbA1c 8%) Numerator complaint (HbA1c >9%) Hemoglobin A1c Screening Test performed during the measurement year, as identified by claim/encounter or automated laboratory data 3045F, 3046F 3046F LOINC , , , , ,

6 A copy of all lab results should be kept in the members Medical Records. Comprehensive Diabetes Care (CDC) Kidney Disease Monitoring/ Medical attention to Nephropathy STAR RATING: Percentage of plan members with diabetes who had a kidney function test during the year Test Performed by: Jan 01- Dec 31 of CY <78 78 to <82 82 to <85 85 to <90 90 HEDIS: The percentage of members years of age with diabetes (type 1 and type 2) who had a urine micro albumin test during the measurement year or who had received medical attention for nephropathy during the measurement year. Description CPT CPT Category II Nephropathy screening test 82042, 82043, 82044, F, 3061F Urine macroalbumin test , F 3066F, 4010F Evidence of treatment for nephropathy 36147, 36800, 36810, 36815, 36818, ,36831,-36833, 50300, 50320,50340, 50360, 50365, 50370,50380, 90935, 90937, 90940, 90945, 90947, 90957,-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, Micro albumin, Random Urine w/createnine or Micro albumin, 24 hour Urine, w/o Createnine test performed during the measurement year, as identified by claim/encounter or automated laboratory data Documented evidence of nephropathy with: o Any positive urine macro albumin test for protein o Medical attention for nephropathy 6

7 o Nephrology consult in current year (include if primary care physician also is a nephrologist) Comprehensive Diabetes Care (CDC) Diabetes Care Eye Exam STAR RATING: Percentage of plan members with diabetes who had an eye exam to check for damage from diabetes during the year Test Performed by: Jan 01- Dec 31 of current or previous year. <47 47 to <54 54 to <64 64 to <81 81 HEDIS: The percentage of members years of age with diabetes (type 1 and type 2) who had a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or a negative retinal exam (no evidence of retinopathy) in the year prior to the measurement year. CPT CPT Category II HCPCS 67028, 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92225, 92226, 92230, 92235, 92240, 92250, 92260, , , , 92134, 92227, F, 2024F, 2026F, 3072F S0620, S0621, S0625, S3000 Referral to an eye care specialist (optometrist or ophthalmologist) for a retinal or dilated eye exam during the measurement year. For eye exam performed in the year prior to the measurement year, a result must be available and documented as part of the medical record indicating a positive or negative result. 7

8 Osteoporosis Management in Women who had a Fracture (OMW) STAR RATING: Percentage of female plan members who broke a bone and got screening or treatment for osteoporosis within 6 months Fracture Date Range: July 01/CY-2 though Jun 30/ CY-1 Test Performed or prescription by: Jan 01- Dec 31 of CY-1 <24 24 to <38 38 to <60 60 to <67 67 BMD (Bone Mineral Density) Exam Osteoporosis Therapies identified through pharmacy data which includes prescription for the following medications: - Alendronate, - Ibandronate, - Risedronate, - Calcitonin, - Raloxifene, - Zoledronic Acid - Denosumab (Administrative Claim/Encounter) HEDIS: The Percentage of women 67 years of age and older who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after the fracture. This measure has an intake period which means that data is captured for 12 months beginning on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year. The intake period is used to capture the first fracture. Continuous Enrollment: 1 year before fracture diagnosis through 6 months after, Allowable Gap: no more than 45 days HEDIS BILLING CODES TO IDENTIFY A FRACTURE ICD 9-CM Procedure , , , , , , , , , , 81.65, J CODES TO IDENTIFY OSTEOPOROSIS THERAPIES J1740, J3488, J3487, J1000, J0630, J3110, J0897 HEDIS BILLING CODES TO IDENTIFY BONE MINERAL DENSITY TEST CPT HCPCS ICD 9-CM Diagnosis ICD 9-CM Procedure 76977, 77078, 77080, 77081, 77082, 78350, G

9 Controlling High Blood Pressure (CBP) STAR RATING: Percent of plan members with high blood pressure who got treatment and were able to maintain a healthy pressure. BP controlled during: Jan 01- Dec 31 of CY <43 43 to <53 53 to to <70 70 Weighted Value- 3 (Hybrid 100% Medical Record Review) HEDIS: The percentage of members years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90) during the measurement year. ICD-9 CM Diagnosis: 401, 401.1, Blood Pressure to be performed at every visit, and controlled during measurement year HEDIS looks at the most recent blood pressure *Note in order to have a positive hit, the blood pressure must be below 140/90. Adult BMI (Body Mass Index) Assessment (ABA) STAR RATING: Percentage of members years of age who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior to the measurement year. Test Performed by: Jan 01- Dec 31 of CY or (CY-1) <25 25 to <50 50 to <61 61 to <80 80 In order to ensure compliance the following must be included: Date of service, weight, height, and BMI calculations. HEDIS: Percentage of members years of age who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior to the measurement year. Exclusions: Members who have a diagnosis of pregnancy during the measurement year or the year prior to the measurement year. Continuous Enrollment: Measurement year and year prior, Allowable Gap: no more than 45 days Description CPT for Office Visit ICD -9 CM Diagnosis , , , , , , Body Mass Index , V85.0-V , , , 99411, 99412, 99420, 99429, 99455,

10 Plan All-Cause Readmissions STAR RATING: Percentage of members 65 years and older discharged from a hospital stay who were readmitted to a hospital within 30 days, either for the same condition as their recent hospital stay or for a different reason. Discharge during: Jan 01- Dec 31 of CY Readmission: within 30 days of discharge >17 >13 to 17 >11 to 13 >3 to 11 3 Weighted Value- 3 (Administrative Claims/Encounter) HEDIS: The percentage of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days, for members 18 years of age and older, in the following categories: 1. Count of Index Hospital Stays (HS denominator) 2. Count of 30-Day Readmission (numerator) 3. Average Adjusted Probability of Readmission Exclusions: Hospital stays where the admission day is the same as the discharge date. Exclusions: Any acute inpatient stays with a discharge date in the 30 days prior to the admission date. Exclusions: Inpatient stays with discharges for death; acute inpatient stays for pregnancy. Continuous Enrollment: 365 days prior to discharge through 30 days after, Allowable Gap: no more than 45 days during 365 day period, no gap during 30 days post discharge. 10

11 Care for Older Adults (COA)- Medication Review (SNP only) STAR RATING: Medication Review Percentage of plan members whose doctor or clinical pharmacist has reviewed a list of everything they take at least once a year. Medication Review once during: Jan 01- Dec 31 of CY <44 44 to <63 63 to <81 81 to <92 92 In order to ensure compliance the following must be included: *Medication Review and Medication listing must be signed AND dated or note of no medications must be documented in the Medical Record. HEDIS: Medication Review At least one medication review conducted by a prescribing practitioner or clinical pharmacist during the measurement year and the presence of a medication list in the medical record, as documented through either administrative data or medical record review. Description CPT CPT Category II Medication Review 90863, 99605, F Description CPT Category II HCPCS Medication List 1159F G8427 Care for Older Adults (COA)- Functional Status Assessment (SNP only) STAR RATING: Functional Status Assessment (Comprehensive) Percent of plan members whose doctor has done a functional status assessment to see how well member is doing activities of daily living etc. Functional Status Assessment once during: Jan 01- Dec 31 of CY <29 29 to <54 54 to <75 75 to <89 89 In order to ensure compliance the following must be included: Evidence of functional assessment and date of service. HEDIS: Functional Status Assessment Documentation in the medical record of at least complete functional status assessment in current year including the date performed. Notations for a complete functional status assessment may include: Assessment of instrumental activities of daily living (IADL) such as shopping for groceries, driving, using public transportation, using the telephone, meal preparation, housework, home repair, laundry, taking medications or handling finances of Assessment of activities of daily living (ADL) such as bathing, dressing, eating, transferring (i.e., getting in and out of chairs), using the toilet and walking or Results using a standardized functional status assessment tool or Assessment of three of the following four components: - Cognitive status - Ambulation status - Sensory ability ( hearing, vision, speech) - Other functional independence (e.g., exercise, ability to perform job) A functional status assessment limited to an acute or single condition, event, or body system (e.g., lower back, leg) NOT meet criteria for a comprehensive functional status assessment. Description CPT Category II ICD 9-CM Procedure Functional Status Assessment 1170F 11

12 Care for Older Adults (COA)- Pain Screening (SNP only) STAR RATING: Pain Screening Percent of plan members who had a pain screening or pain management plan at least once during the measurement year. Pain screening during: Jan 01- Dec 31 of CY <27 27 to <41 41 to <56 56 to <78 78 In order to ensure compliance the following must be included: Evidence of pain management or evidence of pain screening along with date of service. HEDIS: Pain Screening: Documentation that the patient was assessed for pain (which may include positive or negative findings for pain). Result of assessment using a standardized pain assessment tool, not limited to: Numeric rating scales (verbal or written) Face, Legs, Activity, Cry Consolability (FLACC) scale. Verbal descriptor scales (5 7 Word Scales, Present Pain Inventory). Pain Thermometer. Pictorial Pain Scales (Faces Pain Scale, Wong-Baker Pain Scale). Visual analogue scale. Brief Pain Inventory. Chronic Pain Grade. PROMIS Pain Intensity Scale. Pain Assessment in Advanced Dementia (PAINAD) Scale. Description CPT Category II Pain Screening 1125F, 1126F Care for Older Adults (COA)- Advance Care Planning (SNP only) THIS IS NOT A STAR RATINGS MEASURE No Thresholds applicable* HEDIS: Advance Care Planning Evidence of advance care planning must include: An advance care plan in the medical record or Advance care planning discussion with the provider documented and dated or Notation that the member has previously executed an advanced care plan that meets criteria Percent of adults 66 years old and older who have active advance care planning such as Advanced directive Living will Power of attorney Health care proxy Actionable medical decision maker or surrogate decision maker Description CPT Category II HPCPS Advance Care Planning 1157F, 1158F S

13 High Risk Medications (Prescription Drug Event (PDE) Data) STAR RATING: The percent of plan members who got prescriptions for certain drugs with a high risk of serious side effects, when there may be safer drug choices. METRIC: This measure calculates the percentage of Medicare Part D beneficiaries 65 years or older who received at least two prescriptions of the same drug with a high risk of serious side effects in the elderly. Measurement Period: Jan 01- Dec 31 of CY Continuous Enrollment Period: Begins on date of first fill and ends on last day of enrollment period (Fill should occur at least 91 days prior to end of enrollment period). Allowable Gap: no more than 1 month > 10.2 to 28.1 > 8.7 to 10.2 > 7.0 to 8.7 > 5.0 to Weighted Value- 3 NOTE: High Risk Medication Oral Estrogen, Estrogen Patches Carisoprodol, Cyclobenzaprine, Metaxolone, Methocarbamol, Orphenadrine Chlorpropamide Cyproheptadine, Glyburide, Diphenhydramine, Hydroxyzine Dicyclomine Diphenoxylate/Atropine Meprobamate Nifedipine (Short Acting Only) Zolpidem Zaleplon Alternative Estrogen creams. Baclofen Glimeperide, Glipizide Cetirizine (OTC Benefit), Loratadine (OTC Benefit) Cholestyramine, Loperamide, Metamucil (OTC Benefit), Docusate (OTC Benefit), Loperamide Sleep: Temazepam Anxiety: Alprazolam, Buspirone Nifedipine ER, Amlodipine Temazepam Triazolam 13

14 Blood Pressure Medication for People with Diabetes (Prescription Drug Event (PDE) Data) STAR RATING: When people with diabetes also have high blood pressure, there are two types of blood pressure medication recommended. This tells what percent got one of the recommended types of blood pressure medicine. METRIC: This is defined as the percentage of Medicare Part D beneficiaries who were dispensed a medication for diabetes and a medication for hypertension who were receiving an angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or renin inhibitor medication which are recommended for people with diabetes. Measurement Period: Jan 01- Dec 31 of CY) 56.5 to < to < to < to < Weighted Value- 3 NOTE: Targeted Population Members taking a medication for diabetes and a medication for hypertension Recommended Hypertension Medication Preferred Formulary ACE-Inhibitor: benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril (Prinivil, Zestril), moexipril (Univasc), perindopril (Aceon), quinapril (Accupril), ramipril (Altace), trandolapril (Mavik) Preferred Formulary ARB: losartan (Cozaar), Valsartan (Diovan), Irbesartan (Avapro) Or Preferred Formulary Renin Inhibitor: Tekturna Medication Adherence for Oral Diabetes Medications (Prescription Drug Event (PDE) Data) STAR RATING: Percent of plan members with a prescription for oral diabetes medication who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication. ( Oral diabetes medication means a biguanide drug, a sulfonylurea drug, a thiazolidinedione drug, or a DPP-IV inhibitor. Plan members who take insulin are not included.). METRIC: This measure is defined as the percent of Medicare Part D beneficiaries 18 years or older who adhere to their prescribed drug therapy across four classes of oral diabetes medications: biguanides, sulfonylureas, thiazolidinediones, and DiPeptidyl Peptidase (DPP)-IV Inhibitors. Measurement Period: Jan 01- Dec 31 of CY) Continuous Enrollment Period: Begins on date of first fill and ends on last day of enrollment period (Fill should occur at least 91 days prior to end of enrollment period). Allowable Gap: no more than 1 month 52.4 to < to < to < to < Weighted Value- 3 Services Required: 14 Targeted Population Members taking oral diabetes medications in the following therapeutic classes: biguanides, sulfonylureas, thiazolidinediones, and DiPeptidyl Peptidase (DPP)-IV Inhibitors Recommended Adherence Monitoring Ensure Members are taking their medication as directed and order their refills on a monthly basis

15 Proactively assess whether the patient is taking medication as required If you identify barriers to adherence, resolve those barriers and find ways to help the member take his or her medication as directed Medication Adherence for Hypertension (ACEI & ARBs) (Prescription Drug Event (PDE) Data) STAR RATING: Percent of plan members with a prescription for a blood pressure medication who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication. ( Blood pressure medication means an ACE (angiotensin converting enzyme) inhibitor or an ARB (angiotensin receptor blocker) drug.) METRIC: This measure is defined as the percent of Medicare Part D beneficiaries 18 years or older who adhere to their prescribed drug therapy for angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) medications. Measurement Period: Jan 01- Dec 31 of CY) Continuous Enrollment Period: Begins on date of first fill and ends on last day of enrollment period (Fill should occur at least 91 days prior to end of enrollment period). Allowable Gap: no more than 1 month 52.4 to < 67.8 to < to < to < Weighted Value- 3 Targeted Population Members taking hypertension medications in the following therapeutic classes: ACE (Angiotensin Converting Enzyme) or ARB (Angiotensin Receptor Blocker) Services Required: Proactively assess whether the patient is taking medication as required If you identify barriers to adherence, resolve those barriers and find ways to help the member take his or her medication as directed Recommended Adherence Monitoring Ensure Members are taking their medication as directed and order their refills on a monthly basis Medication Adherence for Cholesterol (Statins) (Prescription Drug Event (PDE) Data) STAR RATING: Percent of plan members with a prescription for a cholesterol medication (a statin drug) who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication.. METRIC: This measure is defined as the percent of Medicare Part D beneficiaries 18 years or older that adhere to their prescribed drug therapy for statin cholesterol medications. Measurement Period: Jan 01- Dec 31 of CY) Continuous Enrollment Period: Begins on date of first fill and ends on last day of enrollment period (Fill should occur at least 91 days prior to end of enrollment period). Allowable Gap: no more than 1 month 32.9 to < 63.0 to < to< to < Weighted Value- 3 Targeted Population Members taking a cholesterol medication in the following therapeutic class: Statin Services Required: Proactively assess whether the patient is taking medication as required If you identify barriers to adherence, resolve those barriers and find ways to help the member take his or her medication as directed Recommended Adherence Monitoring Ensure Members are taking their medication as directed and order their refills on a monthly basis 15

16 DISPLAY MEASURES Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) STAR RATING: Percentage of senior plan members with active Chronic Obstructive Pulmonary Disease (COPD) who got appropriate Spirometry testing to confirm the diagnosis. Test Performed by: Jan 01- Dec 31 of CY (Administrative Claim/Encounter) HEDIS: The percentage of members 40 years and older with a new diagnosis of newly active COPD who received appropriate Spirometry testing to confirm the diagnosis. Continuous Enrollment Period: 2 years prior to diagnosis date through 6 months after diagnosis date Allowable Gap: no more than 45 days per 12 month period <20 >20 to <35 >35 to <60 >60 to <83 >83 **2011 Thresholds Identifying Test Spirometry 94010, , 94060, 94070, 94375, , 496 CPT IDC-9 CM Diagnosis Spirometry Test 16

17 Annual Monitoring for Patients on Persistent Medications (MPM) STAR RATING: Percentage of Plan members who got a 6 month (or longer) prescription for a drug known to have a possibly harmful side effects among seniors if used long-term, and who had at least one appropriate follow-up visit during the year to monitor these medications. Provider visit during: Jan 01- Dec 31 of CY <70 >70 to <78 >78 to <90 >90 to <92 >92 **2011 Thresholds (Administrative Claim/Encounter) HEDIS: The Percentage of members 18 years and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring vent for the therapeutic agent in the measurement year. For each of the following: Annual monitoring for members on Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) Annual monitoring for members on digoxin Annual monitoring for members on diuretics Annual monitoring for members on anticonvulsants Physiologic- Monitoring Test CPT Serum Potassium (K+) 80051, , Serum Creatinine (SCr) 82565, , Blood Urea Nitrogen (BUN) 84520, , Description CPT Drug serum concentration for phenobarbital Drug serum concentration for phenytoin 80185, , Drug serum concentration for valproic acid or divalproex sodium CPT Lab Panel CPT 80047, 80048, 80050, 80053, Drug serum concentrations for carbamazepine 80156, ,

18 Rate 1: Members on ACE Inhibitors or ARBs Must order at least one serum potassium and serum createnine during the year or a serum potassium and blood urea nitrogen Rate 2: Member on Digoxin Must order a serum potassium and serum creatinine or a serum potassium and blood urea nitrogen Rate 3: Members on Anticonvulsants Must order serum phenobarbital, or serum phenytoin, or serum valproic acid or serum divalproex, or serum carbamazepine (depending which medication the members is on). Rate 4: Members on Diuretics Must order serum potassium and serum creatinine or serum potassium and blood urea nitrogen. Adults Access to Preventive/Ambulatory Health Services (AAP) (Administrative Claim/Encounter) STAR RATING: Percent of all plan members who saw their primary care doctor during the year. Doctor s visit during: Jan 01- Dec 31 of CY <73 73 to <79 79 to <85 85 to <96 96 **2012 Thresholds HEDIS: The percentage of members 20 years and older who had an ambulatory or preventive care visit. Preventive Ambulatory Health Services Office or other outpatient Services , , Home Services , Nursing Facility Care Domiciliary, rest home or custodial care services Preventive Medicine Ophthalmology and Optometry , 99315, 99316, CPT HCPCS ICD-9- CM Diagnosis , , , , 99411, 99412, 99420, , 92004, 92012, G0344, G0402, G0438, G0439 General Medical Examination S0620, S0621 V70.0, V70.3, V70.5, V70.6, V70.8, V