PROVIDER GUIDE Required information on targeted HEDIS and Part D measures

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1 PROVIDER GUIDE Required information on targeted HEDIS and Part D measures Visit for full measure descriptions. Contact QI@atriohp.com with any questions. Adult Body Mass Index (ABA) Percentage of members years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year. Breast Cancer Screening (BCS) Percentage of women years of age who had a mammogram to screen for breast cancer. Exclusion: Bilateral mastectomy at any time during the member s history through December 31, 2018 Colorectal Cancer Screening (COL) Percentage of members 50 to 75 years of age who have evidence of one of the following five tests: Fecal Occult Blood Test FIT-DNA Flexible sigmoidoscopy CT colonography Colonoscopy Exclusions: Either of the following any time during the member s history through December 31, 2019: Colorectal cancer Total colectomy BMI documented in 2018 thru 2019 Mammogram in Oct 2017 thru 2019 Fecal Occult Blood Test (ifobt or gfobt) during the measurement year FIT-DNA during the measurement year or two years prior to the measurement year Flexible Sigmoidoscopy during the measurement year or the four years prior to the measurement year CT Colonography during the measurement year or the four years prior to the measurement year Encounter/Claim with Codes: ICD-10: Z68.1, Z68.20 thru Z68.39, Z68.41 thru Z68.45 Encounter/Claim with Codes: CPT : , , HCPCS: G0202, G0204, G0206 ICD 9 CM: 87.36, UBREV: 0401, 0403 Encounter/Claim with Codes: Fecal Occult Blood Test (ifobt or gfobt) between 1/1/2019 and 12/31/2019 CPT : 82270, HCPCS: G0328 LOINC: , , , , , , , , , , , , , , , FIT-DNA between 1/1/2017 and 12/31/2019 CPT : HCPCS: G0464 LOINC: , Flexible Sigmoidoscopy between 1/1/2015 and 12/31/2019 CPT : , , , 45349, HCPCS: G0104 ICD 9 CM: CT Colonography between 1/1/2015 and 12/31/2019 CPT : Colonoscopy between 1/1/2010 and 12/31/2019

2 Colonoscopy during the measurement year or the nine years prior to the measurement year. NOTE: Clear documentation of previously performed FIT-DNA, CT Colonography, Flexible Sigmoidoscopy, and/or Colonoscopy, including year performed, is required. CPT : , 45398, , 44397, , HCPCS: G0105, G0121 ICD 9 CM: , 45.25, Chart documentation of previously performed colorectal cancer screening tests. Diabetes - Nephropathy (CDC) Percentage of diabetic members years old who received medical attention for nephropathy (nephropathy screening test or evidence of nephropathy) Nephropathy screening testing on all diabetic members in 2018 with: Timed, Spot (urine dipstick or test strip), or 24 hour urine for albumin or protein. Urine for albumin/creatinine ratio. 24 hour urine for total protein. Random urine for protein/creatinine ratio. Documented evidence of nephropathy with: Medical attention for nephropathy Nephrology consult in 2019 (include if primary care physician is also a nephrologist) Laboratory Claim/Encounter with Codes: CPT : , 81005, , CPT Cat. II: 3060F, 3061F, 3062F LOINC: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Physician Claim/Encounter Office Urine Protein Testing: CPT : , 81005, , CPT Cat. II: 3060F-3062F

3 ACE or ARB Therapy: CPT Cat. II: 4010F Prescribed or currently taking ACE All testing and results should be dated and documented in the inhibitor or ARB medication in 2019 member s medical record Diabetes - HbA1c Control (CDC) Percentage of members years of age with diabetes who have evidence of: HbA1c testing HbA1c control <8.0% Diabetes Dilated or Retinal Eye Exam (CDC) Percentage of members years of age with diabetes who have received a comprehensive eye exam. Controlling High Blood Pressure (CBP) Percentage of members years of age with diagnosed hypertension and whose BP was adequately controlled (<140/90 mmhg). Osteoporosis Screening and Management after Fracture (OMW) Percentage of females 67 to 85 years old who suffered a fracture and who Evidence of stage 4 chronic kidney disease Evidence of ESRD Evidence of Kidney Transplant HbA1c testing on all members with diabetes in 2019 AND Diabetes management so that all members have the most recent HbA1c in 2018 < 8.0% Encourage and/or refer member to see an ophthalmologist or optometrist for a comprehensive eye exam. The most recent blood pressure reading in 2019 adequately controlled according to guideline. Perform bone mineral density testing within six months on members 67 years old and older who experience a fracture Laboratory Encounter/Claim with Codes: CPT : 83036, CPT Cat. II : 3044F, 3045F, 3046F LOINC: , , , , A copy of all lab results should be kept in member s medical record NOTE: In order to pass: HbA1c must be < 8% Claim or Encounter Submission: From either an ophthalmologist or an optometrist in 2019 or 2018 Obtain and place copy of eye exam report in the member s medical record. Include any reports from 2018 or CPT to Identify Eye Exams: 67028, , 67036, , 67101, 67105, , 67110, , 67121, 67141, 67145, 67208, 67210, 67218, , , 92002, 92004, 92012, 92014, , 92134, , 92230, 92235, 92240, 92250, 92260, , , , 3072F, 2022F, 2024F, 2026F HCPC: S0620 S0621, S0625, S3000 Claim/Encounter with Codes: CPT Cat. II : 3074F, 3075F, 3077F, 3078F, 3079F, 3080F Claim/Encounter with Codes: CPT : 76977, 77078, , 77085, ICD9: 88.98

4 had either a bone mineral density (BMD) test or prescription to treat or prevent osteoporosis within 12 months before or six months after the fracture Note that approved osteoporosis therapies include: Biphosphonates: alendronate, alendronatecholecalciferol, calcium carbonate risedronate, ibandronate, risedronate, zoledronic acid Other agents: calcitonin salmon, denosumab, raloxifene, teriparatide Disease modifying Anti rheumatic Drug (DMARD) Therapy for Rheumatoid (ART) Percentage of members 18 and older who were diagnosed with rheumatoid arthritis and were Prescribe a medication to treat Osteoporosis NOTE: Fractures of fingers, toes, face and skull are not included in this measure Assess all patients with diagnosis of rheumatoid arthritis for DMARD treatment in 2019 All patients not currently treated with a DMARD should be referred for ICD10: BP48ZZ1, BP49ZZ1, BP4GZZ1, BP4HZZ1, BP4LZZ1, BP4MZZ1, BP4NZZ1, BP4PZZ1, BQ00ZZ1, BQ01ZZ1, BQ03ZZ1, BQ04ZZ1, BR00ZZ1, BR09ZZ1, BR0GZZ1 Pharmacy claim for osteoporosis drug therapy: HCPCS: G0130, J0630, J0897, J1000, J1740, J3110, J3487, J3488 Codes to identify Fractures: CPT : 21800, 21805, 21810, 21820, 21825, 22305, 22310, 22318, 22319, 22520, 22521, 22523, 22524, 23500, 23505, 23515, 23570, 23575, 23585, 23600, 23605, 23615, 23616, 23620, 23625, 23630, 23665, 23670, 23675, 23680, 24500, 24505, 24515, 24516, 24530, 24535, 24538, 24545, 24546, 24560, 24565, 24566, , 24579, 24582, 24620, 24635, 24650, 24655, 24665, 24666, 24670, 24675, 24685, 25500, 25505, 25515, 25520, 25525, 25526, 25530, 25535, 25545, 25560, 25565, 25574, 25575, 25600, , 25622, 25624, 25628, 25630, 25635, 25645, 25650, 25651, 25652, 25680, 25685, 26600, 26605, 26607, 26608, 26615, 27193, 27194, 27200, 27202, , 27220, 27222, , 27230, 27232, 27235, 27236, 27238, 27240, 27244, 27245, 27246, 27248, 27254, , , , 27513, 27514, 27520, 27524, 27530, 27532, 27535, 27536, 27538, 27540, 27750, 27752, 27756, , 27762, , 27780, 27781, 27784, 27786, 27788, 27792, 27808, 27810, 27814, 27816, 27818, , 28400, 28405, 28406, 28415, 28420, 28430, 28435, 28436, 28445, 28450, 28455, 28456, 28465, 28470, 28475, 28476, 28485, 29850, 29851, 29855, HCPCS: S2360 ICD 9 CM Diagnosis: 733.1, , , , , , ICD 9 CM Procedure: , , , , , , , , , , Identify any patients misdiagnosed with rheumatoid arthritis Identify reasons for not treating with a DMARD on all patients confirmed to have rheumatoid arthritis. Include findings and recommendations of rheumatology consultant CPT : ,

5 dispensed at least one ambulatory prescription for a DMARD in 2019 Note: DMARDS include: Aminoquinolines: Hydroxychloroquine 5 Aminosalicylates: Sulfasalazine Alkylating agents: Cyclophosphamide Antirheumatics: Auranofin, gold sodium thiomalate, leflunomide, methotrexate, penicillamine Immunomodulators: Abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, Tocilizumab Immunosuppressive agents: Azathioprine, cyclosporine, mycophenolate Tetracyclines: Minocycline rheumatology consultation to confirm diagnosis and assess for DMARD therapy Pharmacy claim for DMARD in 2019: HCPCS: J0129, J0135, J0718, J1438, J1600, J1745 Retail/Specialty Pharmacy Medication: Sulfasalazine, cyclophosphamide, hydroxychloroquine, auranofin, leflunomide, penicillamine, gold sodium thiomalate, methotrexate, abatacept, certolizumab pegol, infliximab, adalimumab, etanercept, rituximab, anakinra, golimumab, tocilzumab, certolizumab, azathioprine, cyclosporine, mycophenolate, tofacitinib, minocycline Medication Reconciliation Post Discharge Medication Reconciliation conducted by Encounter/Claim with Codes: (MRP) a prescribing practitioner, clinical CPT : 99495, 99496, 1111F Percentage of discharges from January 1- pharmacist or registered nurse on the December 1 of the measurement year for members 18years of age and older for whom medications date of discharge through 30 days after discharge. were reconciled the date of discharge through 30 days after discharge (31 total days). Provider/Care Team Suggestion High Risk Medications (HRM) in members 65yrs and older The percent of plan members 65 years of age and older who received two or more prescription fills for a high risk medication during The Centers for Medicare and Medicaid Services (CMS) has identified certain drugs as being potentially high risk of serious side effects in beneficiaries 65 years and older. CMS uses the list maintained by the Pharmacy Quality Alliance, who adapted their list from the American Geriatrics Society s Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Consider if there s a reasonable alternative listed on the ATRIO HRM formulary alternative guide. (Note: majority of HRM alternatives do not require PA). The Alternative Guide cautions the use of HRMs in the elderly and suggests alternative medications on ATRIO s formulary where appropriate. No reporting required health plan uses prescription claims data to evaluate this metric. For a copy of ATRIO s HRM formulary alternative guide and other HRM tools, contact QI@atriohp.com

6 Provider/Care Team Suggestion Medication Adherence for Statin Medications Percentage of plan members 18 years or older with a prescription for a cholesterol medication (a statin drug) who fill their prescriptions often enough to cover 80% or more of the time they are supposed to be taking the medication. Medication Adherence for Hypertensive Medications (RAS Antagonists) Percentage of plan members 18 years or older with a prescription for a blood pressure medication who fill their prescriptions often enough to cover 80% or more of the time they are supposed to be taking the medication. Proactively assess if medication is being taken as prescribed. Identify barriers to adherence. Find ways to help the member take their medication as recommended. No reporting required health plan uses prescription claims data to evaluate this metric. Medication Adherence for Oral Diabetic Medications Percentage of plan members 18 years or older with a prescription for diabetes medication who fill their prescriptions often enough to cover 80% or more of the time they are supposed to be taking the medication. HEDIS is a set of standardized performance measures designed to help purchasers and consumers compare the performance of health plans on an apples toapples basis. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Developed by the National Committee for Quality Assurance (NCQA), HEDIS is the most widely used set of performance measures in the managed care industry. It contains measures that show health plans those areas where a stronger focus could lead to improvements in member health. HEDIS reporting is mandated by the NCQA for compliance and accreditation.