2017 HEDIS Pediatric Toolkit

Transcription

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

2 TABLE OF CONTENTS Welcome to 2017 HEDIS TIPS...2 Molina Provider Contacts...3 Modifier Molina Healthcare Medicaid Health Incentives...7 Follow Up Care for Children Prescribed ADHD Medication (ADD)...8 Annual Dental Visits (ADV)...9 Asthma Medication Ratio (AMR)...10 Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)...12 Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)...13 First Line Psychosocial Care for Child Adolescents on Antipsychotics (APP)...15 Adolescent Well-Care Visit (AWC)...17 Children and Adolescents Access to Primary Care Practitioners (CAP)...18 Childhood Immunization Status (CIS)...19 Chlamydia Screening (CHL)...21 Appropriate Testing for Children with Pharyngitis (CWP)...22 Initiation & Engagement of Alcohol & Other Drug Dependence Treatment (IET)...23 Immunizations for Adolescents (IMA)...25 Lead Screening in Children (LSC)...26 Medication Management for People with Asthma (MMA)...27 Non-Recommended Cervical Cancer Screening in Adolescent Females (NCS)...29 Appropriate Treatment for Children with URI (URI)...30 Well-Child Visits First 15 Months of Life (W15)...32 Well-Child Visits 3-6 Years (W34)...33 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (WCC)...34

3 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 pediatric measures applicable to Medicaid (Apple Health) 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 the pediatric 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. 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). 2

4 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 3

5 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 4

6 Modifier 25: Preventative and Acute Care Services at the Same Encounter - Tips & Best Practices Background: For both preventative and acute care services to be reimbursable, all required components of both services must be performed and documented. According to the National Correct Coding Initiative (NCCI): The CPT Manual defines Modifier 25 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. Modifier 25 may be appended to an evaluation and management (E/M) CPT code to indicate that the E/M is significant and separately identifiable from other services reported on the same date of service. The E/M service may be related to the same or different diagnosis as the other procedure(s). Preventative Services (CPT ) Select Preventative Service codes based on the age of the patient on the date of service, as well as whether the patient is new or established Services include an age/gender appropriate history, comprehensive examination, counseling/anticipatory guidance/risk factor interventions, and the ordering of laboratory/diagnostic procedures (Lab and diagnostic procedures are reimbursed separately.) Services also include care of a small problem or pre-existing condition that requires no extra work Acute (Sick) Care Services (CPT ) If a problem or abnormality is encountered and is significant enough to require additional work to perform the key components of a problem-orientated E/M service, then the appropriate code should be reported For New Patients: All three key components of History, Exam and Medical Decision-Making must be met or exceeded to report each particular level For Established Patients: Two out of three of the key components of History, Exam, and Medical Decision- Making must be met or exceeded to reach each level Don t double-dip! Documentation that supports elements of the Preventative Services may not contribute to the elements and level of the Acute Care Service Please refer to your CPT Manual for further E/M level specifics Diagnosis Codes Must Match Be sure you report preventative care diagnoses codes with preventative care CPT codes. Problem-focused diagnosis codes should correspond to problem-focused or sick visits reported with Clinical Examples: A patient presents for a sprained ankle and the physician orders ankle x-rays. On the EMR health maintenance screen, an alert indicates the patient is due for their well visit. The well visit can be conducted with the exam of the sprained ankle as long as the documentation supports an E/M. A with Modifier 25 is reported in addition to appropriately. A patient presents for a well child checkup/preventative visit. During the exam, it is noted the child has minor diaper rash. The physician encourages the mother to change her diaper more frequently. It would not be 5

7 appropriate to report a problem-orientated E/M visit in addition to the preventative service, as the findings of diaper rash were trivial and incidental. Suggestions: As a best practice, educate the member about Preventative Health Exams and Sick Exams. Provide patients with an educational flyer about what occurs in a well exam. A notice can also be used to explain the office visit policy for preventative and sick exams and the reasons for it. It should be sent to patients along with confirmation of their preventative appointment or presented to them when they check in. The policy should also be explained in the information about the practice that you send to patients prior to their first appointment. Involve your scheduling staff. Any patient requesting to schedule a preventative service should be asked if he or she wishes to discuss any other health problems with the doctor. If the patient does not want to discuss other problems and the health problem may be considered insignificant, the scheduler can ask the patient to come in for a problem-orientated visit first and the preventative service at a later date. Encourage the patient to schedule both visits. If the patient indicates that he or she has no health problems to discuss with the doctor, the scheduler should let the patient know that if a health problem arises that another visit may be necessary. Resource Links: Medicare Learning Network (MLN) Documentation Guidelines for Evaluation and Management Services: Washington State Health Care Authority Apple Health (Medicaid): Physician-Related Services Provider Guide American Academy of Family Physicians Understanding When to Use Modifier Department of Health and Human Services, Office of Inspector General Use of Modifier 25 References: NCCI Policy Manual for Medicare Services Effective January 1, nationalcorrectcodinited/ 6

8 Molina Healthcare Medicaid Health Incentives To our Medicaid members: Make healthy choices and earn reward points you can redeem online for health related items up to $200 in total rewards per calendar year. See below for a list of reward-earning appointments. Healthy 15-Month-Olds Take your child in for 6 well child exams by the time they are 15 months old. Healthy Two-Year-Olds Make sure your child gets all required immunizations before they turn 2. Well Child Check Ups, Ages 3, 4, 5 and 6 A yearly well child check-up is a physical exam that includes vision and hearing tests, BMI percentile measurement, nutrition and physical activity counseling and also include immunizations (shots) if they are due. Well Child Check Ups, Ages 7, 8, 9, 10 and 11 A yearly well child check-up is a physical exam that includes vision and hearing tests, BMI percentile measurement, nutrition and physical activity counseling and also include immunizations (shots) if they are due. Adolescent Well Care, Ages A yearly adolescent well care exam that includes a complete physical exam, vision and hearing tests. The provider should also check blood pressure, height, weight and body mass index (BMI) percentile measurement, nutrition and physical activity counseling. Teens may need some shots or boosters. *Health Incentives are subject to change without notice Breast Cancer Members Members who are 50 years to 74 years of age should get a mammogram every two years. Members who have had breast cancer or other breast problems, or have a family history of breast cancer, might need to get mammograms before age 50. They may also need to get them more often. Talk to your health care provider about when to start and how often you should have a mammogram. To receive reward points in this program, get a mammogram at least once every two years. Cervical Cancer Screening Members 21 to 64 years old should schedule a cervical cancer screening and a Human Papillomavirus (HPV) test yearly or according to their doctor s instructions. Prenatal Care See your provider in the first three months of pregnancy or within 42 days of joining Molina. Postpartum Care Visit your provider for an exam days after you ve delivered your baby. Staying Healthy with Diabetes As a member of this program, you can team up with your health care provider to set and reach your diabetes management goals. Members who reduce their Hemoglobin A1C, and get their annual eye exams receive reward points. MolinaHealthcare.com MRC PART # APPROVALS: MHW 3/14/17 HCA 4/7/17 ( ) 7 Questions? Members, please call Member Services at (800) TTY/TDD: 711 Providers, please call Molina s Wellness Quality Line at (800) Ext WA0317

9 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). USING CORRECT BILLING CODES Codes to Identify Follow-up Visits Description Codes CPT : , , 99078, , , , , , , , , , 99411, 99412, HCPCS: G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, Follow-up Visits H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 UB Revenue: 0510, 0513, , , , 0900, , 0907, , 0919, 0982, 0983 Telephone Visits CPT : , (can use for one Continuation and Maintenance Phase visit) Description Follow-up Visits 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 8

10 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. USING CORRECT BILLING CODES Codes to Identify Annual Dental Visit Description 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 9

11 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.) USING CORRECT BILLING CODES Codes to Identify Asthma Description 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 Description 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. 10

12 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

13 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 Description 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 12

14 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 Description Diabetes Screening test during the measurement year Codes to Identify Glucose Tests Codes to Identify HbA1c Tests Codes to Identify Diabetes Screening --AND-- Description Complete at least ONE Codes to Identify Cholesterol Screening test LDL-C Tests during the measurement year 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 Description 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 13

15 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 14

16 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 Description 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 Description 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 15

17 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 16

18 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 USING CORRECT BILLING CODES Description 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 17

19 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. USING CORRECT BILLING CODES Codes to Identify Ambulatory or Preventive Care Visits Description 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 18

20 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 USING CORRECT BILLING CODES Codes to Identify Childhood Immunizations Description 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. 19

21 HEDIS TIPS: CHILDHOOD IMMUNIZATION STATUS (CIS) Use the state immunization registry to keep up to date with state immunization If possible, use a tickler system to remind providers that immunizations are due Recommend immunizations to parents. Parents are more likely to agree with vaccinations when supported by the provider. Address common misconceptions about vaccinations, e.g. MMR causes autism (now completely disproven). If the parents refuse immunizations, document clearly in chart note Complete a blood lead level screening before the age of 2. Document date and results. Some vaccines may have been given before patients were Molina members. Include these on the members vaccination record even if your office did not provide the vaccine. Code appropriately using the above codes as guidelines Refer to the Clinical Practice Guideline (CPG) for Immunizations (within Preventative Services for Children and Adolescents) at: Children-Adolescents.pdf Molina Healthcare offers a member health incentive program for Childhood Immunizations. Medicaid members earn reward points redeemable for health related items. For more information, please call the Molina Health Education Line at (800) Ext Ensure progress note is closed out with a provider signature 20

22 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. USING CORRECT BILLING CODES Codes to Identify Chlamydia Screening Description 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 21

23 HEDIS TIPS: APPROPRIATE TESTING FOR CHILDREN WITH PHARYNGITIS (CWP) Children 3-18 years of age diagnosed with pharyngitis and dispensed an antibiotic should have received a Group A strep test within 3 days prior to the diagnosis date through the 3 days after the diagnosis date. USING CORRECT BILLING CODES Codes to Identify Pharyngitis Description ICD-9 Code ICD-10 Code* Acute pharyngitis 462 J02.8, J02.9 Acute tonsillitis 463, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91 Streptococcal sore throat J02.0 *ICD-10-CM codes are to be used on or after 10/1/15. Please refer to your ICD-10-CM Manual for further code specificity. Codes to Identify Strep Test Description CPT Codes Strep Test 87070, 87071, 87081, 87430, , Document that a rapid strep test or throat culture was done to confirm diagnosis before prescribing antibiotics. Submit this test to Molina Healthcare for payment if the State permits, or as a record that you performed the test. Use the codes above. Never treat red throats empirically, as they are viral even in children with a long history of strep. Clinical findings alone do not adequately distinguish Strep vs. no Strep pharyngitis. The patient s strep may have become resistant and needs a culture Submit any co-morbid diagnosis codes that apply on claim/encounter Educate parents/caregivers that an antibiotic is not necessary for viral infections if rapid strep test and/or throat culture is negative Code appropriately using the above codes as guidelines Additional resources for clinicians and parents/caregivers about pharyngitis can be found here: Ensure progress note is closed out with a provider signature 22

24 HEDIS TIPS: INITIATION & ENGAGEMENT OF ALCOHOL & OTHER DRUG DEPENDENCE TREATMENT (IET) The percentage of adolescent and adult patients 13 years of age and older with a new diagnosis of alcohol or other drug (AOD) dependence with the following: Initiation of AOD Treatment. Initiate treatment through inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of diagnosis. Engagement of AOD Treatment. Initiated treatment and had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit. USING CORRECT BILLING CODES Codes to Identify AOD Dependence ICD-9-CM Diagnosis , , , , 291.9, , , , , , , , , , , , , , , , , , , , , , , , ICD-10-CM* Diagnosis F10.10 F10.20, F10.22 F10.29, F11.10 F11.20, F11.22 F11.29, F12.10 F12.20, F12.22 F12.29, F13.10 F13.20, F13.22 F13.29, F14.10 F14.20, F14.22 F14.29, F15.10 F15.20, F15.22 F15.29, F16.10 F16.20, F16.22 F16.29, F18.10 F18.20, F18.22 F18.29, F19.10 F19.20, F19.22 F19.29, K29.20, K29.21, K70.10, K *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. Codes to Identify Outpatient, Intensive Outpatient and Partial Hospitalization Visits (use these visit codes along with the one of the diagnosis codes above to capture initiation and engagement of AOD treatment) CPT HCPCS UB Revenue , 99078, , , , , , , , , , 99408, 99409, 99411, 99412, G0155, G0176, G0177, G0396, G0397, G0409-G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0020, H0022, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, H2035, H2036, M0064,S0201, S9480, S9484, S9485, T1006, T1012, T1015 CPT 90791, 90792, , , 90845, 90847, 90849, 90853, 90875, WITH 0510, 0513, , , , 0900, , , 0919, 0944, 0945, 0982, 0983 POS 03, 05, 07, 09, 11, 12, 13, 14, 15,16,17,18,19, 20, 22, 33, 49, 50, 52, 53, 57, 71, 72 23

25 HEDIS TIPS: INITIATION & ENGAGEMENT OF ALCOHOL & OTHER DRUG DEPENDENCE TREATMENT (IET) Consider using screening tools to identify substance abuse issues in patients Document identified substance abuse in the patient chart and submit a claim with the appropriate codes, using the codes above as a guideline Avoid inappropriate use of diagnosis codes that are the result of alcohol or drug dependency (e.g. Cirrhosis) as these also qualify patients for the measures Schedule a follow-up visit within 14 days of an AOD diagnosis Schedule at least two additional visits within 30 days after initiation of treatment Refer to a behavioral health provider where applicable Involve family members or others who the patient desires for support and invite their help in intervening with the patient diagnosed with AOD dependence Provide patient educational materials and resources that include information on the treatment process and options Work collaboratively with the Molina Care Manager if they contact you about a recent encounter with a patient for substance dependency to motivate the patient to initiate treatment Continue ongoing discussions with patients about treatment to help increase their willingness to commit to the process as the timeframe for initiating treatment is brief (14 days) Ensure progress note are closed out with a provider signature 24

26 HEDIS TIPS: IMMUNIZATIONS FOR ADOLESCENTS INCLUDING HPV (IMA) Adolescents 13 years of age who received the following vaccines on or before their 13 th birthday: One meningococcal conjugate vaccine (must be completed on or between the 11 th and 13 th birthdays) One Tdap or one tetanus, diphtheria toxoids and acellular pertussis (Tdap) (must be completed on or between the 10 th and 13 th birthdays) Three Human Papillomavirus vaccines with different dates of service on or between the 9 th and 13 th birthdays USING CORRECT BILLING CODES Codes to Identify Adolescent Immunizations Description CPT /CVX Codes Meningococcal CPT : 90644, CVX: 136, 148 Tdap CPT : CVX: 115 Td CPT : Human Papillomavirus (HPV) CPT : 90649,90650, CVX: 62,118,165 Make every office visit count- take advantage of sick visits for catching up on needed vaccines Institute a system for patient reminders, if able Document any vaccines that were given prior to being seen at your office/practice Document and code antigen given, date given and signature of person administering the immunization list to identify patients that need immunizations HPV is now recommended for both male and females Use the State Immunization registry to keep medical records updated Refer to the Clinical Practice Guideline (CPG) for Immunizations (within Preventative Services for Children and Adolescents) at Children-Adolescents.pdf 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 the Molina Health Education Line at (800) Ext Ensure progress note is closed out with a provider signature 25

27 HEDIS TIPS: LEAD SCREENING IN CHILDREN (LSC) Children 2 years of age who had at least one capillary or venous lead blood test for lead poisoning on or before their second birthday. USING CORRECT BILLING CODES Codes to Identify Lead Tests Description CPT Code Lead Tests Avoid missed opportunities by taking advantage of every office visit (including sick visits) to perform lead testing The requirement for this measure is for a blood lead test; not a lead screening questionnaire Consider a standing order for in office lead testing Document lead screening results and code appropriately using the above codes as a guideline Provide in-office testing (capillary) Bill in-office testing where permitted by the State fee schedule and Molina policy Ensure progress note is closed out with a provider signature 26

28 HEDIS TIPS: MEDICATION MANAGEMENT FOR PEOPLE WITH ASTHMA (MMA) The percentage of patients 5 85 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported: 1. The percentage of patients who remained on an asthma controller medication for at least 50% of their treatment period. 2. The percentage of patients who remained on an asthma controller medication for at least 75% of their treatment period. 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/observation visits on different dates of service, with asthma as one of the diagnoses and at least 2 asthma medication dispensing events. Visit type need not be the same for the 4 visits. At least 4 asthma medication dispensing events. If leukotriene modifiers or antibody inhibitors 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 or antibody inhibitor (i.e., measurement year or the year prior.) USING CORRECT BILLING CODES Codes to Identify Asthma Description ICD-9 Code ICD-10 Code* Asthma , , , , J45.901, J45.902, J45.909, J45.990, J Mild Intermittent Asthma , , J45.20, J45.21, J45.22 Mild Persistent Asthma , , J45.30, J45.31, J45.32 Moderate Persistent , , J45.40, J45.41, J45.42 Asthma 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 codes are to be used on or after 10/1/2015. Please refer to your ICD-10-CM Manual for further code specificity. 27

29 HEDIS TIPS: MEDICATION MANAGEMENT FOR PEOPLE WITH ASTHMA (MMA) Asthma Controller Medications Description Prescriptions Antiasthmatic Dyphylline-guaifenesin, Guaifenesin-theophylline combinations Antibody inhibitor Omalizumab Inhaled steroid Budesonide-formoterol, Fluticasone-salmeterol, Mometasone-formoterol combinations Inhaled corticosteroids Beclomethasone, Budesonide, Ciclesonide, Flunisolide, Fluticasone CFC free, Mometasone Leukotriene modifiers Montelukast, Zafirlukast, Zileuton Mast cell stabilizers Cromolyn Methylxanthines Aminophylline, Dyphylline, Theophylline *Please refer to the Molina Healthcare Drug Formulary for asthma controller medications that may require prior authorization or step therapy. 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 missing service list and contact patients who have not filled a controller medication 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 Prescribe a long-term controller medication and provide reminders to your patients to fill controller medications Prescription mail-order delivery is available for Molina Medicare and Marketplace members only Visit Drug Formulary for coverage updates at: medicaid/drug/pages/formulary.aspx or contact Molina Provider Pharmacy at (800) Ext Ensure progress note is closed out with a provider signature 28

30 HEDIS TIPS: NON-RECOMMENDED CERVICAL CANCER SCREENING IN ADOLESCENTS (NCS) Adolescents years of age should not be screened unnecessarily for cervical cancer. Exceptions: Patient has prior history of cervical cancer, HIV or immunodeficiency disorders. USING CORRECT BILLING CODES Codes to Identify Cervical Cancer Screening (adolescents years should not be screened for cervical cancer) Description ICD-9 Codes Cervical Cytology CPT : 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, HCPCS: G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091 UB Rev: 0923 HPV Tests CPT : 87620, 87621, 87622,87624,87625 HCPCS: G0476 Consider not screening patients years of age regardless of age at sexual initiation and other behavior-related risk factors Consider not performing the screening on healthy asymptomatic women An external only genital examination is acceptable Discuss the decision whether or not to perform a complete pelvic examination with the patient as this should be a shared decision between the patient and their health care provider Ensure progress note is closed out with a provider signature Code appropriately using the above codes as guidelines 29