2019 HEDIS 1 Measures Healthcare Effectiveness Data and Information Set
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1 209 HEDIS s Healthcare Effectiveness Data and Information Set *s collected with medical record review. Red= new/addition to measures Blue= Medicare only Prevention and Screening Adult Immunization Status Up-to-date on recommended routine vaccines: Adults 9 years of age and older Prenatal Immunization Status Deliveries in the measurement period * Adult BMI Assessment The percentage of members 8 74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year (208) or the year prior to the measurement year (207). ICD-0 Codes for BMI Value: Z68.; Z Z68.39; Z68.4-Z68.45 Percentile: Z68.5-Z68.54 *Immunizations for Adolescents NOTE: This measure includes the Human Papillomavirus Vaccine (HPV) for both males and females. Children who turn 3 years old during the measurement year (208). CPT Codes: Meningococcal: Tdap: 9075 HPV: Influenza Tetanus and diphtheria (Td) or Tetanus, diphtheria and acellular pertussis (Tdap) Zoster Pneumococcal Women received recommended vaccines: Influenza Tetanus, diphtheria toxoids and acellular pertussis For members ages 20 and older, documentation in the medical record must include: Date of the BMI Weight BMI value For members ages 8-9yo, documentation of BMI percentile is required: BMI documented as a percentile(e.g.,75 th percentile) BMI percentile plotted on an age- growth chart. Documentation of height and weight only does not meet HEDIS criteria. Exclusion: Members with a diagnosis of pregnancy in 207 or 208 may be excluded from this measure. dose Meningococcal vaccine between the th and 3 th birthdays and tetanus, diphtheria toxoids and acelluar pertussis (Tdap) vaccine between the 0 th and 3 th birthdays and 2-dose or 3-dose HPV vaccination series between the9 th and 3 th birthdays. NOTE: All vaccines must be completed on or before the 3 th birthday Documentation of immunizations are up-to-date is not acceptable. Exclusion: Contraindication for a specific vaccine (e.g., anaphylactic reaction to the vaccine or its components) Updated 7/27/208
2 *Childhood Immunization Children who turn 2 years old during the measurement year (208). Vaccines must be completed on or before the 2 nd birthday 4 DTaP (do not count any before 42 days of age) 3 IPV (do not count any before 42 days of age) MMR 3 HiB (do not count any before 42 days of age) 3 Hepatitis B VZV, positive serology, or documented chicken pox disease 4 pneumococcal conjugate Hepatitis A 2 or 3 Rotavirus vaccines- depends on the vaccine administered (do not count any before 42 days of age) 2 Influenza with different dates of service (do not count any vaccine given prior to 6 months afterbirth) Documentation of immunizations are up-to-date is not acceptable. Documentation of an immunization received at delivery or in the hospital may be counted. *Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Members 3-7 years of age, who had an outpatient visit with a PCP or OB/GYN and had evidence of the following documented: BMI percentile Counseling for Nutrition Counseling for Physical Activity ICD-9 Codes: BMI percentile: Z68.5-Z68.54 Counseling for nutrition : Z7.3 Counseling for physical activity: Z02.5 CPT Codes Counseling for nutrition: Exclusion: Contraindication for a specific vaccine (e.g., anaphylactic reaction to the vaccine or its components) BMI Percentile documentation must include date of the BMI and: BMI percentile (may be plotted on age-growth chart) Weight and height must be taken during the measurement year (208). Counseling for Nutrition documentation must include a note indicating the date and evidence of at least one of the following: Engagement in discussion of current nutrition behaviors (eating habits) Checklist indicating nutrition was addressed Counseling or referral for nutrition education Member received educational materials on nutrition during a face-to-face visit Anticipatory guidance for nutrition Weight or obesity counseling Counseling for Physical Activity documentation includes a note indicating the date and evidence of at least one of the following: Discussion of current physical activity behaviors (e.g., exercise routine, participation in sports activities, exam for sports participation) Checklist indicating physical activity was addressed Counseling or referral for physical activity Member received educational materials on physical activity during a face-to-face visit Anticipatory guidance specific to the child s physical activity Weight or obesity counseling Updated 7/27/208 Documentation of meeting Developmental Milestones only does not meet HEDIS criteria for Physical Activity Counseling. Services specific to an acute or chronic condition do not count toward the counseling indicators for either nutrition or physical activity.
3 *Lead Screening in Children (Medicaid only) Children who turn 2 years old during the measurement year (208). CPT Code: At least one capillary or venous lead blood test by their 2 nd birthday. Documentation in the record must include both of the following: Date the test was performed The result or finding Non-recommended PSA-Based Screening in Older Men Men age 70 and older Screened unnecessarily for prostate cancer CPT codes to identify PSA-based Screening: Non-Recommended Cervical Cancer Screening in Adolescent Females Adolescent females ages 6-20 Exclusions: Prostate cancer diagnosis Dysplasia of the prostate A PSA test during the year prior to the measurement year (207) where laboratory data indicate an elevated result. Dispensed prescription for a 5-alpha reductase inhibitor during the measurement year (208). Screened unnecessarily for cervical cancer Note: A lower rate indicates better performance Exclusion: History of cervical cancer, HIV or immunodeficiency *Cervical Cancer Screening Women ages 2-64 CPT Codes to identify Cervical Cancer Screening Cervical cytology: ; ; 8850; ; ; HPV tests: ; A PAP test (cervical cytology) during the measurement year (208) or prior two years (206, 207) for women ages 2-64 Cervical cytology/human papillomavirus (HPV) co-testing during the measurement year (208) or prior four years ( ) for women ages Exclusion: Hysterectomy with no residual cervix. Documentation of complete, total or radical abdominal or vaginal hysterectomy meets the criteria. Documentation of hysterectomy alone does not meet the criteria. Chlamydia Screening Females ages 6-24 and identified as sexually active (by claims or pharmacy data) At least one test for Chlamydia during the measurement year (208). CPT Codes to identify Chlamydia Screening: 870; 87270; 87320; ; 8780 Updated 7/27/208
4 Breast Cancer Screening Women ages Codes to identify Breast Cancer Screening A mammogram or digital breast tomosynthesis on or between October, 206 -December 3,208. CPT: ; ; Exclusion: Bilateral Mastectomy *Colorectal Cancer Screening Adults ages CPT Codes to identify Colorectal Cancer Screening FOBT: 82270; FIT-DNA: 8528 Flexible Sigmoidoscopy: ; ; ; One or more of the following screenings: Colonoscopy in past 0 years( ) Flexible sigmoidoscopy in past 5 years( ) CT Colonography (e.g., virtual colonoscopy) in the past 5 years( ) FIT-DNA (e.g., Cologuard) test in the past 3 years( ) Fecal occult blood test (ifobt or gfobt) annually (208) CT Colonography: Colonoscopy: ; 44397; ; 45355; ; Exclusion: Diagnosis of colorectal cancer or total colectomy. Use of Services *Well-child Exams Ages 0-5 months (turned 5 months during 208) Codes to Identify Well-Child Visits CPT: CPT: ; ; 9946 ICD-0: Z00.00-Z00.0; Z00.0-Z00.; Z00.2; Z00.29; Z00.5; Z00.8; Z02.0-Z02.6; Z02.7; Z02.79; Z02.8-Z02.83; Z02.89; Z02.9; Z76.-Z well-care visits (at least 2 weeks apart) with a PCP/Pediatrician. Each visit must show evidence of all of the following: Health and developmental history (physical and mental) Physical exam Health education/anticipatory guidance *Well-child Exams Ages 3-6 years Codes to Identify Well-Child Visits CPT: ; ; 9946 ICD-0: Z00.00-Z00.0; Z00.0-Z00.; Z00.2; Z00.29; Z00.5; Z00.8; Z02.0-Z02.6; Z02.7; Z02.79; Z02.8-Z02.83; Z02.89; Z02.9; Z76.-Z76.2 At least one well-care visit with a PCP during the measurement year (208). Must show evidence of all the following: Health and development history (physical and mental) Physical exam Health education/anticipatory guidance Updated 7/27/208
5 *Adolescent Well-Care Visit Ages 2-2 years Codes to Identify Adolescent Well Visits CPT: ; ; 9946 ICD-0: Z00.00-Z00.0; Z00.0-Z00.; Z00.2; Z00.29; Z00.5; Z00.8; Z02.0-Z02.6; Z02.7; Z02.79; Z02.8-Z02.83; Z02.89; Z02.9; Z76.-Z76.2 At least one comprehensive well-care visit with a PCP or OB/GYN during the measurement year (208). Must show evidence of all the following: Health and development history (physical and mental) Physical exam Health education/anticipatory guidance Respiratory Conditions Appropriate Testing of Children with Pharyngitis Children ages 3-8 years ICD-0 Codes to Identify Pharyngitis: J02.0; J02.8-J02.9; J03.00-J03.0; J03.80-J03.8; J03.90-J03.9 Diagnosis of pharyngitis, Prescribed an antibiotic, and Received a group A streptococcus (strep) test in the 7 day period from 3 days prior to, through 3 days after, the prescription date. Appropriate Treatment of Children with Upper Respiratory Infections Children ages 3 mos-8 yrs ICD-0 Codes to identify URI: J00; J06.0; J06.9 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Adults ages 8-64 ICD-0 Codes to identify Acute Bronchitis J20.3-J20.9 Diagnosis of Upper Respiratory Infection (URI),and Not prescribed an antibiotic within 3 days of URI diagnosis. Diagnosis of acute bronchitis, and Not dispensed an antibiotic prescription within 3 days of diagnosis. Exclusion: members with a diagnosis of any of the following comorbid conditions: Emphysema; COPD; Cystic Fibrosis; HIV; Malignant neoplasm Use of Spirometry Testing in the Assessment and Diagnosis of COPD Adults age 40 and older Codes for Spirometry Testing: New diagnosis of, (in 208) or newly active, COPD and Spirometry testing to confirm diagnosis. CPT: 9400; ; 94060; 94070; 94375; Updated 7/27/208
6 Pharmacotherapy Management of COPD Exacerbation Adults age 40 and older ICD-0 Codes to identify COPD: J44.0-J44.; J44.9 Medication Management for People with Asthma Members ages 5-64 ICD-0 Codes to identify Persistent Asthma: J45.20-J45.22; J45.30-J45.32; J45.40-J45.42; J45.50-J45.52; J45.90-J45.902; J45.909; J J45.99; J Cardiovascular Statin Therapy for Patients with Cardiovascular Disease Males ages 2-75 and Females ages Moderate or high-intensity statin therapy: Atorvastatin: 0-80mg Amlodipine-atorvastatin: 0-80mg Ezetimibe-atorvastatin: 0-80mg Rosuvastatin: 5-40mg Simvastatin: 20-80mg Ezetimibe-smivastatin:20-80mg Niacin-simvastatin: 20-40mg Sitaglipin-simvastatin: 20-40mg Pravastatin: 40-80mg Lovastatin: 40mg Niacin-lovastatin: 40mg Fluvastatin XL 80mg/Fluvastatin 40mg bid Pitavastatin 2-4mg *Controlling High Blood Pressure Adults ages 8-85 Adequate control is defined as: <40/90 ICD-0 Code to identify HTN: I0 CPT II Codes for BP values: Systolic Less than 40: 3074F, 3075F Systolic Greater then/equal to 40: 3077F Diastolic Less than 80: 3078F Diastolic 80-89: 3079F Diastolic Greater than/equal to 90: 3080F Members discharged from an acute inpatient admission or an ED encounter with a primary diagnosis of COPD who were dispensed both: A systemic corticosteroid within 4 days of the event A bronchodilator within 30 days of the event Identified as having persistent asthma and Dispensed appropriate medication that they remained on during the treatment period. Members remaining on asthma controller medication for at least. 50% of their treatment period % of their treatment period. Identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria:. Received Statin Therapy: Members who were dispensed at least one high or moderate-intensity statin medication during the measurement year (208). 2. Statin Adherence 80%: Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period (from prescription date through end of year). Diagnosis of hypertension Most recent blood pressure reading in the medical record for 208. Member reported BP readings may not be used for HEDIS purposes. Exclusions: Evidence of any of the following during 208: End Stage Renal Disease (ESRD), kidney transplant or dialysis Pregnancy Non-acute inpatient admission Updated 7/27/208
7 Diabetes *Comprehensive Diabetes Care Adults ages 8-75 with diabetes (type or type 2). ICD-0 Codes to identify Diabetes: E0; E; E3 CPT II Codes for BP values: Systolic Less than 40: 3074F, 3075F Systolic Greater then/equal to 40: 3077F Diastolic Less than 80: 3078F Diastolic 80-89: 3079F Diastolic Greater than/equal to 90: 3080F Statin Therapy for Patients with Diabetes Adults ages Musculoskeletal Osteoporosis Management in Women who had a Fracture Women ages CPT Codes to identify BMD test: 76977; 77078; ; HCPCS codes for osteoporosis meds: J0630; J0897; J740; J30; J3487- J3489; Q205 Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis Adults age 8 and older ICD-0 Codes for Rheumatoid Arthritis: M05.00-M06.9. HbAc testing (most recent date and result from208) HbAc < 8.0 % =control HbAc > 9.0 % = poor control 2. Retinal eye exam (most recent date and result from 207 or 208) 3. Medical attention for nephropathy (one of the following during 208): Nephropathy screening or monitoring test ACE/ARB therapy Evidence of nephropathy (CKD, ESRD, kidney transplant, visit with a nephrologist) 4. Blood pressure (most recent date and result from208) BP of < 40/90 =control Exclusions: Members without a diagnosis of diabetes, but with either: Gestational diabetes (during 207 or 208) or Steroid-induced diabetes (during 207 or 208) Identified as having diabetes and do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following criteria:. Received Statin Therapy: Members who were dispensed at least one statin medication of any intensity during the measurement year (208). 2. Statin Adherence 80%: Members who remained on a statin medication of any intensity for at least 80% of the treatment period (from prescription date through end of year). Suffered a fracture and had either: A bone mineral density (BMD) test or A prescription for a drug to treat osteoporosis in the six months after the fracture Diagnoses of rheumatoid arthritis and Received at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD). Exclusions: Diagnosis during 208 of: HIV or Pregnancy Updated 7/27/208
8 Use of Imaging Studies for Low Back Pain Adults ages 8-50 ICD-0 Codes to identify Uncomplicated Low Back Pain: M47.26-M47.28; M47.86-M47.88; M M47.898; M48.06-M48.08; M5.6-M5.7; M5.26-M5.27; M5.36-M5.37; M5.86- M5.87; M53.2X6-M53.2X8; M53.3; M M53.88; M54.6-M54.8; M54.30-M54.32; M54.40-M54.42; M54.5; M54.89-M54.9; M99.03-M99.04; M99.23; M99.33; M99.43; M99.53; M99.63; M99.73; M99.83-M99.84 S33.xxx; S39.xxx Behavioral Health Follow-up Care for Children Prescribed ADHD Medication Ages 6-2 years Primary diagnosis of low back pain who did not have an imaging study (x-ray, MRI, CT) within 28 days of the diagnosis. A higher score indicates appropriate treatment of low back pain Exclusions: An imaging study in the presence of low back pain is considered clinically indicated in patients with a diagnosis of: -Cancer -Recent Trauma -IV Drug Abuse -Neurologic Impairment -Spinal Infection -HIV -Major Organ Transplant -Prolonged Use of Corticosteroids An initial prescription for ADHD medication (or first fill in >20 days) Remained on the medication Had appropriate follow up care visits. Initiation Phase: one follow-up visit with a prescribing practitioner within 30 days 2. Continuation and Maintenance Phase: remained on the medication for at least 20 days and had two additional visits with a practitioner within 270 days (9 months after the Initiation Phase ended). Use of Multiple Concurrent Antipsychotics in Children and Adolescents On 2 or more concurrent antipsychotic medications for 90 days or more during the measurement year(208) Children/Adolescents ages -7 A lower rate indicates better performance for this measure. Metabolic Monitoring for Children and Adolescents on antipsychotics Children/Adolescents ages -7 CPT Codes to identify cholesterol tests other than LDL: 82465; 8378; At least 2 antipsychotic prescriptions (same or different medications) on different dates during the measurement year (208) Blood glucose or HbAc test during the measurement year (208) and LDL-C or cholesterol test during the measurement year (208) Unhealthy Alcohol Use Screening and Follow-Up Adults age 8 and older Screened for unhealthy alcohol use using a standardized tool If screening was positive, received brief counseling or other follow-up care within 2 months Updated 7/27/208
9 Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults Members ages 2 and older ICD-0 Codes to identify Major Depression and Dysthymia: F32.0-F32.5; F32.9; F33.0-F33.3; F43.40-F43.42; F33.9; F34. CPT Codes to identify Depression Encounters: 9079; 90792; 90832; 90834; 90837; ; 99078; ; ; ; ; ; ; ; ; ; ; 9950 LOINC Codes to identify PHQ administered: ; Depression Remission or Response for Adolescents and Adults Members ages 2 and older ICD-0 Codes to identify Major Depression and Dysthymia: F32.0-F32.5; F32.9; F33.0-F33.3; F43.40-F43.42; F33.9; F34. CPT Codes to identify Depression Encounters: 9079; 90792; 90832; 90834; 90837; ; 99078; ; ; ; ; ; ; ; ; ; ; 9950 Diagnosis of major depression or dysthymia Have a PHQ-9 or PHQ-A tool administered during an outpatient encounter at least once during a four-month period. Inclusion in ECDS Rate: The percentage of members 2 and older with a diagnosis of major depression or dysthymia, who are included in an electronic clinical data system (ECDS). 2. Utilization of PHQ-9 Rate: The percentage of PHQ utilization. Members with a diagnosis of major depression or dysthymia who are covered by an ECDS and, if they had an outpatient encounter, have a PHQ-9 score present in their record. Exclusions: Bipolar disorder; Personality disorder; Psychotic disorder, Pervasive Developmental disorder Diagnosis of depression An elevated PHQ-9score Evidence of response or remission within 4-8 months of the elevated score Four rates are reported:. ECDS Coverage: Health plan can receive any electronic clinical quality data 2. Follow-Up PHQ-9 within 5-7 months of the elevated score 3. Depression Remission: PHQ-9 score of<5 4. Depression Response: a PHQ-9 score reduction of at least 50% Exclusions: Bipolar disorder; Personality disorder; Psychotic disorder, Pervasive Developmental disorder Depression Screening and Follow-Up for Adolescents and Adults Ages 2 years and older Screened for depression using a standardized tool If screening was positive, received follow-up care within30 days Antidepressant Medication Management Adults age 8 and older ICD-0 Codes to identify Major Depression: F32.0-F32.4; F32.9; F33.0- F33.3; F33.4; F33.9 Were treated with antidepressant medication Had a diagnosis of major depression and Remained on antidepressant medication treatment.. Effective acute phase: remained on an antidepressant medication for at least 84 days (2weeks) 2. Effective continuation phase: remained on an antidepressant medication for at least 80 days (6months) Updated 7/27/208
10 Adherence to Antipsychotic Medications for Individuals with Schizophrenia Adults ages 9-64 Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who are Using Antipsychotic Medications Adults ages 8-64 ICD-0 Codes to identify diagnosis: Bipolar: F30.0-F30.3; F30.2-F30.4; F30.8- F30.9; F3.0; F3.0-F3.3; F3.2; F3.30-F3.32; F3.4-F3.5; F3.60-F3.64; F3.70-F3.78 Diabetes Monitoring for People with Diabetes and Schizophrenia Adults ages 8-64 Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia Adults ages 8-64 Follow-Up After Emergency Department visit for Mental Illness Ages 6 and over Diagnosis of Schizophrenia Dispensed an antipsychotic medication and Remained on the medication for at least 80% of their treatment period (days between the earliest prescription fill in 208 and the end of the year) Diagnosis of Schizophrenia or Bipolar Disorder Dispensed an Antipsychotic medication Diabetes screening (glucose or HbAc) test during the measurement year (208) CPT Codes to Identify Diabetes Screening: Glucose tests: 80047, 80048, 80050, 80053, 80069, 82947, 82950, 8295 HbAc tests: 83036,83037 Diagnoses of Schizophrenia and Diabetes HbAc test during the measurement year (208) and LDL-C test (direct or calculated) during the measurement year (208) Diagnoses of Cardiovascular Disease and Schizophrenia LDL-C test (direct or calculated) during the measurement year (208) CPT Codes to Identify LDL-C Screening: 8006; 83700; 8370; 83704; 8372 ED visit with a principal diagnosis of Mental Illness Follow-Up visit for Mental Illness. Follow-up visit within 7 days of discharge Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence Ages 3 and older 2. Follow-up visit within 30 days of discharge ED visit with principal diagnosis of Alcohol or Other Drug (AOD) Dependence Follow-Up visit for AOD. Follow-up visit within 7 days of discharge 2. Follow-up visit within 30 days of discharge Updated 7/27/208
11 Follow-up After Hospitalization for Mental Illness Ages 6 and over ICD-0 Codes to identify Mental Health Diagnosis: F20.0-F20.3; F20.5; F20.8; F20.89; F20.9; F2-F24; F25.0-F25.; F25.8- F25.9; F28; F29; F30.0-F30.3; F30.2-F30.4; F30.8-F30.9; F3.0; F3.0-F3.3; F3.2; F3.30-F3.32; F3.4- F3.5; F3.60-F3.64; F3.70- F3.78; F3.8; F3.89; F3.9; F32.0- F32.5; F32.8-F32.8; F32.9; F33.0- F33.3; F33.40-F33.42; F33.8-F33.9; F34.0- F34.; F34.8-F34.8; F34.89; F34.9; F39; F42; F42.2-F42.4; F42.8- F42.9; F43.0; F43.0- F43.2; F F43.25; F43.29; F43.8-F43.9; F44.89; F53; F60.0-F60.7; F60.8; F60.89; F60.9; F63.-F63.3; F63.8; F63.89; F63.9; F68.0-F68.3; F68.8; F84.0; F84.2-F84.3; F84.5; F84.8-F84.9; F90.0- F90.2; F90.8-F90.9; F9.0-F9.3; F9.8- F9.9; F93.0; F93.8-F93.9; F94.0-F94.2; F94.8-F94.9 Discharged from an inpatient admission for select mental illness diagnoses and One follow-up outpatient visit, intensive outpatient encounter, or partial hospitalization with a mental health practitioner. Medication Management and Care Coordination Risk of Continued Opioid Use Members ages 8 and older. Follow-up visit within 7 days of discharge 2. Follow-up visit within 30 days of discharge Have a new episode of opioid use that puts them at risk for continued opioid use Use of Opioids at High Dosage. The percentage of members whose new episode of opioid use lasts at least 5 days in a 30-day period 2. The percentage of members whose new episode of opioid use lasts at least 30 days in a 62-day period Adults ages 8 and older Receiving prescription opioids for 5 days during 207 at a high dosage (average morphine equivalent dose [MED] > 20mg) Use of Opioids From Multiple Providers NOTE: Reported as the rate per,000. A lower rate indicates better performance. Adults ages 8 and older Receiving prescription opioids for 5 days during 208 who received opioids from: Multiple Prescribers (four or more prescribers during 208) Multiple Pharmacies (four or more pharmacies during 208) Multiple Prescribers and Multiple Pharmacies(both four or more prescribers and four or more pharmacies in208) Updated 7/27/208
12 Follow-Up After ED Visit for People with High-Risk Multiple Chronic Conditions Adults ages 8 and older ED Visit High-risk multiple chronic conditions Follow-Up service within 7 days of the ED visit Transitions of Care Medication Reconciliation Post-Discharge Adults ages 8 and older CPT codes for Transitional Care Management Services and Medication Reconciliation: 99495, Documentation in the PCP record of the following in 208: Notification of Inpatient Admission on the day of admission or the day after Receipt of Discharge Information on the day of discharge or the day after Patient Engagement After Inpatient Discharge (e.g., office visits, home visits, telehealth) provided within 30 days after discharge Medication Reconciliation conducted by a prescribing practitioner, clinical pharmacist or registered nurse on the date of discharge through 30 days after discharge (documentation of review of both a list of the members current outpatient medications and the discharge medications, or notation that no medications were prescribed upon discharge). Potentially Harmful Drug- Disease Interactions in the Elderly Adults age 65 and older Three rates are reported:. A history of falls and a prescription for anticonvulsants, SSRI s, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics, or tricyclic antidepressants 2. Dementia and a prescription for antipsychotics, benzodiazepines, non-benzodiazepine hypnotics, tricyclic antidepressants, H2 receptor antagonists, or anticholinergic agents. 3. Chronic kidney disease and a prescription for Cox-2 Selective NSAIDs or non-aspirin NSAIDs Use of High-Risk Medications in the Elderly Adults age 66 and older. Members who received at least one dispensing event for a high-risk medication 2. Members who received at least two dispensing events for the same high-risk medication For both rates, a lower rate represents better performance. Updated 7/27/208
13 Annual Monitoring for Patients on Persistent Medications Adults age 8 and older At least 80 days of ambulatory medication therapy during the measurement year (208) who Received the following lab test monitoring during 208: Medications Annual monitoring lab tests CPT Codes to identify ACE / ARBs Diuretics A serum potassium test and a serum creatinine test (or a panel containing them) 8005, , , 80048, 80050, 80053, Dioxin A Digoxin level test and a lab panel test OR A Digoxin level test and both a serum potassium test and a serum creatinine test , 80048, 80050, 80053, , , Access/Availability of Care Children and Adolescents Access to PCPs Age 2 months to 9 years An ambulatory or preventive care visit with a PCP in the measurement year (208) for ages 2 months to 6 years Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics Ages -7 years in the measurement year or the year prior( ) for ages 7 to 9 years A new prescription (4 month negative medication history) for an antipsychotic medication Documentation of psychosocial care as a first-line treatment Codes to identify psychosocial care: CPT: ; ; ; 90849; 90853; ; Adult Access to Preventive/Ambulatory Care Adults age 20 and over Exclusions: At least one acute inpatient encounter, or at least 2 visits in an outpatient, intensive outpatient or partial hospitalization setting with A diagnosis of schizophrenia, bipolar disorder or other psychotic disorder during the measurement year (208) An ambulatory or preventive care visit in the measurement year (208) for Medicaid and Medicare members in the measurement year or the two years prior ( ) for Commercial members Updated 7/27/208
14 *Prenatal/Postpartum Care Pregnant Women who delivered a live infant between November 6, 207 and November 5, 208 Initiation and Engagement of Alcohol and Other Drug Dependence (AOD) Treatment Age 3 and older Prenatal visit within first trimester (or within 42 days of enrollment) Postpartum visit between 2 and 56 days after delivery A new episode (60 days negative diagnosis history) of alcohol or other drug (AOD) abuse or dependence Codes to identify AOD visits: ; 99078; ; ; ; ; ; ; ; ; ; ; ; 9950 s Collected through CAHPS Health Plan Survey Medical Assistance with Smoking Cessation Current Smoker/Tobacco user age 8 and older Initiate treatment within 4 days of the diagnosis through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth, or medication-assisted treatment (MAT) Receive at least 2 additional AOD services or MAT within 30 days of treatment initiation Received advice to quit during the measurement year(208). Discussed or were recommended cessation medications during the measurement year. Discussed or were provided cessation methods or strategies during the measurement year. Flu Vaccinations for Adults (ages 8-65) Flu Vaccinations for Older Adults (ages 65+) Received an influenza vaccination after July, 208. Pneumococcal Vaccination Status for Older Adults Ages 65 and older Have ever received one or more pneumococcal vaccinations s Collected through Medicare Health Outcomes Survey (HOS) Fall Risk Management Adults ages 65 and older Osteoporosis Testing in Older Women. Discussing Fall Risk Seen by a practitioner in the past 2months Discussed falls or problems with balance or walking with current practitioner 2. Managing Fall Risk Had a fall or problems with balance or walking in the past 2months Seen by a practitioner in the past 2months Received a recommendation for how to prevent falls or treat problems with balance or walking from their current practitioner Women ages Reported ever having received a bone density test to check for osteoporosis Updated 7/27/208
15 Management of Urinary Incontinence in Older Adults Adults ages 65 and older. Discussing Urinary Incontinence Reported having urine leakage in the past6months Discussed their urinary leakage problem with a health care provider 2. Discussing Treatment of Urinary Incontinence Reported having urine leakage in the past6months Discussed treatment options for their current urine leakage problem 3. Impact of Urinary Incontinence Reported having urine leakage in the past6months Reported that urine leakage made them change their daily activities or interfered with their sleep a lot. Physical Activity in Older Adults Adults ages 65 and older. Discussing Physical Activity Had a doctor s visit in the past 2 months Spoke with a doctor or other health provider about their level of exercise or physical activity 2. Advising Physical Activity Had a doctor s visit in the past 2 months Received advice to start, increase or maintain their level of exercise or physical activity For more information regarding HEDIS 209, please contact Quality Improvement Dept. at or toll-free at Updated 7/27/208
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