2017 HEDIS Provider Guide and Toolkit

Transcription

1 2017 HEDIS Provider Guide and Toolkit Prepared By: Quality Improvement Department, Molina Healthcare of Washington MolinaHealthcare.com HEDIS 2017

2 TABLE OF CONTENTS Welcome to 2017 HEDIS TIPS...3 Molina Provider Contacts...4 Adults with Acute Bronchitis (AAB)...6 Adults Access to Preventive/Ambulatory Health Services (AAP)...7 Adult BMI Assessment (ABA)...8 Follow Up Care for Children Prescribed ADHD Medication (ADD)...9 Annual Dental Visits (ADV)...10 Antidepressant Medication Management (AMM)...11 Asthma Medication Ratio (AMR)...13 Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)...15 Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)...16 First Line Psychosocial Care for Child Adolescents on Antipsychotics (APP)...18 Disease Modifying Anti-Rheumatic Drug Therapy (DMARD) for Rheumatoid Arthritis (ART)...20 Adolescent Well-Care Visit (AWC)...21 Breast Cancer Screening (BCS)...22 Children and Adolescents Access to Primary Care Practitioners (CAP)...23 Controlling High Blood Pressure (CBP)...24 Cervical Cancer Screening (CCS)...25 Comprehensive Diabetes Care (CDC)...26 Chlamydia Screening (CHL)...28 Childhood Immunization Status (CIS)...29 Care for Older Adults (COA)...31 Colorectal Cancer Screening (COL)...33 Appropriate Testing for Children with Pharyngitis (CWP)...35 Frequency of Ongoing Prenatal Care (FPC)...36 Follow Up After Hospitalization for Mental Health (FUH)...38 Initiation & Engagement of Alcohol & Other Drug Dependence Treatment (IET)...39 Immunizations for Adolescents (IMA)...41 Low Back Pain (LBP)...42 Lead Screening in Children (LSC)...43 Medication Management for People with Asthma (MMA)...44 Annual Monitoring for Patients on Persistent Medications (MPM)...46 Non-Recommended Cervical Cancer Screening in Adolescent Females (NCS)...47 Osteoporosis Management for Fractures (OMW)...48 Persistence of Beta-Blocker Treatment after a Heart Attack (PBH)...50 Pharmacotherapy Management of COPD Exacerbation (PCE)...52 Postpartum Care (PPC)...54

3 Prenatal Care Timeliness (PPC)...56 Non-Recommended PSA-Based Screening in Older Men (PSA)...58 Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)...60 Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC)...62 Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD)...63 Spirometry Testing in COPD Assessment (SPR)...65 Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who are Using Antipsychotic Medications (SSD)...67 Appropriate Treatment for Children with URI (URI)...69 Well-Child Visits First 15 Months of Life (W15)...71 Well-Child Visits 3-6 Years (W34)...72 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (WCC)...73

4 Welcome to 2017 HEDIS Tips Welcome to Molina s Healthcare Effectiveness Data and Information Set (HEDIS ) Provider Guide and Toolkit. Developed by the National Committee for Quality Assurance (NCQA), HEDIS is a widely used set of performance measures in the managed care industry, part of NCQA accreditation and an essential tool in ensuring that our members are getting the best health care possible. Thus, it is vitally important that our providers understand the HEDIS specifications and guidelines. Our mission is to provide quality health services to financially vulnerable families and individuals covered by government programs and we want to do everything we can do to make this process as easy as possible. This guide is intended to be an easy-to-follow reference that covers all of the 2017 HEDIS measures applicable to Medicaid (Apple Health), Medicare and Marketplace. This guide includes ICD-10 codes, with ICD-9 included only as a reference. We understand that HEDIS specifications can be complex, so we have designed this guide to clearly define Molina s criteria for meeting the guidelines of 46 HEDIS measures. We welcome your feedback and look forward to supporting all your efforts to provide quality healthcare to our members. The information provided in this document is current for 2017 HEDIS at the time it was created, and can be subject to change in order to comply with NCQA and HEDIS requirements. About Molina: Molina Healthcare of Washington is active in 38 of the 39 Washington counties, with over 736,500 members (as of January 2017). NCQA has awarded Molina s Medicaid plan with the rating of Commendable as an organization with well-established programs for service and clinical quality that meets rigorous requirements for consumer protection and quality improvement for our members. Our Marketplace plan is currently rated as Accredited and our Medicare plan received 3.5 Stars. For HEDIS related inquiries, contact us at (800) Ext or MHW_QI_DEPARTMENT@ MolinaHealthcare.com Quality is improving access, removing barriers, providing a positive customer service experience, and delivering preventative and diagnostic care HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). 3

5 Molina Healthcare of Washington Provider Contacts PROVIDER INFORMATION FOR MEDICAID/MEDICARE Prior Authorizations: Medical/Behavioral Health Phone: (855) Fax: (800) Radiology, NICU, Transplant Authorizations: Phone: (855) Fax: (877) Pharmacy Authorizations: Phone: (800) Fax: (800) Provider Customer Service: Phone: (888) Fax: (877) Prior Authorizations: Medical/Behavioral Health Phone: (855) Fax: (800) Radiology, NICU, Transplant Authorizations: Phone: (855) Fax: (877) Pharmacy Authorizations: Phone: (855) Fax: (800) Provider Customer Service: Phone: (888) Fax: (877) Hour Nurse Advice Line: English: (888) (TTY: 1-866/ ) Spanish: (866) (TTY: 1-866/ ) Vision Care: Phone: (888) Fax: (866) Transportation: Covered by Apple Health. A list of brokers can be found at pages/phone.aspx. Click on Regional Broker. Dental: Covered by Apple Health. A list of dental providers and more information on dental benefits is available at dentalproviders/documents/adultdentalcoverage.pdf, or you can call HCA for more information at (800) PROVIDER INFORMATION FOR MARKETPLACE 24 Hour Nurse Advice Line: English: (888) (TTY: 1-866/ ) Spanish: (866) (TTY: 1-866/ ) Vision Care: Phone: (888) Fax: (866) Dental: Phone: (855) Fax: (866) Transplant Authorizations: Phone: (855) Fax: (866) Providers may utilize Molina Healthcare s eportal at: MolinaHealthcare.com Available features include: Electronic authorization submission and status through Clear Coverage application with potential for automatic approval at the time of submission: Claims submission and status Member Eligibility Provider Directory Download Frequently used Forms Nurse Advice Line Report 4

6 Member Customer Service Benefits/Eligibility: Phone: (800) TTY/TDD 711 Fax: (800) Hour Nurse Advice Line: English: (888) (TTY: 711) Member Customer Service Benefits/Eligibility: Phone: (800) Hour Nurse Advice Line: English: (888) Spanish: (866) Member Customer Service Benefits/Eligibility: Phone: (888) Fax: (310) MEMBER INFORMATION FOR MEDICAID Transportation: Phone: (800) Fax: (800) Spanish: (888) (TTY: 711) MEMBER INFORMATION FOR MEDICARE Non-Molina Medicare members can get information: Phone: (866) Transportation: Reservations: (866) Ride Assist: (866) MEMBER INFORMATION FOR MARKETPLACE Transportation: Phone: (888) Fax: (800) Hour Nurse Advice Line: English: (888) Spanish: (866) Check your doctor Check your eligibility View service history My Molina allows members to manage their health care online at MyMolina.com Benefits of registering for My Molina Request and print your ID Card Update your contact information Get health reminders on services you need MOLINA HEALTHCARE VIRTUAL CARE Free 24/7 Virtual Care to Molina Apple Health (Medicaid) member. Visit today at wavirtualcare.molinahealthcare.com. All you need is: a telephone, smartphone, computer or tablet Molina ID member an address 5

7 HEDIS TIPS: ADULTS WITH ACUTE BRONCHITIS (AAB) Adults years of age diagnosed with acute bronchitis should not be dispensed an antibiotic within 3 days of the visit. Note: Prescribing antibiotics for acute bronchitis is not indicated unless there is a comorbid diagnosis or a bacterial infection (examples listed on the right). Only about 10% of cases of acute bronchitis are due to a bacterial infection, so in most cases antibiotics will not help. HOW TO IMPROVE HEDIS SCORES Discuss realistic expectations for recovery time (e.g. cough can last for 4 weeks without being abnormal ) For patients requesting an antibiotic: Give a brief explanation Write a prescription for symptom relief instead of an antibiotic Encourage follow-up in 3 days if symptoms do not get better Submit comorbid diagnosis codes if present on claim/encounter (see codes above) Submit competing diagnosis codes for bacterial infection if present on claim/ encounter (see codes above) Ensure progress note is closed out with a provider signature Codes to Identify Acute Bronchitis ICD-9 Code ICD-10 Code* Acute bronchitis J J20.2 J20.3-J20.9 Codes to Identify Most Common Comorbid Conditions ICD-9 Code ICD-10 Code* Chronic bronchitis 491.8, J41.0, J41.1, J41.8, J42 Emphysema 492.0, J43.0, J43.1, J43.2, J43.8, J43.9, J98.2, J98.3 COPD , , , 496 J44.0, J44.1, J44.9 Codes to Identify Most Common Comorbid Conditions ICD-9 Code ICD-10 Code* Acute sinusitis 461.8, J01.80, J01.90 Otitis media , 382.3, 382.4, Pharyngitis, streptococcal tonsillitis, or acute tonsillitis 034.0, 462, 463 H66, H67, H66.009, H66.3X9, H66.40, H66.90 J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91 * ICD-10-CM codes are to be used on or after 10/1/2015. Please refer to your ICD-10-CM Manual for further code specificity. 6

8 HEDIS TIPS: ADULTS ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES (AAP) Patients 20 years and older who had an ambulatory or preventive care visit during the measurement year. Codes to Identify Preventive/Ambulatory Health Services Codes Ambulatory Visits CPT : , , , , , , , , 99411, 99412, 99420, HCPCS: G0402, G0438, G0439, G0463, T1015 ICD-9: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 UB Rev: , , , ICD-10-CM*: Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9 Other Ambulatory CPT : 92002, 92004, 92012, 92014, , 99315, 99316, 99318, Visits 99328, HCPCS: S0620, S0621 UB Rev: 0524, 0525 *ICD-10-CM and ICD-10-PCS codes are to be used on or after 10/1/2015. Please refer to your ICD-10-CM and ICD-10-PCS Manuals for further code specificity. Document all elements of a preventative exam including health history, developmental history, physical exam and education/anticipatory guidance Code to the highest specificity using the appropriate billing codes as described above Educate patients on the importance of having at least one ambulatory or preventive care visit during each calendar year Contact patients on the needed services list who have not had a preventive or ambulatory health visit Make reminder calls to patients who have appointments to decrease no-show rates Ensure progress note is closed out with a provider signature 7

9 HEDIS TIPS: ADULT BMI ASSESSMENT (ABA) Adults years of age who had an outpatient visit and whose body mass index (BMI) or BMI percentile (for patients younger than 20 years) was documented during the measurement year or the year prior to the measurement year. For patients 20 years of age or older on the date of service, documentation in the medical record must indicate the weight and BMI value, dated during the measurement year or year prior to the measurement year. For patients younger than 20 years on the date of service, documentation in the medical record must indicate the height, weight and BMI percentile, dated during the measurement year or year prior to the measurement year. The following meets criteria for BMI percentile: BMI percentile documented as a value (e.g. 85th percentile) BMI percentile plotted on an age-growth chart Codes to Identify BMI ICD-9 Code ICD-10 Code* BMI <19, adult V85.0 Z68.1 BMI 19 or less, adult V85.0 Z68.1 BMI between 19-24, adult V85.1 BMI between 20-24, adult BMI between 25-29, adult BMI between , adult BMI 40 and over, adult BMI, pediatric, <5th percentile for age BMI, pediatric, 5th percentile to <85th percentile for age BMI, pediatric, 85th percentile to <95th percentile for age BMI, pediatric, 95th percentile for age V V85.25 V V85.39 V V85.45 Z Z68.24 Z Z68.29 Z Z68.39 Z Z68.45 V85.51 Z68.51 V85.52 Z68.52 V85.53 Z68.53 V85.54 Z68.54 *ICD-10-CM and ICD-10-PCS codes are to be used on or after 10/1/2015. Please refer to your ICD-10-CM and ICD- 10-PCS Manuals for further code specificity. Make BMI assessment part of the vital sign assessment at each visit Use correct billing codes to report BMI (Z68.1-Z68.54). Accurate billing and coding will decrease need for additional records requests. Ensure proper documentation for BMI in the medical record with all components (e.g. date, weight, height, and BMI value and percentage). Provider signature must be on the same page. Update the EMR templates to automatically calculate a BMI if on an EMR Place BMI charts near scales (ask Molina for copies). Be sure graphs/charts are labeled for BMI. Calculate the BMI here if not on an EMR: 8

10 HEDIS TIPS: FOLLOW-UP CARE FOR CHILDREN PRESCRIBED ADHD MEDICATION (ADD) Patients 6-12 years old, with a new prescription for an attention-deficit/hyperactivity disorder (ADHD) medication who had: At least one follow-up visit with practitioner with prescribing authority during the first 30 days of when the ADHD medication was dispensed. (Initiation Phase). At least two follow-up visits within 270 days (9 months) after the end of the initiation phase. One of these visits may be a telephone call. (Continuation and Maintenance Phase). Codes to Identify Follow-up Visits Follow-up Visits Telephone Visits Follow-up Visits Codes CPT : , , 99078, , , , , , , , , , 99411, 99412, HCPCS: G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 UB Revenue: 0510, 0513, , , , 0900, , 0907, , 0919, 0982, 0983 CPT : , (can use for one Continuation and Maintenance Phase visit) Codes CPT : 90791, 90792, , , 90845, 90847, 90849, 90853, 90875, CPT : , , 99238, 99239, WITH WITH POS: 03, 05, 07, 09, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 33, 49, 50, 52, 53, 71, 72 POS: 52, 53 When prescribing a new medication, schedule a follow-up visit within 30 days to assess your patient s response to the medication Schedule two more visits in the 9 months after the first 30 days to continue to monitor your patient s progress You may use a phone visit for one of the visits after the first 30 days. This may help you and your patients if getting to an office visit is difficult (codes: , ). Only one phone visit is allowed during the Continuation and Maintenance Phase. If a phone visit is done, at least one face-to-face visit should also be completed. Do not continue these controlled substances without at least 2 visits per year to evaluate a child s progress Refer to the Clinical Practice Guideline (CPG) for the Diagnosis, Evaluation and Treatment of ADHD at Ensure progress note is closed out with a provider signature to last order Code appropriately using the above codes as guidelines 9

11 HEDIS TIPS: ANNUAL DENTAL VISIT (ADV) Patients 2 20 years of age who had at least one dental visit with a dental practitioner during the measurement year. Codes to Identify Annual Dental Visit Codes Dental Visits CPT : 70300, 70310, 70320, 70350, Use appropriate billing codes as described above Document all elements of a dental exam; including physical exam, oral cleaning and x-rays Remind patients of their dental benefits Help patients schedule an appointment to see a dentist Provide appointment reminder calls or postcards to help ensure that patients do not miss appointments Provide preventive services such as fluoride varnish application where appropriate Ensure progress note is closed out with a provider signature 10

12 HEDIS TIPS: ANTIDEPRESSANT MEDICATION MANAGEMENT (AMM) The percentage of adults 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remain on an antidepressant medication treatment. Two rates are reported: Effective Acute Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks). (Continuous treatment allows gaps in treatment up to a total of 30 days during the Acute Phase). Effective Continuation Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 180 days (6 months). (Continuous treatment allows gaps in treatment up to a total of 51 days during the Acute and Continuation Phases combined). Codes to Identify Major Depression ICD-9 Code ICD-10 Code* Major Depression , , 298.0, 311 F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9 *ICD-10-CM and ICD-10-PCS codes are to be used on or after 10/1/2015. Please refer to your ICD- 10-CM and ICD-10-PCS Manuals for further code specificity. ANTIDEPRESSANT MEDICATIONS Codes to Identify BMI Generic Name Brand Name Miscellaneous antidepressants Phenylpiperazine antidepressants Psycho-therapeutic combinations SNRI antidepressants SSRI antidepressants Tetracyclic antidepressants Tricyclic antidepressants Monoamine oxidase inhibitors Bupropion Vilazodone Vortioxetine Nefazodone Trazodone Amitriptylinechlordiazepoxide; Amitriptylineperphenazine; Fluoxetineolanzapine Desvenlafaxine Levomilnacipran Duloxetine Venlafaxine Desvenlafaxine Milnacipran Levomilnacipran Venlafaxine Citalopram Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline Maprotiline Mirtazapine Amitriptyline Amoxapine Clomipramine Desipramine Doxepin (>6mg) Imipramine Nortriptyline Protriptyline Trimipramine Isocarboxazid Phenelzine Selegiline Tranylcypromine Wellbutrin ; Zyban Viibryd Trintellix (Brintellix was changed to Trintellix in June 2016 by the FDA) Serzone Desyrel Limbitrol Triavil ; Etrafon Symbax Pristiq Cymbalta Effexor Pristiq Savella Fetzima Cymbalta Effexor Celexa Lexapro Prozac Luvox Paxil Zoloft Ludiomil Remeron Elavil Asendin Anafranil Norpramin Sinequan Tofranil Pamelor Vivactil Surmontil Marplan Nardil Anipryl ; Emsam Parnate 11

13 HEDIS TIPS: ANTIDEPRESSANT MEDICATION MANAGEMENT (AMM) Document reason for prescribed medication (e.g. depression, sleep) Code to the highest specificity Review missing services list for pharmacy refills to ensure member is getting timely refills If the patient is started on medication for anxiety disorder or other stress reaction disorder, proper coding will exclude the patient from the measure Place reminder calls to remind patients of their appointment Educate patients on the following: The importance of staying on the antidepressant for a minimum of 6 months Strategies for remembering to take the antidepressant on a daily basis Common side effects, how long the side effects may last and how to manage them Refer to Molina Healthcare of Washington Drug Formulary for coverage updates at: or contact Molina Provider Pharmacy at (800) Ext Ensure progress notes are closed out with a provider signature 12

14 HEDIS TIPS: ASTHMA MEDICATION RATIO (AMR) The percentage of patients 5 64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year. Patients are in the measure if they met at least one of the following during both the measurement year and the year prior. At least one ED visit with asthma as the principal diagnosis. At least one acute inpatient claim/encounter, with asthma as the principal diagnosis. At least 4 outpatient asthma visits with asthma as one of the diagnoses and at least 2 asthma medication dispensing events. At least 4 asthma medication dispensing events. If leukotriene modifiers were the sole asthma medication dispensed, there must also be at least one diagnosis of asthma, in any setting, in the same year as the leukotriene modifier (i.e., measurement year or the year prior.) Codes to Identify Asthma ICD-9 Code ICD-10 Code* Asthma , , , , Mild Intermittent Asthma J45.20, J45.21, J45.22 Mild Persistent Asthma J45.30, J45.31, J45.32 Moderate Persistent Asthma J45.40, J45.41, J45.42 Severe Persistent Asthma J45.50, J45.51, J45.52 Other and Unspecified Asthma J45.901, J45.902, J45.909, J45.990, J45.991, J *ICD-10-CM and ICD-10-PCS codes are to be used on or after 10/1/2015. Please refer to your ICD-10-CM and ICD-10-PCS Manuals for further code specificity. Asthma Controller Medications Antiasthmatic combinations Antibody inhibitor Inhaled steroid combinations Inhaled corticosteroids Leukotriene modifiers Mast cell stabilizers Methylxanthines Prescriptions Dyphylline-guaifenesin, Guaifenesin-theophylline Omalizumab Budesonide-formoterol, Fluticasone-salmeterol, Mometasone-formoterol Beclomethasone, Budesonide, Ciclesonide, Flunisolide, Fluticasone CFC free, Mometasone Montelukast, Zafirlukast, Zileuton Cromolyn Aminophylline, Dyphylline, Theophylline *Please refer to the Molina Healthcare Drug Formulary at formulary.aspxfor asthma controller medications that may require prior authorization or step therapy. 13

15 HEDIS TIPS: ASTHMA MEDICATION RATIO (AMR) Ensure proper documentation and coding to avoid coding asthma if the diagnosis is for an asthmalike symptom (e.g. wheezing during viral URI and acute bronchitis is not asthma ) Use the needed services list and contact patients who have not filled a controller medication Inform patients mail-order delivery is available to them Ensure progress note is closed out with a provider signature Patients with chronic conditions such as asthma may qualify for case management and should be referred to the Molina Healthcare Case Management Program for evaluation at (800) Ext

16 HEDIS TIPS: USE OF MULTIPLE CONCURRENT ANTIPSYCHOTICS IN CHILDREN AND ADOLESCENTS (APC) The percentage of children and adolescents 1 to 17 years of age who were on two or more different antipsychotic medications concurrently for at least 90 consecutive days during the measurement year. A lower rate indicates better performance. ANTIPSYCHOTIC MEDICATIONS Generic Name Brand Name First Generation Antipsychotic Medications Second Generation Antipsychotic Medications Chlorpromazine HCL, Fluphenazine HCL, Fluphenazine decanoate, Haloperidol, Haloperidol decanoate, Haloperidol lactate, Loxapine HCL, Loxapine succinate, Molindone HCL, Perphenazine, Pimozide, Thioridazine HCL, Thiothixene, Trifluoperazine HCL Aripiprazole, Asenapine, Brexpiprazole, Cariprazine, Clozapine, Iloperidone, Lurasidone, Olanzapine, Olanzapine pamoate, Paliperidone, Paliperidone palmitate, Quetiapine fumarate, Risperidone, Risperidone microspheres, Ziprasidone HCL, Ziprasidone mesylate Thorazine HCL, Prolixin HCL, Prolixin decanoate, Haldol, Haldol intramuscular, Haldol intravenous, Loxitane HCL, Loxitane succinate, Moban HCL, Trilaphon, Orap, Mellaril HCL, Navane, Stelazine HCL Abilify, Saphris, Rexulti, Vraylar, Clozaril, Fanapt, Latuda, Zyprexa, Zyprexa Relprevv, Invega, Invega Sustenna, Seroquel, Risperdal, Risperdal Consta, Geodon, Geodon for injection Avoid the simultaneous use of multiple antipsychotic medications for children and adolescents per The American Academy of Child and Adolescent Psychiatry Consider monotherapy as the preferred treatment option as it poses a reduced health risk burden for patients associated with multiple concurrent antipsychotics Monitor children and adolescents prescribed antipsychotics closely as they are more at risk for serious health concerns, including weight gain, extrapyramidal side effects, hyperprolactinemia and some metabolic effects Monitor members treated with certain antipsychotics closely as they may also be at increased risk for gynecological problems Inform parents/guardians of the increased side effect burden of multiple concurrent antipsychotics on children s health has implications for future physical health concerns including obesity and diabetes Ensure progress note is closed out with a provider signature 15

17 HEDIS TIPS: METABOLIC MONITORING FOR CHILDREN AND ADOLESCENTS ON ANTIPSYCHOTICS (APM) The percentage of children and adolescents 1 to 17 years of age who had at least two antipsychotic prescriptions of the same or different medications, on different dates of service during the measurement year, and had metabolic testing (one diabetes screening test and one cholesterol screening test). USE CORRECT BILLING CODES Codes to Identify Diabetes Screening Complete at least ONE Diabetes Screening test during the measurement year Codes to Identify Diabetes Screening --AND-- Complete at least ONE Cholesterol Screening test during the measurement year Codes to Identify Glucose Tests Codes to Identify HbA1c Tests Codes to Identify LDL-C Tests Codes to Identify Cholesterol Tests (other than LDL) Generic Name CPT : 80047, 80048, 80050, 80053, 80069, 82947, 82950, CPT : 83036, CPT II: 3044F (if HbA1c<7%), 3045F (if HbA1c 7%-9%), 3046F (if HbA1c>9%) Generic Name CPT : 80061, 83700, 83701, 83704, CPT II: 3048F (if less than 100 mg/dl), 3049F (if mg/dl), 3050F (if greater than or equal to 103 mg/dl) CPT : 82465, 83718, ANTIPSYCHOTIC MEDICATIONS Generic Name Brand Name First Generation Antipsychotic Medications Second Generation Antipsychotic Medications Combinations Chlorpromazine HCL, Fluphenazine HCL, Fluphenazine decanoate, Haloperidol, Haloperidol decanoate, Haloperidol lactate, Loxapine HCL, Loxapine succinate, Molindone HCL, Perphenazine, Pimozide, Thioridazine HCL, Thiothixene, Trifluoperazine HCL Aripiprazole, Asenapine, Brexpiprazole, Cariprazine, Clozapine, Iloperidone, Lurasidone, Olanzapine, Olanzapine pamoate, Paliperidone, Paliperidone palmitate, Quetiapine fumarate, Risperidone, Risperidone microspheres, Ziprasidone HCL, Ziprasidone mesylate Olanzapine-fluoxetine HCL, Perphenazineamitriptyline HCL Thorazine HCL, Prolixin HCL, Prolixin decanoate, Haldol, Haldol intramuscular, Haldol intravenous, Loxitane HCL, Loxitane succinate, Moban HCL, Trilaphon, Orap, Mellaril HCL, Navane, Stelazine HCL Abilify, Saphris, Rexulti, Vraylar, Clozaril, Fanapt, Latuda, Zyprexa, Zyprexa Relprevv, Invega, Invega Sustenna, Seroquel, Risperdal, Risperdal Consta, Geodon, Geodon for injection Symbyax; Etrafon, Triavil 16

18 HEDIS TIPS: METABOLIC MONITORING FOR CHILDREN AND ADOLESCENTS ON ANTIPSYCHOTICS (APM) Document patients response to medication, including the order for glucose and cholesterol levels Document lab results and any action that may be required Use supplemental lab data to update medical records when applicable Monitor the glucose and cholesterol levels of children and adolescents on antipsychotic medications. Metabolic monitoring is recommended by The American Academy of Child and Adolescent Psychiatry. Monitor children on antipsychotic medications to help to avoid metabolic health complications such as weight gain and diabetes Establish a baseline and continuously monitor metabolic indices to ensure appropriate management of side-effects of antipsychotic medication therapy Code appropriately using the above codes as guidelines Ensure progress note is closed out with a provider signature 17

19 HEDIS TIPS: USE OF FIRST-LINE PSYCHOSOCIAL CARE FOR CHILDREN AND ADOLESCENTS ON ANTIPSYCHOTICS (APP) The percentage of children and adolescents 1 to 17 years of age who had a new prescription for an antipsychotic medication and had documentation of psychosocial care as first-line treatment. USE CORRECT BILLING CODES Generic Name Psychosocial Care CPT : , , 99238, 99239, , 99291, 99292, 90791, 90792, , , , 90849, 90853, , 90875, 90876, 90880, , 99078, , , , , , , , , , 99411, 99412, HCPCS: G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0035-H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 ANTIPSYCHOTIC MEDICATIONS Generic Name Brand Name First Generation Antipsychotic Medications Second Generation Antipsychotic Medications Combinations Chlorpromazine HCL, Fluphenazine HCL, Fluphenazine decanoate, Haloperidol, Haloperidol decanoate, Haloperidol lactate, Loxapine HCL, Loxapine succinate, Molindone HCL, Perphenazine, Pimozide, Thioridazine HCL, Thiothixene, Trifluoperazine HCL Aripiprazole, Asenapine, Brexpiprazole, Cariprazine, Clozapine, Iloperidone, Lurasidone, Olanzapine, Olanzapine pamoate, Paliperidone, Paliperidone palmitate, Quetiapine fumarate, Risperidone, Risperidone microspheres, Ziprasidone HCL, Ziprasidone mesylate Olanzapine-fluoxetine HCL, Perphenazine-amitriptyline HCL Thorazine HCL, Prolixin HCL, Prolixin decanoate, Haldol, Haldol intramuscular, Haldol intravenous, Loxitane HCL, Loxitane succinate, Moban HCL, Trilaphon, Orap, Mellaril HCL, Navane, Stelazine HCL Abilify, Saphris, Rexulti, Vraylar, Clozaril, Fanapt, Latuda, Zyprexa, Zyprexa Relprevv, Invega, Invega Sustenna, Seroquel, Risperdal, Risperdal Consta, Geodon, Geodon for injection Symbyax; Etrafon, Triavil 18

20 HEDIS TIPS: USE OF FIRST-LINE PSYCHOSOCIAL CARE FOR CHILDREN AND ADOLESCENTS ON ANTIPSYCHOTICS (APP) Psychosocial care, which includes behavioral interventions, psychological therapies, and skills training, among other, is the recommended first-line treatment option for children and adolescents diagnosed with nonpsychotic conditions such as attention-deficit disorder and disruptive behaviors When prescribed, antipsychotic medications should be part of a comprehensive, multi-modal plan for coordinated treatment that includes psychosocial care Periodically review the ongoing need for continued therapy with antipsychotic medications Patients can be referred for Case Management at (800) Ext Code appropriately using the above codes as guidelines Ensure progress note is closed with a provider signature 19

21 HEDIS TIPS: DISEASE MODIFYING ANTI-RHEUMATIC DRUG THERAPY (DMARD) FOR RHEUMATOID ARTHRITIS (ART) Patients 18 years of age and older who were diagnosed with rheumatoid arthritis (RA) and who were dispensed at least one DMARD prescription during the measurement year. DMARDs: 5-Aminosalicyclates Alkylating agents Aminoquinolines Anti-rheumatics Immunomodulators Immunosuppressive agents Janus kinase (JAK) inhibitor Tetracyclines Prescription Sulfasalazine Cyclophosphamide Hydroxychloroquine Auranofin, Gold sodium thiomalate, Leflunomide, Methotrexate, Penicillamine Abatacept, Adalimumab, Anakinra, Certolizumab, Certolizumab pegol, Etanercept, Golimumab, Infliximab, Rituximab, Tocilizumab Azathioprine, Cyclosporine, Mycophenolate Tofacitinib Minocycline Codes to Identify Rheumatoid Arthritis Codes Rheumatoid Arthritis ICD-9: 714.0, 714.1, 714.2, ICD-10-CM*: M05.00, M06.9, M05.60, M05.10 * ICD-10-CM and ICD-10-PCS codes are to be used on or after 10/1/2015. Please refer to your ICD- 10-CM and ICD-10-PCS Manuals for further code specificity. Codes to Identify DMARD Codes DMARD HCPCS: J0129, J0135, J0717, J1438, J1600, J1602, J1745, J3262, J7502, J7515-J7518, J9250, J9260, J9310 Confirm RA versus osteoarthritis (OA) or joint pain Document diagnosis of RA along with prescription of DMARD Code appropriately using the above codes as guidelines Refer to current American College of Rheumatology standards/guidelines Refer patients to network rheumatologists as appropriate for consultation and/or co-management Audit a sample of charts of members identified as having rheumatoid arthritis to assess accuracy of coding: Usual ratio of OA:RA = 9:1 Aggressive risk adjustment can overstate RA vs. OA Refer to the current American College of Rheumatology practice guidelines at: Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Rheumatoid-Arthritis. Ensure progress note is closed out with a provider signature 20

22 HEDIS TIPS: ADOLESCENT WELL-CARE VISIT (AWC) Patients years of age who had one comprehensive well-care visit with a PCP or OB/GYN during the measurement year. Well-care visit consists of: A health history A physical developmental history A mental developmental history A physical exam Health education/anticipatory guidance Codes Well-Care Visits CPT : 99384, 99385, 99394, HCPCS: G0438, G0439 ICD-9: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 ICD-10*:Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9 * ICD-10-CM and ICD-10-PCS codes are to be used on or after 10/1/2015. Please refer to your ICD-10- CM and ICD-10-PCS Manuals for further code specificity. Avoid missed opportunities by taking advantage of every office visit (including sick visits) to provide well care when possible (immunizations, and BMI value/percentile calculations) Make sports/day care physicals into well-care visits by performing the required services and submitting appropriate codes Document all elements of a well-care visit including health history, developmental history, physical exam and health education/anticipatory guidance Use standardized templates in charts and in EMRs that allow checkboxes for standard counseling activities Refer to the Clinical Practice Guideline (CPG) for Preventative Health of Children and Adolescents at: Code appropriately using the above codes as guidelines Molina Healthcare offers a member health incentive program for Adolescent Well Care. Medicaid member earns reward points redeemable for health related items. For more information, please call WA QI Health Education Line at (800) Ext Ensure progress note is closed out with a provider signature 21

23 HEDIS TIPS: BREAST CANCER SCREENING (BCS) Patients years of age who had one or more mammograms any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year. Exclusions: Bilateral mastectomy Note: This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, MRIs or tomosynthesis (3D mammography) because they are not appropriate methods for primary breast cancer screening. Codes to Identify Breast Cancer Screening Breast Cancer Screening Codes Measure Exclusion Codes: CPT: HCPCS: G0202 ICD-9: 87.36, ICD-10*: BH00ZZZ- BH02ZZZ, BH00ZZZ- BH06ZZZ UB Revenue: 0403 Bilateral Mastectomy ICD-9: 85.42, 85.44, 85.46, ICD-10*: 0HTV0ZZ Unilateral Mastectomy with a Bilateral Modifier or Two Unilateral Mastectomy Codes 14 days or more apart History of Bilateral Mastectomy Unilateral Mastectomy: CPT:19180, 19200, 19220, 19240, ICD-9 Codes: 85.41, 85.43, 85.45, ICD-10*: 0HTT0ZZ, OHTTU0ZZ Bilateral Modifier: CPT: 50, ICD-9: V45.71 ICD-10*: Z90.13 *ICD-10-CM codes are to be used on or after 10/1/2015. Please refer to your ICD-10-CM Manual for further code specificity. Educate patients about the importance of early detection and encourage testing Review missing services list to identify patients in need of mammograms Document diagnosis and code to the highest specificity Increase patient compliance by: Scheduling a mammogram for patient or send/give patient a referral/script (if needed) Have a list of mammogram facilities available to share with the patient (helpful to print on colored paper for easy reference) Discuss possible fears the patient may have about mammograms and inform the patient that currently available testing methods are less uncomfortable and require less radiation Document in the medical record if the patient has had bilateral mastectomy and fax the chart to Molina Healthcare (800) Molina Healthcare offers a member Health Incentive program for Breast Cancer Screening. Medicaid members earn reward points redeemable for health related items. For more information, please call (800) Ext Ensure progress notes is closed out with a provider signature 22

24 HEDIS TIPS: CHILDREN AND ADOLESCENTS ACCESS TO PRIMARY CARE PRACTITIONERS (CAP) The percentage of patients 12 months to 19 years of age who had a visit with a Primary Care Provider (PCP). Four separate percentages are reported for each product line. Children 12 to 24 months and 25 months to 6 years who had a visit with a PCP during the measurement year. Children 7 to 11 years and adolescents 12 to 19 years who had a visit with a PCP during the measurement year or the year prior to the measurement year. Codes to Identify Ambulatory or Preventive Care Visits Codes Ambulatory Visits ICD-9: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8,V70.9 ICD-10*: Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9 CPT : , , , , , , , , 99411, 99412, 99420, HCPCS: G0402, G0438, G0439, G0463, T1015 UBREV: , , , 0982, 0983 *ICD-10-CM codes are to be used on or after 10/1/2015. Please refer to your ICD-10-CM Manual for further code specificity. Avoid missed opportunities by taking advantage of every office visit (including sick visits) to provide well care components when applicable Make sports/day care physicals into ambulatory or preventive care visits by performing the required services and submitting appropriate codes Review missing services list to identify patients that need an appointment Document all elements of a preventative exam including health history, developmental history, physical exam and education/anticipatory guidance Use standardized templates in charts and in EMRs that allow checkboxes for standard counseling activities Code appropriately using the above codes as guidelines Molina Healthcare offers a member Health Incentive program for Well Child Exams. Medicaid members earn reward points redeemable for health related items. For more information, please call (800) Ext Ensure progress note is closed out with a provider signature 23

25 HEDIS TIPS: CONTROLLING HIGH BLOOD PRESSURE (CBP) Patients years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90) during the measurement year. Patients years of age who had a diagnosis of hypertension (HTN) and diabetes and whose BP was adequately controlled (<140/90) during the measurement year. Patients years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<150/90) during the measurement year. Note: Patients are included in the measure if there was a claim/encounter with a diagnosis of hypertension on or before June 30 of the measurement year. The most recent BP during the measurement year is used Codes to Identify Hypertension ICD-9 Code ICD-10 Code* Ambulatory Visits 401.0, 401.1, I10 * ICD-10-CM codes are to be used on or after 10/1/2015. Please refer to your ICD-10-CM Manual for further code specificity. Document diagnosis of hypertension prior to June 30th of the measurement year Take two BP readings. One at the start of the exam and one at the end of the exam. (HEDIS allows us to use the lowest systolic and lowest diastolic readings in the same day). Code appropriately using the above codes as guidelines Close the encounter by dating and signing the chart note Document the exact value of the BP readings; do not round up or down Review and document hypertensive medication history and patient compliance Refer to the Clinical Practice Guideline (CPG) for Hypertension at: providers/wa/medicaid/resource/pdf/cpg-hypertension.pdf Molina also offers a Heart Healthy Living Cardiovascular Program that assists members with their understanding and management of cardiovascular disease, including hypertension. Please contact Molina for further information at (800) Ext If your patient has other conditions complicating hypertension, be sure to document and code as specifically as possible to ensure accurate Risk Adjustment reporting. For example, if the patient has Stage 5 Chronic Kidney Disease or End Stage Renal Disease (CKD/ESRD) in addition to hypertension: Improper and Non-Specific Documentation and Coding: I10 (Essential, primary hypertension) Correct, Complete and Specific Documentation and Coding: I12.0 (Stage 5 CKD/ESRD). An additional code to identify the stage of CKD would also be reported.) Please refer to the Molina HCC Pearl on Chronic Kidney Disease at: 24

26 HEDIS TIPS: CERVICAL CANCER SCREENING (CCS) Patients years of age who were screened for cervical cancer using either of the following criteria: Patients age who had cervical cytology during the measurement year or the two years prior to the measurement year. Patients age who had cervical cytology and human papillomavirus (HPV) co-testing performed during the measurement year or the four years prior to the measurement year. Exclusions: Patients who had a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix. * Molina Healthcare has adopted guidelines recommending cervical cancer screening to begin at age 21 years. Codes to Identify Cervical Cancer Screening Cervical Cytology Codes CPT : , 88147, 88148, 88150, , , 88174, HCPCS: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 UB Revenue: 0923 HPV Tests CPT : , 87624, Measure Exclusion Codes: Absence of Cervix CPT : 51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, , 58548, 58550, , 58570, , 58951, 58953, 58954, 58956, ICD-10*: Q51.5, Z90.710, Z ICD-10* PCS: 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ, 0UT94ZZ, 0UT9FZZ, 0UT97ZZ ICD-9: 618.5, , V88.01, V88.03, 68.41, 68.49, 68.51, 68.59, 68.61, 68.69, 68.71, 68.79, 68.8 *ICD-10-CM codes are to be used on or after 10/1/2015. Please refer to your ICD-10-CM Manual for further code specificity. Review missing services list to identify patients who are due for a Pap and/or an HPV test Document date of Pap/HPV testing along with results of the testing. HEDIS requires they both be collected on the same date in order to meet compliance. Ensure results of Pap tests are sent to you if done outside your facility/practice Document in the medical record if the patient has had a hysterectomy with no residual cervix and fax us the chart. Remember synonyms total, complete, and radical. Don t miss opportunities. Complete a Pap tests during regularly-scheduled well woman visits, sick visits, urine pregnancy tests, UTI, and Chlamydia/STI screenings when appropriate. Utilize ICD-10-CM diagnosis codes to report exclusions to the HEDIS measure such as absence of the cervix (see codes in the above table). Correctly coding these conditions may prevent medical record requests. Refer to the Clinical Practice Guideline (CPG) for Cervical Cancer Screening (within Adult Preventative Services) at: Molina offers a member health incentive program for Cervical Cancer Screening. Medicaid members earn reward points redeemable for health related items. For more information, please call (800) Ext Ensure progress note is closed out with a provider signature 25

27 HEDIS TIPS: COMPREHESIVE DIABETES CARE (CDC) Adults years of age with diabetes (type1 and type 2) who had each of the following: Hemoglobin A1c (HbA1c) testing HbA1c poor control (>9.0%)* * a lower rate is better HbA1c control <8.0% Eye exam (retinal or dilated) performed BP control (<140/90 mmhg) Nephropathy monitoring: Nephropathy screening or monitoring test Treatment for nephropathy or ACE/ARB therapy Stage 4 CKD ESRD Kidney transplant Visit with a nephrologist ACE/ARB dispensed Codes to Identify Comprehensive Diabetes Care Codes Codes to ICD-9: , 357.2, Identify , , Diabetes ICD-10*: E10, E11, E13, O24 (base codes) Codes to Identify HbA1c Tests Codes to Identify Nephropathy Screening Test (Urine Protein Tests) Codes to Identify Eye Exam (must be performed by optometrist or ophthalmologist) Codes to Identify Diabetic Retinal Screening With Eye Care Professional billed by any provider CPT : 83036, CPT II: 3044F (if HbA1c <7%), 3045F (if HbA1c 7% - 9%), 3046F (if HbA1c >9%) CPT : , 81005, 82042, 82043, 82044, CPT II: 3060F, 3061F, 3062F CPT : 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, 92134, , 92230, 92235, 92240, 92250, 92260, , , HCPCS: S0620, S0621, S3000 CPT II: 2022F, 2024F, 2026F, 3072F *ICD-10-CM codes are to be used on or after 10/1/2015. Please refer to your ICD-10-CM Manual for further code specifity. 26

28 HEDIS TIPS: COMPREHESIVE DIABETES CARE (CDC) Ensure all lab results (nephropathy and A1c) are documented and dated, including point of care. Document should include the assessment of the patients condition, vital signs (BP), evidence of monitoring for good control of diabetes. A digital eye exam, remote imaging, and fundus photography MUST be read by an eye care professional (optometrist or ophthalmologist) If member s eye exam was negative or showed low risk for retinopathy in the prior year, use the appropriate code from the above table Refer to the Clinical Practice Guideline (CPG) for Diabetes at: providers/wa/medicaid/resource/pdf/cpg-diabetes.pdf Please also refer to the Molina HCC Pearl for Diabetes at providers/wa/medicaid/comm/pdf/diabetes.pdf Members with chronic conditions such as diabetes may qualify for case management, and should be referred to the Molina Healthcare Case Management Program for evaluation at (800) Ext Molina offers a health incentive program for Medicaid members called Staying Healthy with Diabetes. Members who reduce their Hemoglobin A1c and get their annual eye exams receive reward points. For more information call the Molina Health Education Line at (800) Ext Ensure progress note is closed out with a provider signature and dated 27

29 HEDIS TIPS: CHLAMYDIA SCREENING (CHL) Patients years of age who were identified as sexually active and who had at least one Chlamydia test during the measurement year. Codes to Identify Chlamydia Screening CPT Code Chlamydia 87110, 87270, 87320, Screening 87492, Exclusion: Patients who were included in the measure based on pregnancy test alone and the member had a prescription for isotretinoin or an x-ray on the date of the pregnancy test or the 6 days after the pregnancy test. Perform annual Chlamydia screening on every year old patient identified as sexually active (use any visit opportunity) Review missing services list to identify patients that meet the criteria and need a screening Add Chlamydia screening as a standard lab for patients years old. Use adolescent well care and adult wellness exams for this purpose. Remember that Chlamydia screening can be performed through a urine test. Offer this as an option for your patients. Document progress notes with a provider signature and code appropriately Refer to the Clinical Practice Guideline (CPG) for Chlamydia Screening at: Practice_Guideline_2013.pdf 28

30 HEDIS TIPS: CHILDHOOD IMMUNIZATION STATUS (CIS) Children 2 years of age who had the following vaccines on or before their second birthday: Four DTaP (diphtheria, tetanus and acellular pertussis) Three IPV (polio) One MMR (measles, mumps, rubella) Three HiB (H influenza type B) Three HepB (hepatitis B) One VZV (chicken pox) Four PCV (pneumococcal conjugate) One HepA (hepatitis A) Two or Three RV (rotavirus) Two Influenza Codes to Identify Childhood Immunizations CPT /HCPCS/ICD/CVX Codes DTaP CPT : 90698, 90700, 90721, CVX: 20, 50, 106, 110, 120 IPV CPT : 90698, 90713, CVX: 10, 110, 120 MMR CPT : 90707, 90710, CVX: 03, 94 Measles and CPT : 90708, CVX: 04 rubella Measles CPT : 90705, CVX: 05 Mumps CPT : 90704, CVX: 07 Rubella CPT : 90706, CVX: 06 HiB CPT : , 90698, 90721, CVX: 46-51, 120, 148 Hepatitis B CPT : 90723, 90740, 90744, 90747, 90748, HCPCS: G0010, CVX: 08, 44, 51, 110 Newborn ICD-9: 99.55; ICD-10*: 3E0234Z Hepatitis B VZV CPT : 90710, 90716, CVX: 21, 94 Pneumococcal CPT : 90669, 90670, CVX: 100, conjugate 133, HCPCS: G0009 Hepatitis A CPT : 90633, CVX: 83 Rotavirus (two-dose schedule) Rotavirus (three-dose schedule) CPT : CVX: 119 CPT : CVX: 116 Influenza CPT : 90655, 90657, 90661, 90662, 90673, 90685, 90687, CVX: 135, 140, 141, 153, 155, 161, 166, HCPCS: G0008 *ICD-10-CM and ICD-10-PCS codes are to be used on or after 10/1/2015. Please refer to your ICD-10- CM and ICD-10-PCS Manuals for further code specificity. 29