Clinical Quality Measures

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1 Title Medicare Shared Savings Program Blue Cross Blue Shield Other CI Measures Clinical Quality Measures 2016 Reference Toolkit Version Date: 6/13/2016 Title Page 2016 Measures: Quality Codes Page 1 of 199 Updated: 6/13/2016

2 This page intentionally left blank Clinical Quality Measures: 2016 Page 2 of 199 Updated: 6/13/2016

3 IHP CLINICAL QUALITY MEASURES I. Table of Contents I. TABLE OF CONTENTS...3 II. MEDICARE SHARED SAVINGS PROGRAM MEASURES OVERVIEW...6 TABLE: LIST OF MSSP MEASURES...6 ACO DATA SUBMISSION TO CMS...8 III. MEASURES OVERVIEW: OTHER PAYERS...9 HEDIS MEASURES...9 TABLE: MEASURES REQUIRING CPT II CODES...9 TABLE: MEASURES-NOT REQUIRING CPT II CODES MEASURES NOT REQUIRING CPT II CODES IV. QUALITY REPORTING CODES HCPCS CODES CPT II CODES CMS-1500 CLAIM PQRS EXAMPLE V. MEASURES REQUIRING CPT II CODES DOCUMENTATION OF CURRENT MEDICATIONS IN MEDICAL RECORD FALLS: SCREENING FOR FUTURE FALL RISK INFLUENZA IMMUNIZATION PNEUMONIA VACCINATION STATUS FOR OLDER ADULTS BODY MASS INDEX (BMI) SCREENING AND FOLLOW-UP AVOIDANCE OF ANTIBIOTIC TREATMENT IN ADULTS WITH ACUTE BRONCHITIS APPROPRIATE TREATMENT FOR CHILDREN WITH URI APPROPRIATE TESTING FOR CHILDREN WITH PHARYNGITIS TOBACCO USE: SCREENING AND CESSATION INTERVENTION ASTHMA MEASURES SCREENING FOR CLINICAL DEPRESSION AND FOLLOW-UP PLAN Clinical Quality Measures: 2016 Page 3 of 199 Updated: 6/13/2016

4 MENTAL HEALTH: DEPRESSION REMISSION AT TWELVE MONTHS COLORECTAL CANCER SCREENING BREAST CANCER SCREENING CERVICAL CANCER SCREENING SCREENING FOR HIGH BLOOD PRESSURE AND FOLLOW-UP DOCUMENTED HYPERTENSION: CONTROLLING HIGH BLOOD PRESSURE DIABETES: BP CONTROL < 140/90 MMHG HEART FAILURE: BETA-BLOCKER THERAPY FOR LVSD DIABETES: HBA1C TESTING & HBA1C CONTROL DIABETES: HEMOGLOBIN A1C POOR CONTROL DIABETES: EYE EXAM DIABETES: ATTENTION TO NEPHROPATHY DIABETES: SCREENING FOR DEPRESSION ACE INHIBITOR OR ARB THERAPY DIABETES OR LVSD (LVEF < 40%) STATIN THERAPY FOR THE PREVENTION AND TREATMENT OF CARDIOVASCULAR DISEASE IVD: USE OF ASPIRIN OR ANOTHER ANTITHROMBOTIC VI. OTHER ACO MEASURES: NOT REQUIRING CPT II CODING CHILDHOOD IMMUNIZATIONS MMR CHILDHOOD IMMUNIZATION - COMBINATION IMMUNIZATIONS FOR ADOLESCENTS HUMAN PAPILLOMAVIRUS VACCINE OSTEOPOROSIS MANAGEMENT IN WOMEN WITH FRACTURE DISEASE MODIFYING ANTI-RHEUMATIC DRUG THERAPY FOR RHEUMATOID ARTHRITIS MEDICATION MANAGEMENT FOR PEOPLE WITH ASTHMA USE OF IMAGING STUDIES FOR LOW BACK PAIN CHLAMYDIA SCREENING CAHPS PATIENT EXPERIENCE SURVEY MEASURES ACO # 8: RISK STANDARDIZED ALL CONDITION READMISSION ACO 9: ACSCA: COPD OR ASTHMA IN OLDER ADULTS ACO 10: ACSCA: ADMISSIONS FOR HEART FAILURE (HF) ACO 10: PREVENTION QUALITY INDICATOR: AMBULATORY CARE SENSITIVE CONDITIONS ADMISSIONS: ADMISSIONS FOR HEART FAILURE (HF) ACO # 11: PERCENT OF PCP S WHO SUCCESSFULLY MEET MUR ACO #35: SKILLED NURSING FACILITY 30-DAY ALL-CAUSE READMISSION MEASURES (SNFRM) ACO #36: ALL-CAUSE UNPLANNED ADMISSIONS FOR PATIENTS WITH DIABETES ACO # 37: ALL-CAUSE UNPLANNED ADMISSION FOR PATIENTS WITH HEART FAILURE ACO #38: ALL-CAUSE UNPLANNED ADMISSIONS FOR PATIENTS WITH MCCS VII. DOCUMENTATION REQUIREMENTS Clinical Quality Measures: 2016 Page 4 of 199 Updated: 6/13/2016

5 Quality Reporting Overview Click here to go to Table of Contents Clinical Quality Measures: 2016 Page 5 of 199 Updated: 6/13/2016

6 II. Medicare Shared Savings Program Measures Overview MEASURES FOR USE IN ESTABLISHING QUALITY PERFORMANCE STANDARDS THAT ACOS MUST MEET FOR SHARED SAVINGS CMS will measure quality of care using the 34 Medicare Shared Savings Program measures in 4 key domains. The below table will help you identify how measure data is collected and which measures require CPT II coding: Better Care for Individuals Better Health for Populations DOMAIN: Patient/Caregiver Experience measures DOMAIN: Care Coordination and Patient Safety measures DOMAIN: At- Risk Population measures DOMAIN: Preventive Care Measures measures Table: List of MSSP Measures DOMAIN: Patient/Caregiver Experience ACO # Measure Name NQF Measure Method of Data CPT II # Steward Submission Coding? ACO-1 CAHPS for ACOs: Getting Timely Care, Appointments, & 0005 AHRQ Survey No Information ACO-2 CAHPS for ACOs: How Well Your Providers Communicate 0005 AHRQ Survey No ACO-3 CAHPS for ACOs: Patient Rating of Provider 0005 AHRQ Survey No ACO-4 CAHPS for ACOs: Access to Specialist N/A CMS Survey No ACO-5 CAHPS for ACOs: Health Promotion and Education N/A CMS Survey No ACO-6 CAHPS for ACOs: Shared Decision Making N/A CMS Survey No ACO-7 CAHPS for ACOs: Health Status/Functional Status N/A CMS Survey No ACO-34 CAHPS for ACOs: Stewardship of Patient Resources N/A CMS Survey No DOMAIN: Care Coordination and Patient Safety ACO # Measure Name NQF # ACO- 8 Risk Standardized All Condition Readmission 1789 ACO -9 Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults 0275 AHRQ Measure Method CPT II Steward of Submission Coding? CMS Claims No ACO-10 Ambulatory Sensitive Conditions Admissions: Heart Failure (HF) 0277 AHRQ Claims No ACO-11 % of PCPs who successfully meet Meaningful Use requirements N/A CMS Claims & Admin Data No ACO-35 Skilled Nursing Facility 30-Day All-Cause Readmission (SNFRM) N/A CMS Claims No ACO-36 All-Cause Unplanned Admissions for Patients with Diabetes N/A CMS Claims No ACO-37 All-Cause Unplanned Admission for Patients with Heart Failure N/A CMS Claims No All-Cause Unplanned Admissions for Patients with Multiple Chronic No ACO-38 Conditions N/A CMS ACO-39 (CARE-3) ACO-13 (CARE-2) CARE MODULE (with 2 individual measures) Documentation of Current Medications in the Medical Record 0419 CMS Falls: Screening for Future Fall Risk 0101 AMA-PCPI- NCQA Claims ACO submits data to CMS ACO submits data to CMS No MSSP 2016 Measures Page 6 of 199 Updated: 6/13/2016 Methods of Data Submission to CMS

7 1 COMPOSITE of 2 MEASURES DOMAIN: Preventive Health ACO # Measure Name NQF # ACO-20 (PREV-5) Breast Cancer Screening NA Measure Steward NCQA ACO-19 (PREV-6) Colorectal Cancer Screening 0034 NCQA ACO-14 (PREV-7) Influenza Immunization 0041 AMA/PCPI ACO-15 (PREV-8) Pneumonia Vaccination Status for Older Adults 0043 NCQA ACO-16 (PREV-9) Body Mass Index (BMI) Screening and Follow-Up 0421 CMS ACO-17 (PREV-10) Tobacco Use: Screening and Cessation Intervention 0028 AMA/PCPI ACO-21 (PREV-11) Screening for High BP and Follow-Up Documented NA CMS ACO-18 (PREV-12) Screening for Clinical Depression and Follow-Up Plan 0418 CMS ACO-42 (PREV-13) DOMAIN: Statin Therapy for Prevention and Treatment of Cardiovascular Disease NA CMS Clinical Care for At- Risk Population ACO # Modules (6) Measure Name NQF # Measure Steward Method of Submission ACO submits data to CMS ACO submits data to CMS ACO submits data to CMS ACO submits data to CMS ACO submits data to CMS ACO submits data to CMS ACO submits data to CMS ACO submits data to CMS ACO submits data to CMS Method of Submission CPT II Coding CPT II Coding ACO-27 (DM-2) ACO-41 (DM-7) DM Module Diabetes: Hemoglobin A1c Poor Control 0059 NCQA ACO submits data to CMS Diabetes: Eye Exam 0055 NCQA ACO submits data to CMS ACO-28 (HTN-2) ACO-31 (HF-6) ACO-30 (IVD-2) ACO-33 (CAD-7) ACO-40 (MH-1) HTN Module Controlling High Blood Pressure 0018 NCQA ACO submits data to CMS HF Module IVD Module CAD Module MH Module Heart Failure: Beta-Blocker Therapy for LVSD 0083 AMA/PCPI/ ACC/AHA ACO submits data to CMS Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic 0068 NCQA ACO submits data to CMS Coronary Artery Disease: ACE Inhibitor or ARB Therapy Diabetes or LVSD (LVEF < 40%) 0066 AMA/PCPI/A CC/ AHA ACO submits data to CMS Mental Health: Depression Remission at Twelve Months 0710 MNCM ACO submits data to CMS MSSP 2016 Measures Page 7 of 199 Updated: 6/13/2016 Methods of Data Submission to CMS

8 ACO Data Submission to CMS Methods of ACO Data Submission to CMS The 34 quality measures will be reported through a combination of: CMS Claims and Administrative data CMS-provided web portal designed (i.e., the Group Practice Reporting Option [GPRO] Web Interface [WI]) for capturing ACO-reported clinical quality measure data Patient Experience of Care Survey 8 measures 18 measures 8 measures IHP will be using the CPT II codes, explained below, to facilitate data collection from practices for the measures that ACO will be reporting using the CMS GPRO Web Interface. Please note: A table identifying which metrics apply to each specialty is enclosed as a supplement to this document. MSSP 2016 Measures Page 8 of 199 Updated: 6/13/2016 Methods of Data Submission to CMS

9 III. Measures Overview: Other Payers Payers leverage quality measures established by the National Committee for Quality Assurance (NCQA) and Healthcare Effectiveness Data and Information Set (HEDIS) to measure performance. HEDIS Measures The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows direct, objective comparison of quality across health plans an "apples-to-apples" basis. HEDIS measures focus largely on the processes of care. Measures reflect care that patients actually receive and coded, not ordered for them. To improve performance on HEDIS measures: Chart documentation must reflect the services billed. Use correct diagnosis and procedure codes. Ensure Accurate and timely submission of claim/encounter data. Payers require ACO s to utilize HEDIS specifications when evaluating performance on measures which are listed below. Table: Measures Requiring CPT II Codes Measures Requiring CPT II Codes CPT II Coding 1. Breast Cancer Screening 2. Cervical Cancer Screening 3. Colorectal Cancer Screening 4. Comprehensive Diabetes Care HbA1c Testing HbA1c Control (<8.0%) HbA1c Control (< or = 9.0%) Blood Pressure Control < 140/90 mmhg Diabetes Retinal Eye Exam Diabetes Nephropathy Screening Depression Screening 5. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 6. Appropriate Treatment for Children With Upper Respiratory Infection 7. Appropriate Testing for Children with Pharyngitis 8. BMI Screening 9. Asthma Measure Set : Asthma Control 2016 Measures Page 9 of 199 Updated: 6/13/2016 Quality Codes

10 Table: Measures-Not Requiring CPT II Codes Measures Not Requiring CPT II Codes 1. Asthma Measure Set : Asthma Action Plan Asthma Follow-Up 2. Childhood Immunization Status MMR No 3. Childhood Immunizations Combo 10 No 4. Adolescent Immunizations No 5. Human Papillomavirus Vaccine (females, age 13) No 6. Medication Management for People with Asthma No 7. Use of Imaging Studies for Low Back Pain No 8. Osteoporosis Management in women who had a fracture No 9. Rheumatoid Arthritis Management No No No 2016 Measures Page 10 of 199 Updated: 6/13/2016 Quality Codes

11 IV. Quality Reporting Codes Tracking Performance for Quality Improvement This section provides an overview of the coding methodologies that are required to track performance for the Clinical Integration/ ACO program metrics from practices that do not use an EHR. Quality-Data Codes (QDCs): HCPCS and CPT II Codes QDCs are non-payable Healthcare Common Procedure Coding System (HCPCS) codes comprised of specified CPT Category II codes and/or G-codes that describe the quality action required by a measure s numerator. Practices will be using. CPT II Codes and HCPCS G codes s to report compliance with the MSSP measures. HCPCS Codes CPT II Codes Healthcare Common Procedure Coding System (HCPCS), often pronounced by its acronym as "hick picks", is a collection of standardized codes that represent medical procedures, supplies, products and services. The codes are used to ensure that the healthcare claims are processed by Medicare and other insurers in an orderly and consistent manner. The Healthcare Portability and Protection Act of 1996 (HIPPA) mandated that all healthcare claims be reported using HCPCS. HCPCS is divided into two subsystems, Level I and Level II. HCPCS Level I consists of the Current Procedural Terminology (CPT) codes. HCPCS Level II codes CPT (Current Procedural Terminology) The CPT system is maintained and copyrighted by the American Medical Association (AMA). CPT is currently identified by the CMS as Level 1 of the HCPCS. CPT system is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures provided by healthcare providers such as physician, nurse practitioners and physician assistants. Each CPT code is numeric and has five digits. Has 3 categories, detailed on right CPT Category I Includes procedures that are consistent with contemporary medical practice and are widely performed. Category I codes are the fivedigit numeric codes included in the main body of CPT. Category I is the section that coders usually identify with when talking about CPT. CPT Category II Codes Supplementary tracking codes used for performance measurement. Facilitate data collection about the quality of care rendered by coding certain services and test results that support nationally established performance measures and that have an evidence base as contributing to quality patient care. CPT II codes are alphanumeric containing five characters, with four digits followed by an alphabetical fifth character, the letter F. These are optional codes used to facilitate data collection and are never used as substitutes for the standard Category I CPT codes. Use of Category II codes for performance measurement can decrease the need for record abstraction and chart review when measuring the quality of patient care. CPT II codes are not modified or updated during the reporting period and remain valid for the entire program year as published in the measure specifications manuals. CPT Category III Temporary codes for emerging technology, services and procedures. They are used to report new technology, services or procedures that do not currently have a CPT code assigned Level II of the HCPCS is a standardized coding system primarily represents items and supplies and nonphysician services not covered by the AMA s CPT-4 codes. HCPCS is established and maintained by the Centers for Medicare and Medicaid Services (CMS) Level II codes are alpha-numeric and are composed of a single letter in the range A to V, followed by 4 digits. The G codes are used to identify professional health care procedures and services that would otherwise be coded in CPT but for which there are no CPT codes. G codes are used for quality reporting. Only Level II codes are referred to as HCPCS. HCPCS Level II is the section that coders usually identify with when referring to the HCPCS codes. CPT II codes HCPCS G codes 2016 Measures Page 11 of 199 Updated: 6/13/2016 Quality Codes

12 Quality Reporting Codes Determining which codes to use: When both a CPT and a HCPCS Level II code have virtually identical narratives for a procedure or service, use the CPT code. If, however, the narratives are not identical, use the HCPCS Level II code. For more on Code Sets: Some measures require more than one quality action and therefore, have more than one CPT Category II code (G-code) or a combination associated with them. The CPT Category II code, which supplies the numerator, must be reported on the same claim form as the payment ICD- 10 and CPT Category I codes, which supply the measure s denominator. Multiple CPT Category II codes can be reported on the same claim, as long as the corresponding denominator codes are also included as line items for that claim. Quality-data codes can relay information such as: The measure requirement was met; The measure requirement was not met due to documented allowable performance exclusions (i.e., using performance exclusion modifiers); and The measure requirement was not met and the reason is not documented in the medical record (i.e. using the 8P reporting modifier). Individual quality-data codes can be associated with more than one measure. In order to determine which quality-data codes and modifiers to report as a line item on a claim, you will need to understand the measures that you have selected to report. Based on CMS specifications, this guide will help you: Identify eligible cases based on ICD-10-CM and CPT Category I codes; Choose the correct quality-data codes to report; Know when to use exclusion modifiers (i.e., 1P, 2P, and 3P); and Know when to use a reporting modifier (i.e., 8P). Use of CPT II Modifiers CPT II modifiers are unique to CPT II codes and may be used to report measures by appending the appropriate modifier to a CPT II code as specified for a given measure. Use of the modifiers is unique to CPT II codes and may not be used with other types of CPT codes. Use of modifiers is guided by the measure s coding instructions. Reporting for some measures may require that you append a modifier to a CPT Category II code. CPT Category II modifiers serve to exclude patients from a given measure s denominator when the measure s specification permits their use, and may only be reported with CPT II codes. They cannot be used with G-codes. Coding instructions included in the Specifications document indicate when a modifier is required. There are two types of CPT II modifiers. CPT II Modifier Types 1. Exclusion modifiers 2. 8P reporting modifier 1. Exclusion Modifiers Exclusion modifiers may be appended to a CPT II code to indicate that an action specified in the measure was not provided due to medical, patient, or system reason(s) documented in the medical record. Some measures do not allow performance exclusions. Reasons for appending a performance measure exclusion modifier fall into one of three categories: 2016 Measures Page 12 of 199 Updated: 6/13/2016 Quality Codes

13 Quality Reporting Codes Three Categories of Performance Measure Exclusion Modifiers 1P - Medical Reasons: e.g., Contraindicated (patient allergic history, potential adverse drug interaction, other) 2P - Patient Reasons: Includes: Patient declined; other patient reasons 3P - System Reasons: Includes: Resources to perform the services not available; insurance coverage/payor-related limitations; other reasons attributable to health care delivery system 2. 8P Reporting Modifiers 8P - action not performed, reason not otherwise specified Use of the 8P reporting modifier indicates that the patient is eligible for the measure. However, there is no indication in the record that the action described in the measure was performed, nor was there any documented reason attributable to the exclusion modifiers. The 8P reporting modifier facilitates reporting an eligible case on a given measure when the quality action does not apply to a specific encounter. The eligible professionals can use the 8P modifier to receive credit for satisfactory reporting but will not receive credit for performance Measures Page 13 of 199 Updated: 6/13/2016 Quality Codes

14 CMS-1500 Claim PQRS Example Below is an example of an individual NPI reporting on a single CMS-1500 claim. See for more information and complete billing requirements. The patient was seen for an office visit (99213). The provider is reporting several measures related to Osteoporosis, ischemic vascular disease (IVD), hypertension and urinary incontinence: Measure #41 (Osteoporosis) with QDC 4005F + osteoporosis line-item diagnosis (24E points to DX M80.069A iitem 21); Measure #48 (Assessment - Urinary Incontinence) with QDC 1090F. For PQRS, there is no specific diagnosis associated with this measure. Point to the appropriate diagnosis for the encounter. Measure #204 (IVD) with QDC G IVD line-item diagnosis (24E points to Dx I20.0 in Item 21); and Measure #236 (Controlling Hypertension) with QDCs G G Hypertension line-item diagnosis (24E points to Dx I10 in Item 21). Note: All diagnoses listed in Item 21 will be used for PQRS analysis. Measures that require the reporting of two or more diagnoses on claim will be analyzed as submitted in Item 21. NPI placement: Item 24J must contain the NPI of the individual provider that rendered the service when a group is billing. If billing software limits the line items on a claim, you may add a nominal line-item charge of a penny to one of the QDC line items on that second claim. PQRS analysis will subsequently join both claims based on the same beneficiary, for the same date-of-service, for the same TIN/NPI and analyze as one claim Measures: Quality Codes Page 14 of 199 Updated: 6/13/2016

15 V. Measures Requiring CPT II Codes Measures Requiring CPT II CODES Click here to go to Table of Contents 2016 Measures: Quality Codes Page 15 of 199 Updated: 6/13/2016

16 Documentation of Current Medications in Medical Record Measure: MSSP Documentation of Current Medications in the Medical Record Domain: Care Coordination/Patient Safety ACO 39 CARE -3 PQRS 130 NQF 0419 Measure Steward: CMS ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP 2016 Measures Page 16 of 199 Updated: 6/13/2016 Documentation of Current Medications in the Medical Record

17 2016 MSSP ACO Measures Reporting Tracking Performance for Quality Improvement Documentation of Current Medications in the Medical Record This measure looks at the percentage of visits for patients aged 18 years and older for which the eligible professional attests* to documenting a list of current medications using all immediate resources available on the date of the encounter. *This measure requires supporting documentation within the context of the note in the medical record to include list of current medications including name, dose, frequency and route. A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from performance Measurement RATIONALE: Critical patient information, including medical and medication histories, current medications the patient is receiving and taking, and sources of medications, is essential to the delivery of safe medical care. However, interruptions in the continuity of care and information gaps in patient health records are common and significantly affect patient outcomes. Consequently, clinical judgments may be based on incomplete, inaccurate, poorly documented or unavailable information about the patient and his or her medication. (Reference AMA s Physician s Role in Medication Reconciliation (2007) retrieved at CLINICAL RECOMMENDATION STATEMENT: The Joint Commission s 2015 Ambulatory Care National Patient Safety Goals guide providers to maintain and communicate accurate patient medication information. -Joint Commission, 2015, retrieved at: ELIGILBLE POPULATION Measure Specifications Patients aged 18 years and older. + Patient encounter(s) during the measurement period (must be done at each visit) NUMERATOR Performance Met Eligible professional attests to documenting, updating or reviewing the patient s current medications using all immediate resources available on the date of the encounter. This list must include: ALL known prescriptions, over-the counters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain each medication s : Name Dosages Frequency and Route of administration DENOMINATOR Exclusion: None Exception: Medical Reason: Documentation must include patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient s health status. Procedure Codes & Code Descriptors Choose one of the following options: PERFORMANCE MET HCPCS Code G8427: Current Medications Documented and contains required elements or documentation that patient is not currently taking any medications. OR Exclusion/Exception from Performance Measurement HCPCS Code G8430: Current Medications NOT Documented, Patient NOT eligible due to medical reasons. OR PERFORMANCE NOT MET HCPCS Code G8428: Current Medications with Name, Dosage, Frequency, or Route NOT Documented, Reason NOT Given Definitions: Current Medications Medications the patient is presently taking including all prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication s name, dosage, frequency and administered route. Route Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical) MSSP 2016 Measures Page 17 of 199 Updated: 6/13/2016 Documentation of Current Medications in the Medical Record

18 CARE 3: Documentation of Current Medications in the Medical Record 2016 Description: Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration. Denominator Exclusions: None Denominator Exceptions: Medical reasons - patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient s health status What is the Quality Action? Documenting, updating or reviewing the patient s current medications using all immediate resources available on the date of the encounter. Current medications is defined as medications the patient is presently taking including all prescriptions, over-the-counter (OTC) medications, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication s name, dosage, frequency and route of administration Where may the Quality Action take place? Must take place in a healthcare setting. Who may perform the Quality Action? Eligible professionals reporting this measure may document measure information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources. When must the Quality Action be performed? This measure is applicable to every encounter during the measurement period. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain for each pre-filled office visit: A list of all prescriptions, over-the-counter (OTC) products, herbals, vitamins, minerals, dietary (nutritional) supplements AND must contain the medication s name, dosage, frequency and route of administration OR if the patient is not currently taking any medications. Documentation of the reason why the Quality Action is not performed due to an exclusion (see Data Guidance for specific medical reason exclusion). MSSP 2016 Measures Page 18 of 199 Updated: 6/13/2016 Documentation of Current Medications in the Medical Record

19 2016 MSSP Reporting Data Collection Form Documentation of Current Medications in the Medical Record Target Population Age: All patients aged 18 years and older. Patient Name: (First) (M.I.) (Last) DOB: Gender: M F mm / dd / yyyy Medical Record Number: Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient 18 years and older? Yes No Meets age criteria. Continue to Q2 Does Not Meet Age Criteria. Stop. Date of Service : mm / dd / yyyy Q2: Was this patient seen for a visit in the measurement year? (Note: All visits count. Report separately for each encounter) Yes If Yes, Continue to Q3 No If No, Continue to Step3 Q3: Did the patient have a medical reason (urgent or emergent medical situation where time is of essence and to delay treatment would jeopardize the patient s health status) for not having documentation of current medications? Yes No If yes to Question 3 patient is not eligible and is a If no, continue to Step 2 Performance Exclusion, go to step 3 and check mark Performance Exclusion Step 2 Did you meet the measure? Q3: Does the provider attest to documenting, updating or reviewing a patient s CURRENT MEDICATIONS* using all immediate resources available on the date of encounter? or Did the provider document the patient was not taking any medications? Yes If yes, continue to Step 3, Performance Met If yes, save the documentation in the medical record* No Go to Step 3 Performance Not Met Step 3 Reporting Options. Check One: Current Medications* Documented. Performance Met HCPCS G Code G8427 Current Medications not Documented. Patient not Eligible HCPCS G Code G8430 Performance Exclusion Current Medications with Name, Dosage, Frequency, or Route not HCPCS G Code G8428 Documented, Reason not Given. Performance Not Met * Current Medications Medications the patient is presently taking including all prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication s name, dosage, frequency and administered route. For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 19 of 199 Updated: 6/13/2016 Documentation of Current Medications in the Medical Record

20 Falls: Screening for Future Fall Risk Measure: MSSP Falls : Screening for Future Fall Risk Domain: Care Coordination/Patient Safety ACO 13 CARE 2 NQF 0101 PQRS ~154 Measure Steward: CMS ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP 2016 Measures Page 20 of 199 Updated: 6/13/2016 Falls: Screening for Future Falls Risk

21 2016 MSSP ACO Measures Reporting Tracking Performance for Quality Improvement Screening for Future Fall Risk This measure looks at the percentage of patients aged 65 years and older who were screened for future fall risk at least once during the measurement period. A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: Falls are one of the most common and significant health issues facing people aged 65 years or older. Patients may not volunteer information regarding falls. Data elements required for the measure can be captured and the measure is actionable by the physician. CLINICAL RECOMMENDATAION STATEMENT: Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a health care professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualized, multifactorial intervention. AGA Clinical practice guidelines: mary_of_recommendations ELIGIBLE POPULATION Target Population Patients aged 65 years and older + Patient encounter during the measurement period NUMERATOR Patients who were screened for future falls risk at least once within the 12 month measurement period. DENOMINATOR Exclusion: None Exception: Medical reasons for not screening for future falls risk - e.g. patient is not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound, dependent on helper pushing wheelchair, independent in wheelchair or minimal help in wheelchair) Procedure Codes & Code Descriptors Two codes are required for reporting this measure Performance Met CPT II code 3288F: Fall risk assessment documented AND CPT II code 1100F: Patient screened for future fall risk; documentation of two or more falls in the past year OR any fall with injury in the past year OR Performance Met CPTII code 3288 F: Fall risk assessment documented AND CPT II code 1101F: Patient screened for future fall risk; documentation of no falls in the past year OR only one fall without injury in the past year. Patient is not a fall risk OR Exclusion/Exception from Performance Measurement CPT II code: 3288F- 1P : Medical reason for not completing assessment AND CPT II code 1100F: Patient NOT eligible due to medical reasons OR Performance Not Met CPT II code 3288F-1P: Screening is not performed and the reason is not otherwise specified. DEFINITIONS: Future fall risk: Patients are considered at risk for future falls if they have had 2 or more falls in the past year or any fall with injury in the past year. Fall A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force. MSSP 2016 Measures Page 21 of 199 Updated: 6/13/2016 Falls: Screening for Future Falls Risk

22 Eligible Cases for: Screening for Future Falls Risk Patients aged 65 years + Encounter dates in the measurement period Exceptions: Medical Reasons AND Patient encounter during the reporting period following CPT or HCPCS codes are reported: CPT where one or more of the 92540, 92541, 92542, 92548, 97001, 97002, 97003, 97004, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, or HCPCS G0402, G0438, G0439 STRATEGIES TO IMPROVE AND ENHANCE YOUR PERFORMANCE CMS specifications state that the falls screening should be performed by a clinician with appropriate skills and experience. This would include physicians and other healthcare professionals such as physical therapist. The measure is looking to see if there is documentation in the medical record that a screening for future fall risk was done AND whether the patient was assessed for a history of falls or any falls with injury. Specifically ask for falls in the past year to elicit the information. Specify time. Screening for future fall risk will count if it includes documentation of: no falls in the past year or only one fall without injury in the past year or documentation of two or more falls in the past year or any fall with injury in the past year. If you use Falls Assessment Tools like Morse Fall Scale, please note that the tool asks for history of falling in past 3 months only and will not meet the measure unless it specifically states no falls in the past year, only one fall with no injury in the past year, or documentation of 2 or more falls within the past year or any fall with injury in the past year. MSSP 2016 Measures Page 22 of 199 Updated: 6/13/2016 Falls: Screening for Future Falls Risk

23 CARE 2: Screening for Future Fall Risk 2016 Description: Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period. Denominator Exclusions: None Denominator Exceptions: Medical reasons What is the Quality Action? Completion of a fall risk screening. The screening may be done with a formal screening tool as long as it fulfills the fall history documentation requirements (see below). Where may the Quality Action take place? Must take place in a healthcare setting. Who may perform the Quality Action? Any healthcare professional may perform a fall risk screening. When must the Quality Action be performed? The screening may take place at any time within the measurement period. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: Documentation of any of the following regarding the patient s past history of falls: No falls; or One fall without major injury; or Two or more falls; or Any fall with major injury. Documentation of the reason why the Quality Action is not performed due to an exception (see Data Guidance for specific medical reason exceptions). MSSP 2016 Measures Page 23 of 199 Updated: 6/13/2016 Falls: Screening for Future Falls Risk

24 2016MSSP Reporting Data Collection Form Screening For Future Fall Risk Target Population Age: All patients aged 65 years and older. Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient 65 years or older? Yes Meets age criteria. Continue to Q2 No Does Not Meet Age Criteria. Stop. Q2: Does the patient have any Medical reason for not screening for future falls risk - e.g., pt. not ambulatory? Yes No If Yes, Document Reason in Patient Chart to Continue to Q 3 Exclude from Measure. Stop Continue to Q3 and select third choice below Step 2 Did you meet the measure? Reporting Options Q3: Determine if the patient was screened for future fall risk at least once during the measurement period (2016)? Screening for future fall risk must include: Documentation of no falls in the past year or only one fall without injury in the past year or documentation of two or more falls in the past year or any fall with injury in the past year Patient Screened for Future Falls Risk: Documentation of two or more falls in the past year OR any fall with injury in the past year Patient At Risk for Falls Patient Screened for Future Falls Risk: Patient screened for future fall risk; documentation of no falls in the past year OR only one fall without injury in the past year Patient Not at Risk for Falls Screening for future fall risk NOT performed: Medical Reasons Documented (e.g. patient is not ambulatory) Screening for future fall risk NOT performed: Reason not specified CPT II code 1100F CPT II code 1101F CPT II code 1101F - 1P CPT II code 1101F - 8P For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 24 of 199 Updated: 6/13/2016 Falls: Screening for Future Falls Risk

25 Influenza Immunization Measure: MSSP Influenza Immunization Domain: Preventive Care and Screening ACO 14 PREV- 7 PQRS -110 NQF 0041 ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP 2016 Measures Page 25 of 199 Updated: 6/13/2016 Influenza Immunization

26 2016 MSSP ACO Measures Reporting Tracking Performance for Quality Improvement Influenza Immunization This measure looks at the percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization. For 2016 reporting, the flu season would be from October March Vaccines given between August 1, 2015 March 2016 will count towards 2016 reporting period and should be coded. If patient reports they previously received a flu shot, count any influenza vaccine given since August 1, 2015 when practice reports for 2016 measurement year. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement A higher score indicates better quality. RATIONALE: Annual influenza vaccination is the most effective method for preventing influenza virus infection and its complications. CLINICAL RECOMMENDATIONS STATEMENT: Routine annual influenza vaccination is recommended for all persons aged 6 months and older who do not have contraindications to vaccination. To permit time for production of protective antibody levels, vaccination should optimally occur before onset of influenza activity in the community, and providers should offer vaccination as soon as vaccine is available. Vaccination also should continue to be offered throughout the influenza season. (CDC/ACIP, 2014) Measure Specifications ELIGIBLE POPULATION All patients aged 6 months and older + Seen for a visit between October 1 and March 31 (Influenza season) NUMERATOR: Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization * Documentation in the medical record should confirm that Influenza vaccination was received during the timeframe specified in the measurement specifications. If exact date is not known, documenting the month and year the vaccination was administered will also meet the measure if it was given in the specified period. DENOMINATOR Exclusion: None Exception: 1. Medical reasons for not receiving an influenza immunization during the flu season (e.g., patient allergy, other medical reasons) 2. Patient reasons for not receiving an influenza immunization during the flu season (e.g., patient declined, other patient reasons) 3. System reasons for not receiving an influenza immunization during the flu season (e.g., vaccine not available, other system reasons) must be documented DEFINITIONS: Procedure Codes & Code Descriptors Choose one of the following options Performance Met HCPCS Code G8482: Influenza immunization administered OR previously received OR Exclusion/Exception from Performance Measurement HCPCS Code G8483: Influenza immunization was not ordered or administered for reasons documented by clinician OR Performance Not Met HCPCS Code G8484: Influenza immunization was not ordered or administered, reason not given PREVIOUS RECEIPT is defined as receipt of the current season s influenza immunization from another provider OR from same provider prior to the visit to which the measure is applied. Typically, prior vaccination would include influenza vaccine given since August 1 st. MSSP 2016 Measures Page 26 of 199 Updated: 6/13/2016 Influenza Immunization

27 Eligible Cases for Influenza Immunization measure All patients 6 months and older + Seen for a visit between October 1, 2015 and March 31, 2016 Exclusions: Documentation of Medical/Patient/System Exclusions listed above AND Patient encounter during the reporting period where one or more of the following CPT or HCPCS codes are reported: CPT 90945, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, or HCPCS G0438, G0439 MSSP 2016 Measures Page 27 of 199 Updated: 6/13/2016 Influenza Immunization

28 PREV 7: Influenza Immunization 2016 Description: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization. Denominator Exclusions: None Denominator Exceptions: Medical reasons, patient reasons, or system reasons What is the Quality Action? Receipt of an influenza immunization between August 1, 2015 and March 31, (The flu shots given between August March 2016 will count towards 2016 reporting period and should be coded as well) Where may the Quality Action take place? May take place in any setting. Who may perform the Quality Action? Any healthcare professional may provide the influenza immunization. Patient reported data is also acceptable. When must the Quality Action be performed? The influenza immunization must be given between August 1, 2015 and March 31, What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: Indication the patient received an influenza immunization between August 1, 2015 and March 31, 2016; or Documentation of the reason why the Quality Action is not performed due to an exception (see Data Guidance for specific medical, patient or system reason exceptions). MSSP 2016 Measures Page 28 of 199 Updated: 6/13/2016 Influenza Immunization

29 2016 MSSP Reporting Data Collection Form Influenza Immunization Target Population Age: Patients aged 6 MONTHS and older. Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient 6 months or older? Yes Continue to Q2 Q2: Was the patient seen for a visit between October 1 and March 31 (Influenza season) Yes Continue to Q3 No Stop No Stop Step 2 Did you meet the measure? Q3: Determine if the patient was seen for a visit between October 1 and March 31 AND received an influenza immunization OR reported previous receipt of an influenza immunization. Yes This meets the measure, do not answer Q4. Go to Step 3 No If Influenza vaccine was not given, go to Q4 Q4: Determine the reason why the patient did not receive the vaccine. Medical Reasons: Select this option if the patient did not receive an influenza immunization for medical reasons (e.g., patient allergy, other medical reasons) Patient Reasons: Select this option if the patient did not receive an influenza immunization for patient reasons (e.g., patient declined, other patient reasons) System Reasons: Select this option if the patient did not receive an influenza immunization for system reasons (e.g., vaccine not available, other system reasons) No Reason Documented Step 3 Reporting Options. Check One: Influenza immunization Administered OR previously received HCPCS Code G8482 Influenza Immunization not Administered for reasons documented by clinician (e.g., patient allergy/other medical reason, patient declined/other patient reasons, or other system reasons) HCPCS Code G8483 Influenza Immunization not Ordered or Administered, Reason not Given HCPCS Code G8484 For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 29 of 199 Updated: 6/13/2016 Influenza Immunization

30 Pneumonia Vaccination Status for Older Adults Measure: MSSP Pneumonia Vaccination Status for Patients 65 Yrs & Older Domain: Preventive Care and Screening ACO 15 PREV- 8 PQRS NQF 0043 Measure Steward: NCQA ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP 2016 Measures Page 30 of 199 Updated: 6/13/2016 Pneumonia Vaccination

31 2016 MSSP ACO Measures Reporting Tracking Performance for Quality Improvement Pneumonia Vaccination Status for Older Adults This measure looks at the percentage of patients 65 years of age and older who have EVER received a pneumococcal vaccine. A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: Pneumonia is a common cause of illness and death in the elderly and persons with certain underlying conditions. The disease burden is large for older adults and the potential for prevention is high. Pneumococcal infections result in significant health care expenditures each year, and vaccination is safe and effective. CLINICAL RECOMMENDATION STATEMENTS: It is recommended that patients 65 years of age or older receive one pneumococcal vaccination in their lifetime. The Advisory Committee on Immunization Practices (ACIP) Updated Recommendations for Prevention of Invasive Pneumococcal Disease Among Adults Using the 23-Valent Pneumococcal Polysaccharide Vaccine recommends pneumococcal vaccine for all immunocompetent individuals who are 65 and older or otherwise at increased risk for pneumococcal disease. Routine revaccination is not recommended, but a second dose is appropriate for those who received PPV23 before age 65 years for any indication if at least 5 years have passed since their previous dose (USPSTF, 1989; ACIP, 2010). ELIGILBLE POPULATION Measure Specifications Patients 65 years of age and older + Patient encounter during the measurement period NUMERATOR: Patients who have ever received a pneumococcal vaccination Either 13 valent pneumococcal conjugate vaccine (PCV13) or 23 - valent pneumococcal polysaccharide vaccine (PPSV23) or both If exact date is not known, documenting month and year the vaccination was administered will also meet the measure if it was given in the specified period. Denominator Exclusions: None Exceptions: None Procedure Codes & Code Descriptors Performance Met CPT II code 4040F: Pneumococcal vaccine administered or previously received Exclusion/Exception from Performance Measurement Exclusions: None Exceptions: None OR Performance Not Met CPT II code 4040F- 8P :Pneumococcal Vaccination not Administered or Previously Received - Reason Not Documented Eligible Cases for: Pneumonia Vaccination for Patients 65 Years and Older Patients aged 65 years + Encounter occurring during the measurement period Exclusions/Exceptions None/None AND Patient encounter during the reporting period where one or more of the following CPT or HCPCS codes are reported: CPT 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215,, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, Or HCPCS G0402, G0438, G0439 MSSP 2016 Measures Page 31 of 199 Updated: 6/13/2016 Pneumonia Vaccination

32 PREV 8: Pneumonia Vaccination Status for Older Adults 2016 Description: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine. Denominator Exclusions: None Denominator Exceptions: None What is the Quality Action? Receipt of a pneumonia vaccination. Where may the Quality Action take place? May take place in any setting. Who may perform the Quality Action? Any healthcare professional may provide a pneumonia vaccination. Patient reported data is also acceptable. Medical record documentation of past (prior to 2015) patient reported receipt of a pneumonia vaccination which does not include the date and type of vaccine, would be considered acceptable. If a patient is reporting vaccination in 2015, the patient would need to provide the year of the vaccination and confirm the type of vaccine as PPSV23 or PCV 13. When must the Quality Action be performed? The pneumonia vaccination may occur at any time in the patient s history, but must be prior to the end of the measurement period. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: - Documentation of receipt of a pneumonia vaccination. - The medical record should state the year (up through the last day of the measurement period) and type of pneumonia vaccination provided If patient reported prior to 2015, documentation indicating receipt of a pneumonia vaccination is sufficient If patient reported in 2015, documentation indicating the year of the vaccination and confirmation of the type as PPSV23 or Prevnar 13 is required. MSSP 2016 Measures Page 32 of 199 Updated: 6/13/2016 Pneumonia Vaccination

33 2016 MSSP Reporting Data Collection Form Pneumonia Vaccination for Patients 65 Years and Older Target Population Age: Patients aged 65 years and older. Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient 65 years or older? Yes Continue to Q2 No Stop Q2: Was the patient seen for a visit in the measurement year? Yes Continue to Q3 No Stop Step 2 Did you meet the measure? Q3: Determine if the patient has ever received a Pneumococcal Vaccine. (If patient reported prior to 2015, documentation indicating receipt of a pneumonia vaccination is sufficient. If patient reported in 2015, documentation indicating the year of the vaccination and confirmation of the type as PCV13 or PPSV23 is required.) Yes No Step 3 Reporting Options. Check One: Pneumococcal Vaccination Administered or Previously Received CPT II Code 4040F Pneumococcal Vaccination not Administered or Previously Received - Reason Not Documented CPT II Code 4040F - 8P For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 33 of 199 Updated: 6/13/2016 Pneumonia Vaccination

34 Body Mass Index (BMI) Screening and Follow-Up Measure: MSSP United Medicare Body Mass Index (BMI) Screening & Follow-Up Plan Domain: Preventive Care and Screening ACO 16 PREV- 9 PQRS NQF 0421 Measure Steward: CMS ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP 2016 Measures Page 34 of 199 Updated: 6/13/2016 BMI Screening & Follow-Up Plan

35 2016 MSSP ACO Measures Reporting Tracking Performance for Quality Improvement Body Mass Index (BMI) Screening & Follow-Up Plan This measure looks at the percentage of patients 18 years and older with a BMI documented during the current encounter or during the previous six months of the current encounter. AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. United Medicare: Screening measure only A higher score indicates better quality. Normal Parameters: Age 65 years and older BMI 23 and < 30 kg/m 2 Age years BMI 18.5 and <25 kg/m 2 Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement CLINICAL RECOMMENDATION STATEMENTS: The US Preventive Health Services Task Force (USPSTF) recommends screening all adults (aged 18 years and older) for obesity. Clinicians should offer or refer patients with a BMI of 30 or higher to intensive, multicomponent behavioral interventions. This is a B recommendation (Moyer, 2012). Similarly, the 2013 joint report/guideline from the American Heart Association, American College of Cardiology and The Obesity Society also recommend measuring height and weight and calculating BMI at annual visits or more frequently, using the current cutpoints for overweight (BMI> kg/m 2 ) and obesity (BMI 30 kg/m 2 ) to identify adults who may be at elevated risk of CVD and the current cutpoints for obesity to identify adults who may be at elevated risk of mortality from all causes. They also recommend counseling overweight and obese individuals on their increased risk for CVD, type 2 diabetes, all-cause mortality and need for lifestyle changes. ELIGILBLE POPULATION Measure Specifications All patients aged 18 years and older + Patient encounter during the measurement period. NUMERATOR Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. Numerator Instructions: Height and Weight - An eligible professional or their staff is required to measure both height and weight. Both height and weight must be measured within six months of the current encounter and may be obtained from separate encounters. Self-reported values cannot be used. Follow-Up Plan If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous six months of the current encounter. The documented follow-up plan must be based on the most recent documented BMI, outside of normal parameters, example: Patient referred to nutrition counseling for BMI above normal parameters. DENOMINATOR Exclusions: None Exceptions: 1. Patient is receiving palliative care 2. Patient is pregnant 3. Patient refuses BMI measurement (refuses height and/or weight) 4. Any other reason documented in the medical record by the provider why BMI measurement was not appropriate. 5. Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient s health status Procedure Codes & Code Descriptors Performance Met HCPCS Code G8420: BMI is documented as Normal and No Follow-Up plan is required HCPCS Code G8417: BMI is documented as Above Normal Parameters AND a Follow-Up plan is documented HCPCS Code G8418: BMI is documented as Below Normal Parameters AND a Follow-Up plan is documented OR Exclusion/Exception from Performance Measurement HCPCS Code G8938: BMI is documented as being outside of normal limits, Follow-Up plan is not documented but there is documentation in medical record that the patient is not eligible (exclusion) for Follow- Up plan HCPCS Code G8422: BMI not documented but there is documentation in medical record that the patient is not eligible (exclusion) for BMI calculation (e.g., patient is pregnant) Performance Not Met HCPCS Code G8419: BMI documented outside normal parameters, No Follow-Up plan documented, NO REASON IS GIVEN HCPCS Code G8421: BMI not documented and NO REASON IS GIVEN MSSP 2016 Measures Page 35 of 199 Updated: 6/13/2016 BMI Screening & Follow-Up Plan

36 Definitions: BMI Body mass index (BMI) is a number calculated using the Quetelet index: weight divided by height squared (W/H2) and is commonly used to classify weight categories. BMI can be calculated using: Metric Units: BMI = Weight (kg) / (Height (m) x Height (m)) OR English Units: BMI = Weight (lbs) / (Height (in) x Height (in)) x 703 Follow-Up Plan Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. A follow-up plan may include, but is not limited to: documentation of education, referral (e.g., a registered dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional or surgeon), pharmacological interventions, dietary supplements, exercise counseling or nutrition counseling. Eligible Cases for: Body Mass Index (BMI) Screening and Follow-Up Patients aged 18 years + Seen for a visit in the measurement year Exclusions: Documentation of Medical/Patient Exclusions listed above AND Patient encounter during the reporting period (CPT or HCPCS) CPT 90791, 90792, 90832, 90834, 90837, 90839, 96150, 96151, 96152, 97001, 97003, 97802, 97803, 98960, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, or HCPCS HCPCS D Code: D7140, D7210 HCPCS G Code: G0101, G0108, G0270, G0271, G0402, G0438, G0439, G0447 MSSP 2016 Measures Page 36 of 199 Updated: 6/13/2016 BMI Screening & Follow-Up Plan

37 PREV 9: BMI Assessment and Follow-up 2016 Description: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. Denominator Exclusions: Patient is receiving palliative care or the patient is pregnant. Denominator Exceptions: Patient refuses BMI measurement (refuses height and/or weight), any other reason documented in the medical record by the provider why BMI measurement was not appropriate, patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient s health status. What is the Quality Action? Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. Normal Parameters are as follows: Aged years: BMI > 18.5 and < 25 Aged 65 years or older: BMI > 23 and < 30 Examples of a follow-up plan may include but are not limited to: Providing an educational document (e.g., exercise, nutrition, healthy living) Referring the patient to another healthcare professional, i.e., dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, surgeon, etc. Prescribing weight loss medication or dietary supplements Providing exercise or nutrition counseling Where may the Quality Action take place? Must take place in a healthcare setting. Who may perform the Quality Action? Any healthcare professional may perform a BMI screening and recommend an appropriate follow-up plan. Patient reported values of height, weight, or BMI are not acceptable. When must the Quality Action be performed? The BMI screening may take place during the most recent visit within the measurement period or within the 6 months prior to that visit. If a follow-up plan is needed, the documentation of a follow-up plan must be based on the most recent BMI within the previous six months. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: BMI screening date and results; If a follow-up plan is required, documentation of discussion of the plan. The follow-up plan must be specified as an intervention that pertains to the BMI outside of normal parameters; or Documentation of the reason why the Quality Action is not performed due to an exception (see Data Guidance for specific medical or patient reason exceptions) or documentation of exclusion criteria. MSSP 2016 Measures Page 37 of 199 Updated: 6/13/2016 BMI Screening & Follow-Up Plan

38 2016 MSSP Reporting Data Collection Form Body Mass Index (BMI) Screening and Follow-Up Target Population Age: Patients aged 18 years and older Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient 18 years of age or older? Yes Continue to Q2 No Stop Q2: Was the patient was seen for a visit in the measurement year? Yes Continue to Q3 No Stop Q3: Are there any exclusions for not performing the BMI? (Applicable Exclusions include: pregnancy, medical reasons, patient reasons see details above) No Continue to Q4 Yes Stop Step 2 Did you meet the measure? Q4: Determine if the patient had a BMI calculated during the most recent visit or within the past 6 months of most recent visit. Yes Continue to Q6 No If no BMI calculated during the most recent visit or within the past 6 months of most recent visit, go to Q5 Q5: Determine if there is documented medical or patient reason(s) for not performing the BMI (a) Medical Reasons: Select this option if the patient has not had a BMI calculated for medical reasons and the reason is documented. (b) Patient Reasons: Select this option if the patient has not had a BMI calculated for patient (c) No Reason Documented If (a) or (b) or (c) are checked, Stop. MSSP 2016 Measures Page 38 of 199 Updated: 6/13/2016 BMI Screening & Follow-Up Plan

39 Q6: Is the patient s BMI within normal parameters? Normal Parameters for BMI: Age 65 years and older BMI 23 and < 30 Age years BMI 18.5 and < 25 Yes BMI Within Normal Parameters: Stop. No BMI Outside of Normal Parameters: Continue to Q7 on Follow-Up Plan. Q7: If BMI is outside of parameters, is there a follow-up plan documented during the encounter or during the previous six months of the encounter? The documentation of a follow-up plan must be based on the most recent documented BMI within the previous six months Yes No Step 2 Reporting Options Check One: BMI is documented as Normal and No Follow-Up plan is required HCPCS Code G8420 BMI is documented as Above Normal Parameters AND a Follow-Up plan is documented HCPCS Code G8417 BMI is documented as Below Normal Parameters AND a Follow-Up plan is documented HCPCS Code G8418 BMI is documented as being outside of normal limits, Follow-Up plan is not documented, but there is documentation in medical record that the patient is not eligible for Follow-Up plan BMI not documented. There is documentation in medical record that the patient is not eligible for BMI calculation BMI documented outside normal parameters, Follow-Up plan NOT documented, NO REASON IS GIVEN HCPCS Code G8938 HCPCS Code G8422 HCPCS Code G8419 BMI NOT documented and NO REASON IS GIVEN HCPCS Code G8421 For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 39 of 199 Updated: 6/13/2016 BMI Screening & Follow-Up Plan

40 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Measure: BCBS Commercial United Commercial Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis HEDIS Measure NQF 0058 PQRS 116 CPT II coding required: YES Click here to go to Table of Contents BCBS, United Measure: Page 40 of 199 Updated: 6/13/2016 Avoidance of Antibiotics Treatment in Adults with Acute Bronchitis

41 2016 BCBS ACO Measures Reporting Tracking Performance for Quality Improvement Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis These measures looks at the percentage of adults years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription on or three days after the Index Episode Start Date. 18 years to 64 years of age who: Were given a diagnosis of acute bronchitis No comorbid condition during the twelve month period prior to the encounter No prescription for an antibiotic medication filled 30 days prior to the encounter Had no evidence of competing diagnosis during the period from 30 days prior to the encounter to 7 days after the encounter, and AND were treated appropriately (i.e., were not dispensed an antibiotic prescription on or 3 days after the episode) A higher score indicates better quality (appropriate treatment of adults with acute bronchitis (i.e., proportion for whom antibiotics were not prescribed). Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: Antibiotics are most often inappropriately prescribed for adults with acute bronchitis. Antibiotics are not indicated in clinical guidelines for treating adults with acute bronchitis who do not have a comorbidity or other infection for which antibiotics may be appropriate. Inappropriate antibiotic treatment of adults with acute bronchitis is of clinical concern, especially since misuse and overuse of antibiotics lead to antibiotic drug resistance. RESOURCE: The intent of this measure to avoid the inappropriate treatment of adults with acute bronchitis who do not have a comorbidity or other infection for which antibiotics may be appropriate. HEDIS Specification ELIGILBLE POPULATION Adults 18 years - 64 years of age + An outpatient visit or observation visit or ED visit for Acute Bronchitis during the Intake Period (January 1 Dec 24 of the measurement year) NUMERATOR The member was not dispensed a prescription for antibiotic medication on or three days after the Index Episode Start Date. Denominator Exclusions: 1. Claims/encounters with more than one diagnosis code. 2. ED visits that result in an inpatient admission. 3. Episode Dates where a new or refill prescription for an antibiotic medication was filled 30 days prior to the Episode Date or was active on the Episode Date 4. Comorbid condition during the twelve month period prior to the encounter 5. Episode Dates where the member had a claim/encounter with any diagnosis for a comorbid condition during the 12 months prior to or on the Episode Date. Procedure Codes & Code Descriptors Performance Met HCPCS Code G8708: Patient NOT prescribed nor dispensed antibiotic Or Exclusion/Exception from Performance Measurement HCPCS Code G8709: Patient meets exclusion as listed under exclusions Or Performance not Met HCPCS Code G8710: Antibiotic prescribed or dispensed BCBS, United Measure: Page 41 of 199 Updated: 6/13/2016 Avoidance of Antibiotics Treatment in Adults with Acute Bronchitis

42 Step 1 Identify all members in the specified age range who had an outpatient visit (Outpatient Value Set), an observation visit (Observation Value Set) or an ED visit (ED Value Set) during the Intake Period, with a diagnosis of acute bronchitis (Acute Bronchitis Value Set). Do not include ED visits that result in an inpatient admission. Table 1: Codes to Identify Visit Type Description CPT UB Revenue HCPCS Outpatient , , , , , , , , 99411, 99412, 99420, 99429, , , , 0982, 0983 G0402, G0438, G0439, G0463, T1015 Observation ED* , 0456, 0459, 0981 Source: HEDIS 2016 Specification Manual *Do not include ED visits that result in an inpatient admission. Table 2: Codes to Identify Acute Bronchitis Description ICD-10-CM Diagnosis Acute Bronchitis J20.3 J20.9 Source: HEDIS 2016 Specification Manual Step 2: Determine all Acute Bronchitis Episode Dates. For each member identified in step 1, determine all outpatient or ED claims/ encounters with only an Acute Bronchitis diagnosis. Exclude claims/encounters with more than one diagnosis. Step 3: Test for a 12-month Negative Diagnosis History for Comorbid Conditions (requiring treatment with antibiotics) history prior to and including the Episode Date. Table 3: Codes to identify comorbid conditions: Please refer to HEDIS 2016 Specifications, value set name comorbid conditions for the complete list of codes. Description ICD-10-CM Diagnosis HIV Value Set Malignant Neoplasm Value Set Emphysema Value Set COPD Value Set Refer to HEDIS 2016 Spec Refer to HEDIS 2016 Spec Refer to HEDIS 2016 Spec Refer to HEDIS 2016 Spec Cystic Fibrosis Value Set Refer to HEDIS 2016 Spec Comorbid Conditions Value Set Refer to HEDIS 2016 Spec Source: HEDIS 2016 Specification Manual BCBS, United Measure: Page 42 of 199 Updated: 6/13/2016 Avoidance of Antibiotics Treatment in Adults with Acute Bronchitis

43 Step 4: Test for Negative Medication History. To determine eligibility, look for any of the listed antibiotic drugs below in the 30 days prior to the visit with an Acute Bronchitis diagnosis. As long as there are no prescriptions for the listed antibiotics during this time period, the patient is eligible for denominator inclusion. Exclude Episode Dates where a new or refill prescription for an antibiotic medication (Table 4) was filled in 30 days prior to the Episode Date or was active on the Episode Date. Table 4: Antibiotic Medications Description Aminoglycosides Amikacin Gentamicin Kanamycin Streptomycin Aminopenicillins Amoxicillin Ampicillin Antipseudomonal penicillins Beta-lactamase inhibitors Piperacillin Amoxicillin-clavulanate Ampicillin-sulbactam Piperacillintazobactam Prescription Tobramycin Ticarcillin-clavulanate First-generation cephalosporins Cefadroxil Cefazolin Cephalexin Fourth-generation cephalosporins Ketolides Cefepime Telithromycin Lincomycin derivatives Clindamycin Lincomycin Macrolides Miscellaneous antibiotics Natural penicillins Azithromycin Clarithromycin Aztreonam Chloramphenicol Dalfopristinquinupristin Penicillin G benzathine-procaine Penicillin G potassium Erythromycin Erythromycin ethylsuccinate Daptomycin Erythromycin-sulfisoxazole Linezolid Penicillin G procaine Penicillin G sodium Penicillinase resistant penicillins Dicloxacillin Nafcillin Oxacillin Quinolones Rifamycin derivatives Second generation cephalosporin Ciprofloxacin Gemifloxacin Rifampin Cefaclor Cefotetan Levofloxacin Moxifloxacin Cefoxitin Cefprozil Erythromycin lactobionate Erythromycin stearate Metronidazole Vancomycin Penicillin V potassium Penicillin G benzathine Norfloxacin Ofloxacin Cefuroxime Sulfonamides Sulfadiazine Sulfamethoxazole-trimethoprim Tetracyclines Doxycycline Minocycline Tetracycline Third generation cephalosporins Urinary anti-infectives Source: HEDIS 2016 Specification Manual Cefdinir Cefditoren Cefixime Fosfomycin Nitrofurantoin Nitrofurantoin macrocrystals Cefotaxime Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Nitrofurantoin macrocrystals-monohydrate Trimethoprim Step 5: Test for Negative Competing Diagnosis. Exclude Episode Dates where the member had a claim/encounter with a competing diagnosis 30 days prior to or 7 days after the Episode Date (inclusive). A code from either of the following meets criteria for a competing diagnosis: Pharyngitis Competing Diagnosis Value Set. BCBS, United Measure: Page 43 of 199 Updated: 6/13/2016 Avoidance of Antibiotics Treatment in Adults with Acute Bronchitis

44 2016 BCBS ACO Reporting Data Collection Form Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Target Population Age: Patients aged years. Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient between years of age? Yes Continue to Q2 No Stop Q2: Was the patient seen for the outpatient or ED visit during the measurement year AND diagnosed with only Acute Bronchitis? Yes No Continue to Q3 Stop Q3: Was the patient dispensed a prescription for an antibiotic on or within 3 days after the Acute Bronchitis Episode date? Yes No Continue to Q4 Stop Q4: Does the patient have a history for co-morbid conditions in the 12 months prior to and including the Episode date? No Yes Continue to Q5 Stop Q5: Does the patient have a history of prescription for an antibiotic filled during the time period from thirty days prior through one day prior to the pharyngitis episode start date. No Yes Continue to Q6 Stop Q6: Does the patient have a competing diagnosis history of prescription for an antibiotic filled during the time period from thirty days prior through seven days after the episode start date (inclusive). No Yes Continue to next step Stop. Excluded from denominator Step 2 Did you meet the measure? Q7: Determine the reason why the patient was prescribed or dispensed an antibiotic. Patient had a documented Medical Reasons for being prescribed or dispensed an antibiotic No Reason Documented Step 3 Reporting Options. Check One: Patient NOT prescribed nor dispensed antibiotic HCPCS Code G8708 Acute Bronchitis patients with documented medical reasons for HCPCS Code G8709 prescribing or dispensing an antibiotic Antibiotic prescribed or dispensed HCPCS Code G8710 For Practice Use: Form Completed by: Date: BCBS, United Measure: Page 44 of 199 Updated: 6/13/2016 Avoidance of Antibiotics Treatment in Adults with Acute Bronchitis

45 Appropriate Treatment for Children with URI Measure: BCBS Commercial Appropriate Treatment for Children with Upper Respiratory Infection HEDIS Measure CPT II coding required: YES Click here to go to Table of Contents BCBS Measure: Page 45 of 199 Updated: 6/13/2016 Appropriate Treatment for Children with URI

46 2016 BCBS ACO Measures Reporting Tracking Performance for Quality Improvement Appropriate Treatment for Children with Upper Respiratory Infection The measure looks at the percentage of children 3 months to 18 years of age who: Were given a diagnosis of upper respiratory infection (URI), AND were not dispensed an antibiotic A higher score indicates better quality: A higher rate indicates appropriate treatment of children with URI (i.e. the proportion for whom antibiotics were not dispensed. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement Rationale: The common cold (or upper respiratory infection [URI]) is a frequent reason for children visiting the doctor's office. Though existing clinical guidelines do not support the use of antibiotics for the common cold, physicians often prescribe them for this ailment. Pediatric clinical practice guidelines do not recommend antibiotics for a majority of upper respiratory tract infections because of the viral etiology of these infections, including the common cold. A performance measure of antibiotic use for URI sheds light on the prevalence of inappropriate antibiotic prescribing in clinical practice and raises awareness of the importance of reducing inappropriate antibiotic use to combat antibiotic resistance in the community. The clinical intent is to ensure that children diagnosed with nonspecific upper respiratory infections are not being inappropriately treated with antibiotics. ELIGILBLE POPULATION Children 3 months - 18 years and: an outpatient or ED visit for URI. NUMERATOR Patients who were NOT prescribed or dispensed a prescription for antibiotic medication on or within 3 days after the URI Episode date. Denominator Exclusions: None Exceptions: 1. Claims/encounters with more than one diagnosis code. 2. ED visits that result in an inpatient admission. 3. Episode Dates where a new or refill prescription for an antibiotic medication was filled 30 days prior to the Episode Date or was active on the Episode Date 4. Comorbid condition during the twelve month period prior to the encounter 5. Episode Dates where the member had a claim/encounter with a competing diagnosis on or 3 days after the Episode Date. A code from either of the following meets criteria for a competing diagnosis: Pharyngitis Competing Diagnosis Value Set Procedure Codes & Code Descriptors Performance Met HCPCS Code G8708 : Patient NOT prescribed nor dispensed antibiotic OR Exclusion/Exception from Performance Measure HCPCS Code G8709: URI patients with documented medical reasons for prescribing or dispensing an antibiotic Or Performance Not Met HCPCS Code G8710: Antibiotics prescribed or dispensed BCBS Measure: Page 46 of 199 Updated: 6/13/2016 Appropriate Treatment for Children with URI

47 To Determine the Denominator Step 1: Identify all members who are: aged 3 months 18 years who had: an outpatient visit, an observation visit or an ED visit during the Intake Period Table 1: Codes to Identify Visit Type Description CPT UB Revenue HCPCS Outpatient , , , , , , , , 99411, 99412, 99420, 99429, , , , 0982, 0983 G0402, G0438, G0439, G0463, T1015 Observation ED* , 0456, 0459, 0981 Source: HEDIS 2016 Specification Manual, *Do not include ED visits that result in an inpatient admission. with a diagnosis of URI. Table 2: Codes to Identify Upper Respiratory Infection (URI) ) ICD-10-CM Diagnosis URI Value Set J00, J06.0, J06.9 Source: HEDIS 2016 Specification Manual Step 2: Determine all URI Episode Dates. For each member identified in step 1, determine all outpatient or ED claims/encounters with only a URI diagnosis. Exclude claims/encounters with more than one diagnosis. Step 3: Test for Negative Medication History. To determine eligibility, look for any of the listed antibiotic drugs (by following the link below) in the 30 days prior to the visit with the URI diagnosis. As long as there are no prescriptions for the listed antibiotics during this time period, the patient is eligible for denominator inclusion. Exclude Episode Dates where a new or refill prescription for an antibiotic medication was filled 30 days prior to the Episode Date or was active on the Episode Date. Detailed list of antibiotic medication available at: final-ndc-lists BCBS Measure: Page 47 of 199 Updated: 6/13/2016 Appropriate Treatment for Children with URI

48 Step 4: Test for Negative Competing Diagnosis. Exclude Episode Dates where the member had a claim/encounter with a competing diagnosis on or three days after the Episode Date. A code from either of the following meets criteria for a competing diagnosis: Pharyngitis Value Set. Competing Diagnosis Value Set. Table 4.1: Competing diagnosis codes: Description ICD-10-CM Diagnosis Pharyngitis Value Set J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91 Competing Diagnosis Value Set Refer to HEDIS 2016 Specification Manual for complete list BCBS Measure: Page 48 of 199 Updated: 6/13/2016 Appropriate Treatment for Children with URI

49 2016 BCBS ACO Reporting Data Collection Form Appropriate Treatment for Children with Upper Respiratory Infection Target Population Age: Patients aged 3 MONTHS-18 YEARS. Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient between 3 months- 18 years of age? Yes Continue to Q2 Q2: Was the patient seen for an outpatient or ED visit during the measurement year? Yes Continue to Q3 No Stop No Stop Q3: Was the patient seen for the outpatient or ED visit during the measurement year and diagnosed with only URI? Yes No Continue to Q4 Stop Q4: Was the patient dispensed a prescription for an antibiotic on or within 3 days after the URI Episode date? Yes No Continue to Step 2 Stop Q5: Does the child have a history of prescription for an antibiotic filled during the time period from thirty days prior through one day prior to the pharyngitis episode start date. Yes No Stop. Excluded from denominator Stop. Continue to Q 6 Step 2 Did you meet the measure? Q6: Determine the reason why the patient was prescribed or dispensed an antibiotic. Medical Reasons: Select this option if the patient had a documented medical reasons for being prescribed or dispensed an antibiotic No Reason Documented Step 3 Reporting Options. Check One: Patient NOT prescribed nor dispensed antibiotic HCPCS Code G8708 URI patients with documented medical reasons for prescribing or HCPCS Code G8709 dispensing an antibiotic Antibiotic prescribed or dispensed HCPCS Code G8710 For Practice Use: Form Completed by: Date: BCBS Measure: Page 49 of 199 Updated: 6/13/2016 Appropriate Treatment for Children with URI

50 Appropriate Testing for Children with Pharyngitis Measure: BCBS Commercial Appropriate Testing for Children with Pharyngitis HEDIS Measure CPT II coding required: YES Click here to go to Table of Contents Page 50 of 199

51 2016 BCBS ACO Measures Reporting Tracking Performance for Quality Improvement Appropriate Testing for Children with Pharyngitis This measure looks at the percentage of children 2 18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a Group A streptococcus test. A higher rate indicates better performance Key: Performance Met Exclusion/Exception from Performance Measurement Performance Not Met RATIONALE: Pharyngitis, or sore throat, is a leading cause of pediatric ambulatory care visits and can be caused by a virus or by bacteria. Group A beta-hemolytic streptococcus (GABHS) is the most common bacterial cause of pharyngitis and accounts for % of cases where antibiotics should be prescribed. This makes it increasingly important for appropriate testing, diagnosis and treatment of children with pharyngitis. The clinical intent of this measure is to ensure that members 2-18 years of age diagnosed with pharyngitis and treated with antibiotics receive appropriate testing for streptococcus pharyngitis. ELIGILBLE POPULATION Children 2 years 18 years of age and: who were diagnosed with only pharyngitis in an outpatient or emergency room setting during the 1 year period starting 6 months prior to the measurement year and: And who filled a prescription for an antibiotic during the 0-3 days following the Episode Start Date NUMERATOR Patients who had a group A streptococcus test in the seven-day period from three days prior to the Episode start date through three days after the Episode Start Date. Denominator Exclusions: 1. Encounters with more than one diagnosis 2. Children with a history of prescription for an antibiotic filled during the time period from thirty days prior through one day prior to the pharyngitis episode start date. Exceptions: Procedure Codes & Code Descriptors The correct combination of numerator code(s) must be reported on the claim form in order to properly report this measure. Group A Streptococcus Test Performed and Antibiotic Prescribed 2 codes are required to report this option CPT II Code 3210F: Group A Strep Test Performed AND HCPCS Code G8711: Prescribed or dispensed antibiotic OR Exclusion/Exception from Performance Measurement 2 codes required to report this option CPT II Code 3210F with 1P: Group A Streptococcus Test not Performed for Medical Reasons Documentation of medical reason(s) for not Performing Group A Strep Test AND HCPCS Code G8711: Prescribed or dispensed antibiotic OR Patient is not eligible for this measure because patient was not prescribed antibiotics HCPCS Code G8712: Antibiotic not prescribed / dispensed OR Group A Streptococcus Test not Performed, Reason not Otherwise Specified 2 codes required to report this option CPT II Code 3210F with 8P: Group A Strep Test not Performed, reason not otherwise specified AND HCPCS Code G8711: Prescribed or dispensed antibiotic BCBS Measure: Page 51 of 199 Updated: 6/13/2016 Appropriate Testing for Children with Pharyngitis

52 To Determine the Denominator Step 1: Identify all members: aged 2 through 18 years who had: an outpatient, observation, or ED visit (Table below): Table 1: Codes to Identify Visit Type Description CPT UB Revenue HCPCS Outpatient , , , , , , , , 99411, 99412, 99420, 99429, , , , 0982, 0983 G0402, G0438, G0439, G0463, T1015 Observation ED* , 0456, 0459, 0981 Source HEDIS 2016 Specification Manual *Do not include ED visits that result in an inpatient admission. with only a diagnosis of pharyngitis (Table below) during the Intake Period. Table 2: Codes to Identify Pharyngitis ICD-9-CM Diagnosis ICD-10-CM Diagnosis Pharyngitis Value Set Acute pharyngitis 462 J02.0, J02.8, J02.9, J03.00, J03.01, J03..80, J03.81, J03.90, J03.91 Acute tonsillitis 463 Streptococcal sore throat Source HEDIS 2016 Specification Manual Step 2: Determine all pharyngitis Episode Dates (. For each member identified in step 1, determine all outpatient or ED claims/encounters with only a diagnosis of pharyngitis. Episode Date: The date of service for any outpatient or ED visit during the Intake Period with only a diagnosis of pharyngitis. Exclude BCBS Measure: Page 52 of 199 Updated: 6/13/2016 Appropriate Testing for Children with Pharyngitis

53 Step 3: Determine: if antibiotics (table below) were dispensed for any of the Episode Dates. For each Episode Date with a qualifying diagnosis, determine if antibiotics were dispensed on or up to three days after. Exclude Episode Dates if the member did not receive antibiotics on or three days after the Episode Date. Table 3: Antibiotic Medications Description Prescription Aminopenicillins Amoxicillin Ampicillin Beta-lactamase inhibitors Amoxicillin-Clavulanate First generation cephalosporins Cefadroxil Cephalexin Folate antagonist Lincomycin derivatives Macrolides Miscellaneous antibiotics Natural penicillins Penicillinase-resistant penicillins Cefazolin Trimethoprim Clindamycin Azithromycin Clarithromycin Erythromycin Erythromycin-Sulfisoxazole Erythromycin Ethylsuccinate Erythromycin lactobionate Erythromycin Stearate Penicillin G Potassium Penicillin V Potassium Penicillin G Sodium Dicloxacillin Quinolones Ciprofloxacin Moxifloxacin Levofloxacin Ofloxacin Second generation cephalosporins Cefaclor Cefuroxime Cefprozil Sulfonamides Sulfamethoxazole-Trimethoprim Sulfisoxazole Tetracyclines Doxycycline Tetracycline Third generation cephalosporins Source: HEDIS 2016 Table CWP-C Antibiotics Medications Minocycline Cefdinir Cefixime Cefpodoxime Ceftibuten Cefditoren Ceftriaxone Step 4: Test for Negative Medication History. Exclude Episode Dates where a new or refill prescription for an antibiotic medication was filled 1-30 days prior to the Episode Date or where a prescription filled more than 1-30 days prior to the Episode Date was active on the Episode Date. BCBS Measure: Page 53 of 199 Updated: 6/13/2016 Appropriate Testing for Children with Pharyngitis

54 To Determine the Numerator Patients who were dispensed an antibiotic and who received a group A streptococcus (strep) test for the episode in the 7 day period starting 3 days prior to the episode start date and ending 3 days after the episode start date (inclusive of episode start date). Table 4: Codes to Identify Group A Streptococcus tests Group A Streptococcus Tests HEDIS 2016 Specifications Manual CPT 87070, 87071, 87081, 87430, , LOINC 626-2, , , , , , , , , , , , BCBS Measure: Page 54 of 199 Updated: 6/13/2016 Appropriate Testing for Children with Pharyngitis

55 2016 BCBS ACO Reporting Data Collection Form Appropriate Testing for Children with Pharyngitis Target Population Age: Patients aged 2-18 YEARS. Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient between 2-18 years of age? Yes Continue to Q2 No Stop Q2: Was the patient seen for an outpatient or ED visit during the measurement year? Yes No Continue to Q3 Stop Q3: Was the patient seen for the outpatient or ED visit during the measurement year and diagnosed with only pharyngitis? Yes No Continue to Q4 Stop Q4: Was the patient dispensed a prescription for an antibiotic during the 0-3 days following the Index Episode Start Date.? Yes No Continue to Q5 Stop Q5: Does the child have a history of prescription for an antibiotic filled during the time period from thirty days prior through one day prior to the pharyngitis episode start date. No Yes Continue to Q6 Stop Step 2 Did you meet the measure? Q6: Determine if the patient who was dispensed an antibiotic ALSO received a group A strep test for the episode in the 7 day period starting 3 days prior to the index date and ending 3 days after the index date (inclusive of index date). Yes No This meets the measure. Stop. If strep test was not given, go to Q7 Q7: Determine the reason why the patient did not receive the strep test. Medical Reasons: Select this option if the patient did not receive a strep for medical reasons No Reason Documented BCBS Measure: Page 55 of 199 Updated: 6/13/2016 Appropriate Testing for Children with Pharyngitis

56 Step 3 Reporting Options. Check One: Group A Streptococcus Test Performed and Antibiotic Prescribed CPT II 3210F: Group A Strep Test Performed AND G8711: Prescribed or dispensed antibiotic Group A Streptococcus Test not Performed for Medical Reasons Patient is not eligible for this measure because patient was not prescribed antibiotics Patient was prescribed antibiotics AND Group A Streptococcus Test not Performed, Reason not Otherwise Specified 3210F with 1P: Documentation of medical reason(s) for not Performing Group A Strep Test AND G8711: Prescribed or dispensed antibiotic G8712: Antibiotic not prescribed / dispensed 3210F with 8P: Group A Strep Test not Performed, reason not otherwise specified AND G8711: Prescribed or dispensed antibiotic For Practice Use: Form Completed by: Date: BCBS Measure: Page 56 of 199 Updated: 6/13/2016 Appropriate Testing for Children with Pharyngitis

57 Tobacco Use: Screening and Cessation Intervention Measure: MSSP Tobacco Use: Screening & Cessation Intervention Domain: Preventive Care and Screening ACO 17 PREV- 10 PQRS NQF 0028 Measure Steward: AMA/PCPI ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP 2016 Measures Page 57 of 199 Updated: 6/13/2016 Tobacco Use: Screening & Cessation Intervention

58 2016 MSSP ACO Measures Reporting Tracking Performance for Quality Improvement Tobacco Use: Screening and Cessation Intervention This measure looks at the percentage of patients aged 12 years* and older who were screened for tobacco use one or more times within 24 months** AND who received cessation counseling intervention if identified as a tobacco user. *MSSP age range = 18 years and older Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement A higher score indicates better quality. RATIONALE: This measure is intended to promote adult tobacco screening and tobacco cessation interventions for those who use tobacco products. There is good evidence that tobacco screening and brief cessation intervention (including counseling and/or pharmacotherapy) is successful in helping tobacco users quit. Tobacco users who are able to stop smoking lower their risk for heart disease, lung disease, and stroke. CLINICAL RECOMMENDATION STATEMENTS: All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status or the use of other reminder systems such as chart stickers or computer prompts, significantly increase rates of clinician intervention. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008) All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008). Measure Specification Procedure Codes & Code Descriptors ELIGILBLE POPULATION All patients aged 12 years and older + Encounter during the measurement period NUMERATOR: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user If there is more than 1 patient query regarding tobacco use, use the most recent DENOMINATOR Exclusions: None Exceptions: 1. Documentation of MEDICAL REASON(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason) Definitions: ** Within 24 months is defined as:the 24-month look-back from the measurement period end date Dec 31 st. Tobacco Use Includes any type of tobacco. Cessation Counseling Intervention Includes brief counseling (3 minutes or less) and/or pharmacotherapy Choose one of the codes below: Performance Met CPT II code 1036F: Screened and identified as a tobacco non-user CPT II code 4004F: Screened AND identified as a user and received cessation intervention (brief counseling and/or pharmacotherapy) Exclusion/Exception from Performance Measurement CPT II code 4004F - 1P: Screening not performed AND medical reason is documented (e.g. limited life expectancy) Performance Not Met CPT II code 4004F - 8P: Tobacco screening OR tobacco cessation intervention not performed and reason is not otherwise specified MSSP 2016 Measures Page 58 of 199 Updated: 6/13/2016 Tobacco Use: Screening & Cessation Intervention

59 Tobacco Use: Screening and Cessation Intervention: Eligible Cases Patient encounter during the reporting period (CPT or HCPCS) Patients aged 12 years + Encounter occurring during the measurement period Exclusions MEDICAL REASONS for Not Screening for Tobacco Use: Limited life expectancy, other medical reasons AND CPT Checked:90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 92522, 92523, 92524, 92540, 92557, 92625, 96150, 96151, 96152, 97003, 97004, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99406, G0438, G0439 or HCPCS MSSP 2016 Measures Page 59 of 199 Updated: 6/13/2016 Tobacco Use: Screening & Cessation Intervention

60 PREV 10: Tobacco Use: Screening and Cessation Intervention 2016 Description: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation counseling if identified as a tobacco user. MSSP definition 12 yrs and older Denominator Exclusions: None Denominator Exceptions: Medical reasons What is the Quality Action? Screening for tobacco use at least once within 24 months. For any patient identified as a tobacco user, tobacco cessation counseling must also be provided. Tobacco use includes any type of tobacco. Where may the Quality Action take place? Must take place in a healthcare setting Who may perform the Quality Action? Any healthcare professional may screen for tobacco use. When must the Quality Action be performed? The screening for tobacco use must occur within the 24 months prior to the end of the measurement period. The same time frame also applies for cessation intervention for those patients identified as tobacco users. If there is more than one tobacco screening, use the most recent. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: The date and results of a query of the patient s use of tobacco; If identified as a tobacco user, documentation of a related cessation counseling intervention; or Documentation of the reason why the Quality Action is not performed due to an exception (see Data Guidance for specific medical reason exceptions). MSSP 2016 Measures Page 60 of 199 Updated: 6/13/2016 Tobacco Use: Screening & Cessation Intervention

61 2016 MSSP Reporting Data Collection Form Tobacco Use: Screening and Cessation Intervention Target Population Age: Patients aged 12 years and older. Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient 12 years of age or older? Yes Continue to Q2 Q2: Was the patient was seen for a visit in the measurement year? Yes Continue to Q3 Step 2 Did you meet the measure? No Stop No Stop Q3: Determine if the patient was screened for tobacco use at least once within 24 months AND identified as a tobacco non-user Yes No Go directly to Step 3 If no, go to Q4 Q4: Determine if the patient was screened for tobacco use at least once within 24 months AND identified as a tobacco user Yes Not Screened or Tobacco Status Unknown Continue to Q6 Continue to Q5 Q5: Determine if there is documented medical reason(s) for not screening the patient for tobacco use (a) Medical Reasons: Select this option if the patient was not screened for tobacco use for medical reasons and the reason is documented (e.g., Limited life expectancy, other medical reasons) (b) No Reason Documented If (a) or (b) are checked, Stop. Do Not Answer Cessation Counseling Intervention Q6: Determine if tobacco cessation counseling intervention was received Cessation Counseling Intervention - Includes brief counseling (3 minutes or less), and/or pharmacotherapy Yes No Step 3 Reporting Options Check One: Screened for Tobacco use and identified as Current tobacco non-user CPT II 1036F Screened AND received cessation intervention (counseling or pharmacotherapy, or both) if CPT II 4004F tobacco user Screening not performed AND medical reason is documented (e.g. limited life expectancy) CPT II 4004F - 1P Tobacco screening OR tobacco cessation intervention not performed and reason is not otherwise specified CPT II 4004F - 8P For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 61 of 199 Updated: 6/13/2016 Tobacco Use: Screening & Cessation Intervention

62 Asthma Measures Measure: BCBS HMO Asthma Action Plan Measure BCBS Asthma Measure Set Asthma Control Measure Asthma Follow-Up Measure Click here to go to Table of Contents BCBS Measures Page 62 of 199 Dated: 6/13/16 Asthma Measure Set

63 2016 BCBS QIPP Measures Reporting Tracking Performance for Quality Improvement Asthma Measures These measures look at the percentage of asthmatic members age 5-85 yrs, from 11/1/15-10/31/16 and includes 3 measures: Who receive a written asthma action plan Whose asthma is well controlled Who have a face-to-face visit with their physician to review asthma care if asthma is not well controlled Written Asthma Action Plan Asthma Control Interventions When Asthma Is Not Well Controlled Same eligibility and exclusion criteria apply to the 3 measures: ELIGILBLE POPULATION (Denominator) for the 3 Asthma Measures Population: Patients age 5 to 85 years who, in the previous year, have had any of the following*: Emergency Department visit with asthma as the principal diagnosis or an Acute inpatient discharge with asthma as the principal diagnosis or Four outpatient visits with asthma as one of the diagnoses, and at least two asthma medication dispensing events or Four or more asthma medication dispensing events (plus at least one claim or encounter in the outpatient setting with asthma as one of the listed diagnoses) EXCLUSIONS for the 3 Measures Exclusions apply only if patient did not have any of the above* criteria for inclusion in the denominator. Diagnosis of: 1. COPD 2. Emphysema 3. Cystic Fibrosis (CF) 4. Acute Respiratory Failure 5. Patient died prior to the end of the measurement period 6. Patient a permanent nursing home resident or was in hospice or palliative care any time during the measurement year hma Action Plan Measure BCBS Measures Page 63 of 199 Updated: 6/2016 Asthma Measure Set

64 Written Asthma Action Plan Measure Written Asthma Action Plan Measure This measure looks at the percentage of members aged 5-85 yrs with asthma who were given an asthma action plan between 11/1/2015 and 10/31/2016 containing all of the required elements including physician involvement. ELIGILBLE POPULATION members aged 5-85yrs with asthma NUMERATOR: number of members in the denominator who were provided with an asthma action plan containing all required elements including physician involvement. In order to qualify as an acceptable asthma action plan, all of the following required elements must be met: The asthma action plan must contain: the list of medications (if any) to take for asthma with dose, frequency, route instructions regarding how the patient should monitor his or her asthma (peak flow or symptoms); and instructions regarding what changes in treatment should result from changes in peak flow readings and/or symptoms The asthma action plan must have been developed by the physician, licensed Physician Assistant or licensed Advanced Practice Nurse who has provided clinical services to the member. There must be documentation that: the plan was reviewed with the member. Date of review is required. a copy of the written plan was given to the member. Date when given required. The asthma action plan must be part of the member s permanent medical record. Note that an asthma action plan provided to the member by mail or is acceptable only if there is clear documentation that the asthma action plan was verbally reviewed with the member. Asthma Control Asthma Control Looks at % of patients 5-85 yrs with asthma who meet the criteria for being "Well Controlled" between 11/1/2015 and 10/31/2016 based on an assessment of asthma control performed using a standardized tool or NAEPP components of control: ACT score 20 ATAQ score =0 ACQ score <1.0 ELIGILBLE POPULATION members aged 5-85 yrs with asthma minus exclusions NUMERATOR: Number of members in the denominator that meet criteria for Well Controlled asthma, based upon an assessment of asthma control performed with a standardized tool or the NAEPP Components of Control that was reviewed by a physician, licensed Physician Assistant or licensed Advanced Practice Nurse who is caring for the member. BCBS Measures Page 64 of 199 Updated: 6/13/2016 Asthma Measure Set

65 Requirements Tools to Assess for Control Assessment of asthma control GlaxoSmithKline Asthma Control Test (ACT ) is the only IHP approved standardized asthma assessment tool The result of the assessment of asthma control must be: Part of the member s permanent medical record Reviewed by the physician, licensed PA or licensed APN Provider review of the results must be documented - In order to meet criteria for Well Controlled asthma, supporting documentation must substantiate either: o a score from a standardized asthma control assessment tool that meets NAEPP criteria for being Well Controlled: ACT score 20 ATAQ score = 0 ACQ score < OR - Evidence of asthma control based on the Components of Control in the NAEPP guidelines, available at: For the patient s asthma to be considered Well Controlled, at least three of the five Components of Control for asthma impairment must be met on the same date of service. Components of Control 5-11 Years of Age > 12 Years of Age 1. Symptoms <2 days per week but not more <2 days per week than once on each day 2. Nighttime awakenings <1 time per month <2 times per month 3. Interference with normal activity 4. Short-acting beta 2 agonist use for symptom control (not prevention of Exercised Induced Bronchospasm) 5. Lung function: o FEV1 or peak flow 1 1 o FEV1/FVC None None <2 days per week <2 days per week >80% of predicted/personal best 1 1 >80% >80% of predicted/personal best 1 1 NA Quality Codes (Source: PQRS measure # 398) Asthma well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score and results documented Death, permanent nursing home resident or receiving hospice or palliative care any time during the measurement period Asthma not well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score, OR specified asthma control tool not used, reason not given G9432 G9433 G9434 BCBS Measures Page 65 of 199 Updated: 6/13/2016 Asthma Measure Set

66 Interventions When Asthma Is Not Well Controlled This measure looks at the percentage of members aged 5-85 yrs with asthma whose asthma was not well controlled and who had a face to face asthma follow-up visit with a physician, licensed PA or APN who is caring for the member between 11/1/2014 and 10/31/2015 AND This measure now includes Depression screening for Ages 12 years and older This measure looks at the percentage of members aged yrs with asthma whose asthma was not well controlled and who were screened for depression between 11/1/2013 and 10/31/2015. Perform Annually. Use a standardized tool (PHQ-2) ELIGILBLE POPULATION Number of members who were assessed using a standardized asthma assessment tool with results indicating that the member s asthma is not Well Controlled. NUMERATOR: Number of members whose asthma was not Well Controlled who had a face-to-face visit with a physician, licensed PA or licensed APN for review of asthma treatment to determine if a change is needed. DENOMINATOR Exclusions Members who have documentation of Well Controlled asthma are excluded. Members who did not have an assessment of asthma control are also excluded. Interventions When Asthma Is Not Well-Controlled For members whose asthma is Not Well Controlled: Did the member has a face-to-face visit with a physician on or after the date of the asthma control assessment? If yes, was asthma treatment reviewed at this visit to determine whether changes in treatment were needed? If Yes, the date of the face-to-face visit will be required. Acceptable Documentation of the face-to-face visit: A progress note on the same date, or after the date of the assessment, that indicates the member had a face-to-face visit with a physician at which asthma treatment was reviewed to determine whether a change is needed Patients with asthma that is Not Well Controlled require care so that asthma control can be addressed. Therefore, the face-to-face visit should occur promptly following the assessment of asthma control (no more than days, preferably less). Asthma control varies over time, so if the visit is delayed, a new assessment of asthma control should be performed, so that an appropriate treatment plan can be developed and implemented. Interventions When Asthma Is Not Well Controlled BCBS Measures Page 66 of 199 Updated: 6/13/2016 Asthma Measure Set

67 ADULT, ENGLISH BCBS Measures Page 67 of 199 Updated: 6/13/2016 Asthma Measure Set

68 ACT, CHILD, ENGLISH BCBS Measures Page 68 of 199 Updated: 6/13/2016 Asthma Measure Set

69 Screening for Clinical Depression and Follow-Up Plan Measure: MSSP Screening for Clinical Depression & Follow-Up Plan Domain: Preventive Care and Screening ACO 18 PREV- 12 PQRS NQF 0418 Measure Steward: CMS ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP 2016 Measures Page 69 of 199 Updated: 6/13/2016 Screening for Clinical Depression & Follow-Up Plan

70 2016 MSSP ACO Measures Reporting Tracking Performance for Quality Improvement Screening for Clinical Depression and Follow-Up Plan This measure looks at the percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen. A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: The World Health Organization (WHO) found that major depression was the leading cause of disability worldwide. Depression causes suffering, decreases quality of life, and causes impairment in social and occupational functioning. It is associated with increased health care costs as well as with higher rates of many chronic medical conditions. Studies have shown that a higher number of depression symptoms are associated with poor health and impaired functioning, whether or not the criteria for a diagnosis of major depression are met. The negative outcomes associated with early onset depression, make it crucial to identify and treat depression in its early stages. CLINICAL RECOMMENDATION STATEMENTS: Adolescent Recommendation (12-18 years): The USPSTF recommends screening of adolescents (12-18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up Adult Recommendation (18 years and older): The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. ELIGILBLE POPULATION Measure Specifications All patients aged 12 years and older + Seen for a visit during the measurement year screen annually NUMERATOR Patients screened for clinical depression on the date of the encounter using an age appropriate standardized tool AND, if positive, a follow-up plan is documented on the date of the positive screen The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. DENOMINATOR Exceptions: 1. PATIENT REASON: Patient refuses to participate 2. MEDICAL REASON: Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient s health status 3. Situations where the patient s functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools. For example: certain court appointed cases or cases of delirium 4. Patient has an active diagnosis of Depression 5. Patient has a diagnosed Bipolar Disorder Exclusions: None Procedure Codes & Code Descriptors Choose one of the codes below: Performance Met HCPCS Code G8431: Screening for Clinical Depression Documented as Positive, AND Follow-Up Plan documented Performance Met HCPCS Code G8510: Screening for Clinical Depression Documented as Negative, Follow-Up Plan not Required Exclusion/Exception from Performance Measurement HCPCS Code G8433: Screening for Clinical Depression not Documented, Documentation States Patient not Eligible per exclusion definitions Exclusions/Exceptions from Performance Measurement HCPCS Code G8940: Screening for Clinical Depression Documented as Positive, Follow-Up Plan not Documented, Patient not Eligible per exclusion definitions Performance Not Met HCPCS Code G8432: Screening for Clinical Depression not Documented, Reason not Given Performance Not Met HCPCS Code G8511: Screening for Clinical Depression Documented as Positive, Follow-Up Plan not Documented, Reason not Given MSSP 2016 Measures Page 70 of 199 Updated: 6/13/2016 Screening for Clinical Depression & Follow-Up Plan

71 Screening for Clinical Depression and Follow-Up Plan: Eligible Cases Patient encounter during the reporting period (CPT or HCPCS) Patients aged 12 years + Encounter during the measurement period Exclusions: Documentation of Medical / Patient Exclusions listed above AND CPT Checked 90791, 90792, 90832, 90834, 90837, 90839, 92625, 96116, 96118, 96150, 96151, 97003, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, or HCPCS HCPCS G Code: G0101, G0402, G0438, G0439, G0444 STRATEGIES TO IMPROVE AND ENHANCE YOUR PERFORMANCE Examples of depression screening tools include but are not limited to: Adolescent Screening Tools (12-17 years) Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire (MFQ), Center for Epidemiologic Studies Depression Scale (CES-D), and PRIME MD-PHQ2 Adult Screening Tools (18 years and older) Patient Health Questionnaire (PHQ-9), Beck Depression Inventory (BDI or BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke Anxiety-Depression Scale (DADS), Geriatric Depression Scale (GDS), Cornell Scale Screening, and PRIME MD-PHQ2 Follow-up for a positive depression screening. The follow up plan must be documented on the date of the positive screen. The follow up plan must be related to a positive depression screening, example: Patient referred for psychiatric evaluation due to positive depression screening. Follow-up must include one or more of the following: -Additional evaluation for depression -Suicide Risk Assessment -Referral to a practitioner who is qualified to diagnose and treat depression -Pharmacological interventions -Other interventions or follow-up for the diagnosis or treatment of depression MSSP 2016 Measures Page 71 of 199 Updated: 6/13/2016 Screening for Clinical Depression & Follow-Up Plan

72 PREV 12: Depression Screening and Follow-up Plan 2016 Description: Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen. Denominator Exclusions: Active diagnosis of depression or bipolar disorder Denominator Exceptions: Medical reasons or patient reasons What is the Quality Action? Completion of a depression screening using an age appropriate standardized depression screening tool. If the screening is positive, a follow-up plan is also required. A follow-up plan for a positive screen must contain one or more of the following: Additional evaluation for depression Suicide risk assessment Referral to a practitioner who is qualified to diagnose and treat depression Pharmacological interventions Other interventions or follow-up for the diagnosis or treatment of depression Where may the Quality Action take place? May take place in any setting. The patient may have access to the screening tool prior to the visit, but the results of the screening must be discussed during the visit. Who may perform the Quality Action? A qualified healthcare professional must administer the screening tool. When must the Quality Action be performed? The depression screening must be performed during the measurement period. If a followup plan is required, it must be documented on the date of the positive screen. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: The date and results of an age appropriate standardized depression screening tool; If a follow-up plan is required, documentation of discussion of the plan. The followup plan must be specified as an intervention that pertains to depression; or Documentation of the reason why the Quality Action is not performed due to an exception (see Data Guidance for specific medical or patient reason exceptions); or documentation of exclusion criteria. MSSP 2016 Measures Page 72 of 199 Updated: 6/13/2016 Screening for Clinical Depression & Follow-Up Plan

73 2016 MSSP Reporting Data Collection Form Screening for Clinical Depression and Follow-Up Plan Target Population Age: Patients aged 12 years and older Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient 12 years of age or older? Yes Continue to Q2 No Stop Q2: Was the patient was seen for a visit in the measurement year? Yes Continue to Q3 No Stop Q3: Are there any exclusions for patient disqualification from the measure? No Continue to Q4 Step 2 Did you meet the measure? Yes Go to Q5 to specify reason Q4: Determine if the patient was screened for clinical depression using an age appropriate standardized tool during the measurement period and screening was performed in the office of the provider on the date of the positive screen Note: Use most recent screening for depression Yes Continue to Q6 No If, go to Q5 Q5: Determine if there is documented medical or patient reason(s) for not screening the patient for clinical depression (a) Medical Reasons: Select this option if the patient was not screened for clinical depression using a standardized tool due to medical reasons and the reason is documented. (b) Patient Reasons: Select this option if the patient was not screened for clinical depression using a standardized tool due to patient reasons and the reason is documented (c) No Reason Documented If (a) or (b) or (c) are checked, Stop. MSSP 2016 Measures Page 73 of 199 Updated: 6/13/2016 Screening for Clinical Depression & Follow-Up Plan

74 Q6: Determine if the patient's screen was positive for clinical depression using a standardized tool Not Positive If selected - do not answer Follow-Up Plan Positive If selected Go To Q7 for Follow-Up Plan Q7: If the patient had a positive screen for clinical depression, determine if a follow-up plan for depression was documented during the measurement period. Note: The follow up plan must be documented on the date of the positive screen Yes - Documented No Not Documented Step 3 Reporting Options Check One: Screening for clinical depression is documented as being positive AND a follow-up plan is documented Screening for clinical depression is documented as negative, a follow-up plan is not required Screening for clinical depression not documented, documentation stating the patient is not eligible Screening for clinical depression documented as positive, a follow-up plan not documented, documentation stating the patient is not eligible Clinical depression screening not documented, Reason not given Screening for Clinical Depression Documented as Positive, Follow-Up Plan not Documented, Reason not Given HCPCS Code G8431 HCPCS Code G8510 HCPCS Code G8433 HCPCS Code G8940 HCPCS Code G8432 HCPCS Code G8511 For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 74 of 199 Updated: 6/13/2016 Screening for Clinical Depression & Follow-Up Plan

75 Mental Health: Depression Remission at Twelve Months Measure: MSSP Mental Health Depression Remission at Twelve Months Domain: At Risk Population ACO 40 MH-1 NQF 0710 PQRS: 370 Measure Steward: MNCM ACO submits data to CMS CPT II coding required: Yes Click here to go to Table of Contents MSSP 2016 Measures Page 75 of 199 Updated: 6/13/2016 Depression Remission

76 Mental Health: Depression Remission at Twelve Months Tracking Performance for Quality Improvement This measure looks at the adult patients age 18 and older with major depression or dysthymia AND an initial PHQ-9 score >9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: Major depression is a treatable cause of pain, suffering, disability and death, yet primary care clinicians detect major depression in only one-third to one-half of their patients with major depression (Williams Jr, 2002; Schonfeld, 1997). Improvement in the symptoms of depression and an ongoing assessment of the current treatment plan is crucial to the reduction of symptoms and psychosocial well-being of patients with major depression. Details at: ELIGILBLE POPULATION >18 years Measure Specifications + Diagnosis of major depression or dysthymia (newly diagnosed and existing diagnosis of depression) + an initial PHQ-9 score greater than nine during an outpatient encounter NUMERATOR: Adults with an initial PHQ-9 score > nine who achieved remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score < five DENOMINATOR Exclusions Patients who died Patients who received hospice services Patients who were permanent nursing home residents Patients with a diagnosis of bipolar disorder Patients with a diagnosis of personality disorder Exceptions: None Procedure Codes & Code Descriptors Choose one of the options below Performance Met HCPCS G Code G9509: Patient With An Initial PHQ-9 Score Greater Than Nine Who Achieves Remission At Twelve Months As Demonstrated By A Twelve Month (+/- 30 Days) PHQ-9 Score Of Less Than Five Exclusion/Exception from Performance Measurement Patients who died, received hospice or palliative care service. Patients who are permanent residents in a nursing home. Patients with a diagnosis of bipolar disorder or personality disorder. OR Performance Not Met HCPCS G Code G9510: Patient With An Initial PHQ-9 Score Greater Than Nine Who Did Not Achieve Remission At Twelve Months As Demonstrated By A Twelve Month (+/- 30 Days) Phq-9 Score Greater Than Or Equal To Five OR Performance Not Met HCPCS G Code G9510 : Patient With An Initial PHQ-9 Score Greater Than Nine Who Was Not Assessed For Remission At Twelve Months (+/- 30 Days Definitions: Twelve Months is defined as the point in time from the date in the measurement period that a patient meets the inclusion criteria (diagnosis and elevated PHQ-9 >9) extending out twelve months and then allowing a grace period of thirty days prior to and thirty days after this date. Any PHQ-9 less than five obtained during this period is deemed as remission at 12 months, values obtained prior to or after this period are not counted as numerator compliant (remission). MSSP 2016 Measures Page 76 of 199 Updated: 6/13/2016 Depression Remission

77 Mental Health: Depression Remission at Twelve Months Patients >18 Yrs of age Exclusions: Listed above AND Patient encounter during the reporting with: ICD-9 Diagnosis Codes for Identifying Major Depression or Dysthymia Major Depression Diagnosis for MDD (ICD-10-CM): F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.9, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.9, F34.1 And Patient Encounter During the Reporting Period (CPT or HCPCS): CPT Checked 90791, 90792, 90832, 90834, 90837, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, or HCPCS G0402, G0438, G0439, G9511 To Determine the Numerator Adults who achieved remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than five. For 2016 measurement year, this needs to be a PHQ-9 administered 12 months (+/- 30 days) from the INDEX DATE determined above. Example, if an 18 years or older patient had an active diagnosis of major depression on 7/1/2014 along with the PHQ-9 score >9, then 7/1/2014 is the INDEX DATE. You look to see if the patient had a PHQ-9 administered 12 months (+/- 30 days) from this index date (i.e., in the time frame of 6/1/2015 to 7/30/2015). If the PHQ was administered in that time and the score is <5, you pass the measure. MSSP 2016 Measures Page 77 of 199 Updated: 6/13/2016 Depression Remission

78 MH-1: Depression Remission at 12 Months 2016 Description: Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5. This measure applies to patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. Denominator Exclusions: Permanent nursing home residents Active diagnosis of bipolar or personality disorder Denominator Exceptions: None What is the Quality Action? Remission attained at 12 months (+/- 30 days) from the index date. Remission is defined as a PHQ-9 score less than five. The index date is defined as the first PHQ-9 score greater than 9 between 12/1/2014 to 11/30/ Where may the Quality Action take place? The patient needs to be seen by an eligible professional to have the diagnosis of depression, but the actual tool does not have to be administered by an eligible provider. Multiple modes of administration are allowed: office visit/in-person, telephone encounter, e-visit, mail (post), electronic administration ( , patient portal, ipad/tablet, patient kiosk) Who may perform the Quality Action? Any healthcare professional may administer the screening tool. When must the Quality Action be performed? An initial PHQ-9 score greater than 9 between 12/1/2014 and 11/30/2015. A follow-up PHQ-9 score less than 5 at 12 months (+/- 30 days) from the index date. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: A diagnosis of major depression or dysthymia; and A PHQ-9 score greater than 9 during an outpatient encounter between 12/1/2013 and 11/30/2014; and A follow-up PHQ-9 score less than 5 at 12 months (+/- 30 days) of the initial PHQ-9 score greater than 9; or Documentation of exclusion criteria. MSSP 2016 Measures Page 78 of 199 Updated: 6/13/2016 Depression Remission

79 2016 MSSP Reporting Data Collection Form Mental Health: Depression Remission at Twelve Months Target Population Age: Patients aged 18 years and older. Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient 18 years or older? Yes Continue to Q2 No Stop Q2: Was the patient seen by a provider during the measurement period? Yes Continue to Q3 No Stop Q3: Does the patient have an Active Diagnosis of Major Depression Including Remission or Dysthymia During Denominator Identification Period (12/1/2014 throught 11/30/2015) documented in the medical record? Yes Continue to Q4 No Stop. Patient will not be in the denominator Q4: Are there any exclusions that will disqualify the patient from this measure? Applicable denominator exclusions include: patients who were permanent nursing home residents (> 1 year anytime before the start of the measurement period), active diagnosis of bipolar disorder, active diagnosis of personality disorder No Yes Continue to Q5 Stop. Patient will not be in the denominator Q5: Determine if the patient had one or more PHQ-9s administered during the denominator identification measurement period (Index Date) between 12/1/2014 and 11/30/2015 Note: Index Date = the first instance of elevated PHQ-9 greater than 9 (12/1/2014 to 11/30/2015) and diagnosis of depression or dysthymia to identify the denominator of eligible patients for follow-up for remission during the assessment period (12/1/2015 to 12/31/2016) to determine if the patient is in remission Yes No Continue to Q6 Stop. Patient will not be in the denominator Q6: Was one or more PHQ-9s Administered during the denominator identification measurement period (12/1/2014 through 11/30/2015)? Yes No Continue to Q7 Stop. Patient will not be in the denominator MSSP 2016 Measures Page 79 of 199 Updated: 6/13/2016 Depression Remission

80 Q7: Determine if the patient had a PHQ-9 score > 9 during an outpatient encounter between 12/1/2014 and 11/30/2015. Yes No Record the date and the score below: Stop. Patient will not be in the denominator If Yes to Q7, record the date in mm/dd/yyyy format and the score of the first instance of PHO-9 >9 that is also associated with an active diagnosis of major depression or dysthymia during the denominator identification measurement period of 12/1/2014 and 11/30/2015 (this is considered to be the INDEX DATE for performance calculations) Date: Score mm/dd/yyyy THIS IS THE INDEX DATE Note: The index date marks the start of the measurement assessment period for each patient which is 13 months (12 months +/- 30 days) in length to allow for a follow-up PHQ-9 between 11 and 13 months following the index date. This assessment period is fixed and does not start over with a higher PHQ-9 that may occur after the index date. Patients must be aged 18 years and older on the index date Step 2 Did you meet the measure? Q8: Determine if the patient was administered one or more PHQs during the measurement assessment period (12 months +/- 30 days from the Index date) Yes No Continue to next step Stop. Performance Not Met Q9: Determine if the patient achieved remission with a follow-up PHQ-9 performed and a score less than 5 at 12 months (+/- 30 days) of the initial (index date) PHQ-9 score greater than 9. Note: If more than one PHQ-9 score was obtained between the 11 and 13 month window, select the most recent PHQ-9 date and score within that window Note: Remission is defined as a PHQ-9 score of less than five Yes. PHQ-9 score <5 No. PHQ-9 score >5 Continue to next step Stop. Performance Not Met If yes to Q10, record the date in mm/dd/yyyy format and the score of the MOST RECENT PHQ-9 < 5 that was adminstered during the measurement assessment period (within the window of months from the index date) Date: mm/dd/yyyy Score Step 3 Reporting Options. Check One: Patient With An Initial PHQ-9 Score Greater Than Nine Who Achieves Remission At Twelve Months As Demonstrated By A Twelve Month (+/- 30 Days) PHQ-9 Score Of Less Than Five Patient With An Initial PHQ-9 Score Greater Than Nine Who Did Not Achieve Remission At Twelve Months As Demonstrated By A Twelve Month (+/- 30 Days) Phq-9 Score Greater Than Or Equal To Five G9396 : Patient With An Initial PHQ-9 Score Greater Than Nine Who Was Not Assessed For Remission At Twelve Months (+/- 30 Days) HCPCS G Code G9509 HCPCS G Code G9510 HCPCS G Code G9510 This page intentionally left blank MSSP 2016 Measures Page 80 of 199 Updated: 6/13/2016 Depression Remission

81 Colorectal Cancer Screening Measure: MSSP BCBS HMO BCBS Commercial United Commercial United Medicare Colorectal Cancer Screening Domain: Preventive Care and Screening ACO - 19 PREV-6 PQRS -113 NQF 0034 Measure Steward: NCQA ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP, BCBS, United 2016 Measures Page 81 of 199 Updated: 6/13/2016 Colorectal Cancer Screening

82 2016 MSSP and BCBS ACO Measures Reporting Tracking Performance for Quality Improvement Colorectal Cancer Screening This measure looks at the percentage of patients aged years who received the appropriate colorectal cancer screening A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: Colorectal cancer is the third leading cause of cancer-related death in the United States. Screening for colorectal cancer is extremely important as there are no signs or symptoms of the cancer in the early stages. Colorectal cancer screening can detect premalignant polyps so they can be removed at any early stage. Screening can also help find colorectal cancer at an early stage, when treatment often leads to cure. CLINICAL RECOMMENDATIONS STATEMENT: The USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years (The United States Preventive Services Task Force, 2008) DENOMINATOR: HEDIS 2016 Measure Specifications Patients aged years of age + Seen for a visit during the measurement period NUMERATOR: Patients who had at least one or more screenings for colorectal cancer during or prior to the measurement period. Appropriate screenings are defined by any one of the following criteria below: Fecal occult blood test (FOBT) during the measurement period Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period Colonoscopy during the measurement period or the nine years prior to the measurement period. Procedure Codes & Code Descriptors Choose one of the options below: Performance Met CPT II code 3017F: Colorectal cancer screening results documented and reviewed OR Exclusion/Exception from Performance Measurement CPT II code 3017F - 1P: Documentation of medical reason(s) for not performing a colorectal cancer screening (e.g., diagnosis of colorectal cancer or total colectomy) OR Performance Not Met CPT II code 3017F - 8P: Colorectal cancer screening results were not documented and reviewed, reason not otherwise specified Documentation in the medical record must include both of the following: Date of the screening AND Results of screening DENOMINATOR : Exclusions: None Exceptions: 1.Documentation of MEDICAL REASON(s) for not performing a colorectal cancer screening, i.e., Diagnosis or past history of total colectomy or colorectal cancer, terminal illness, other reason documented by practitioner for not performing colorectal cancer screening. MSSP, BCBS, United 2016 Measures Page 82 of 199 Updated: 6/13/2016 Colorectal Cancer Screening

83 Colorectal Cancer Screening Patients yrs of age Exclusions: Medical reasons - Listed above AND Patient encounter during the reporting period with: CPT or HCPCS 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439 STRATEGIES TO IMPROVE AND ENHANCE YOUR PERFORMANCE FAQs: To pass the measure, you need to have documentation in the medical record that screening is up to date or current. Note: If you have a copy of the screening, you don't necessarily need "up to date" in the medical record. A result is not required if the documentation is clearly part of the medical history section of the record. If this is not clear, the result or finding must also be present (this ensures that the screening was performed and not merely ordered). If the medical record states that a patient had a colonoscopy in 2011 but does not give specific date? This measure does not require a date. Because the reference in the record ensures the reader that a colonoscopy was performed during the measurement period or the nine years prior to the measurement period, a Yes answer is appropriate to signify the patient is current. What if the information is only in the Billing System? If the information is available to the provider that s providing the care at the point of care, then it's okay. But if the FOBT is only listed in the billing system and is not available to the provider, then it's not sufficient. When looking for exclusionary documentation for this measure, look for evidence of colorectal cancer or total colectomy as far back as possible in the member s history. MSSP, BCBS, United 2016 Measures Page 83 of 199 Updated: 6/13/2016 Colorectal Cancer Screening

84 PREV 6: Colorectal Cancer Screening 2016 Description: Percentage of adults years of age who had appropriate screening for colorectal cancer. Denominator Exclusions: A diagnosis or past history of total colectomy or colorectal cancer Denominator Exceptions: None What is the Quality Action? An appropriate colorectal cancer screening defined by any one of the following criteria: Fecal occult blood test (FOBT) during the measurement period Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period Colonoscopy during the measurement period or the nine years prior to the measurement period. Where may the Quality Action take place? Must take place in a healthcare setting. Who may perform the Quality Action? Any qualified healthcare professional may perform the cancer screening. When must the Quality Action be performed? The colorectal cancer screening must be current, which is defined by the type of screening administered. Please refer to the What is the Quality Action section above for the outline of when the screening must be performed. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: Indication of a current colorectal cancer screening, as evidenced by the completion of one of the previously mentioned tests or procedures within its corresponding timeframe; or Documentation of exclusion criteria. MSSP, BCBS, United 2016 Measures Page 84 of 199 Updated: 6/13/2016 Colorectal Cancer Screening

85 2016 MSSP & BCBS ACO Reporting Data Collection Form Preventive Care and Screening: Colorectal Cancer Screening Target Population Age to do CPT II CODING: Patients aged years Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient years of age? Yes Continue to Q2 Q2: Was the patient seen for a visit in the measurement year? Yes Continue to Q3 No Stop No Stop Q3: Are there any medical reasons for excluding the patient from this measure? (e.g., Diagnosis or past history of total colectomy or colorectal cancer and the reason is documented.) No Yes Continue to Q4 Stop. Do Not Answer Q 4. Go to Step 3 for Reporting Options Step 2 Did you meet the measure? Q4: Determine if colorectal cancer screening is current during the measurement period. (see above for guidelines) Yes Not current Step 3 Reporting Options. Colorectal cancer screening results documented and reviewed CPT II 3017F Documentation of medical reason(s) for not performing a colorectal cancer screening (e.g., diagnosis of colorectal cancer or total colectomy) Colorectal cancer screening results were not documented and reviewed, reason not otherwise specified CPT II 3017F - 1P CPT II 3017F - 8P For Practice Use: Form Completed by: Date: You will also be required to provide the supporting medical record documentation if the ACO is selected for audit following the data collection period. MSSP, BCBS, United 2016 Measures Page 85 of 199 Updated: 6/13/2016 Colorectal Cancer Screening

86 Breast Cancer Screening Measure: MSSP BCBS United Medicare United Commercial Breast Cancer Screening Domain: Preventive Care and Screening ACO 20 PREV- 5 PQRS 112 NQF 2372 Measure steward: NCQA ACO submits data to CMS: YES HEDIS Measure Submitted to BCBS : Yes CPT II coding required: YES Click here to go to Table of Contents MSSP & BCBS 2016 Measures Page 86 of 199 Updated: 6/13/2016 Breast Cancer Screening

87 2016 MSSP and BCBS ACO Measures Reporting Tracking Performance for Quality Improvement Breast Cancer Screening / Screening Mammography This measure looks at the percentage of women aged years of age who had a mammogram to screen for breast cancer within 24 months A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: Breast cancer ranks as the second leading cause of cancer related deaths in women. For women 40 to 69 years of age, mammography can reduce mortality by 17 percent. American Medical Association (AMA, 2003). The clinical intent of the measure is to ensure that all eligible women age receive a mammography to screen for breast cancer. CLINICAL RECOMMENDATIONS STATEMENT: U.S. Preventive Services Task Force (2009): The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. Measures Specifications (This measure s guidelines below are a combination of MSSP and BCBS and United specifications) DENOMINATOR: Women aged years of age + Visit during the measurement period NUMERATOR: Women who had a screening mammogram for breast cancer on date of service or at least once within 24 months prior to the date of service. Documentation in the medical record must include both Date of the mammogram AND Results documented and reviewed Denominator Exclusions: Medical Reasons: 1. Bilateral mastectomy or history of bilateral mastectomy 2. Unilateral mastectomy with a bilateral modifier 3. Two unilateral mastectomies with service dates 14 days or more apart. 4. Both of the following (on the same or a different date of service): o Unilateral mastectomy with a right-side modifier (same date of service). o Unilateral mastectomy with a left-side modifier (same date of service). Procedure Codes & Code Descriptors Choose one of the following options: Performance Met CPT II code 3014F: Screening mammography results documented and reviewed OR Exclusion/Exception from Performance Measurement: CPT II code 3014F -1P: Documentation of medical reason(s) for not performing a mammogram (i.e., women who had a bilateral mastectomy or two unilateral mastectomies). OR Performance Not Met CPT II code 3014F: Mammogram not performed, reason not specified. CPT II code 3014F - 8P: Screening mammography results were not documented and reviewed, reason not otherwise specified 5. Absence of the left breast and absence of the right breast on same or different date of service 6. Left unilateral mastectomy and right unilateral mastectomy on the same or different date of service. Exceptions: None BCBS, United Measure: Cervical Cancer Screening Page 87 of 199 Updated: 6/13/2016

88 Eligible Cases for Breast Cancer Screening/Screening Mammography Measure Women years of age + Seen during the measurement period Exclusions: MEDICAL REASONS AND Patient encounter during the reporting period (CPT or HCPCS) CPT 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, HCPCS G0402, G0438, G0439 NOTE: This measure evaluates primary screening. Do not count biopsies, breast ultrasounds or MRIs because they are not appropriate methods for primary breast cancer screening. Table 1: Codes to identify Breast Cancer Screening Description CPT HCPCS Mammogram 77055, 77056, G0202, G0204, G0206 ICD-9-CM ICD-10-CM Procedure 87.36, None Source: HEDIS 2016 Specification Manual Table2: Codes to identify exclusions Value Set Name CPT ICD 10 CM ICD 9 Bilateral Modifier 50, History of Bilateral Z90.13 Mastectomy Left Modifier LT Right Modifier RT Unilateral Mastectomy 19180, 19200, 19220, 19240, , 85.43, 85.45, Unilateral Mastectomy Left Unilateral Mastectomy Right Source: HEDIS 2016 Specification Manual OHTU0ZZ OHTTU0ZZ MSSP & BCBS 2016 Measures Page 88 of 199 Updated: 6/13/2016 Breast Cancer Screening

89 PREV 5: Breast Cancer Screening 2016 Description: Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer within 24 months Exclusions: A bilateral mastectomy or two unilateral mastectomies Exceptions: None What is the Quality Action? A mammogram to screen for breast cancer. Where may the Quality Action take place? Must take place in a healthcare setting where mammography screening is performed. Who may perform the Quality Action? Any qualified healthcare professional may perform the mammogram. When must the Quality Action be performed? The mammogram must be performed during the measurement period, or 27 months prior to the end of the measurement period (i.e., between October 1, 2013 December 31, 2015); however, it may not precede the patient s 50th birthday. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: Date the mammogram was performed and the results; or Documentation of exclusion criteria. MSSP & BCBS 2016 Measures Page 89 of 199 Updated: 6/13/2016 Breast Cancer Screening

90 2016 MSSP & BCBS Reporting Data Collection Form Breast Cancer Screening / Screening Mammography Target Population Age: Women aged years Patient Name: yyyy DOB: (First) (M.I.) (Last) mm / dd / Gender: M F Medical Record Number: Date of Service : yyyy Step 1 Determine if the patient is eligible for this measure? mm / dd / Q1: Is the patient years of age? Yes Continue to Q2 Q2: Was the patient was seen for a visit in the measurement year? Yes Continue to Q3 No Stop No Stop Q3: Are there any medical exclusions for excluding the patient from this measure? Applicable denominator exclusions include: bilateral mastectomy or two unilateral mastectomies and the reason is documented. No Yes Continue to Q4 Stop. Do not answer Q 4. Go to Step 3 for Reporting Options Step 2 Did you meet the measure? Q4: Determine if a mammogram to screen for breast cancer was performed at least once on the date of service OR within 27 months prior to the date of service. Note: Documentation in the medical record must include both of the following to answer YES: A note indicating the date the breast cancer screening was performed AND The review of findings Yes No Step 3 Reporting Options. Screening mammography results documented and reviewed CPT II Code 3014F Documentation of medical reason(s) for not performing a mammogram (i.e., women who had a bilateral mastectomy or two unilateral mastectomies). Screening mammography results were not documented and reviewed, reason not otherwise specified CPT II Code 3014F - 1P CPT II Code 3014F - 8P For Practice Use: Form Completed by: Date: MSSP & BCBS 2016 Measures Page 90 of 199 Updated: 6/13/2016 Breast Cancer Screening

91 Cervical Cancer Screening Measure: MSSP BCBS Commercial United Commercial United Medicare Cervical Cancer Screening NQF: 0032 PQRS: 309 HEDIS Measure CPT II coding required: YES Click here to go to Table of Contents BCBS, United Measure: Cervical Cancer Screening Page 91 of 199 Updated: 6/13/2016

92 2016 BCBS/United ACO Measures Reporting Tracking Performance for Quality Improvement Cervical Cancer Screening This measure looks at the percentage of women years of age who were screened for cervical cancer using either of the following criteria: Women aged who had cervical cytology (PAP) performed every 3 years. Key: Performance Met Performance Not Met Exclusion/Exceptions from Performance Measurement Women age who had cervical cytology /human papillomavirus (PAP /HPV) co-testing performed every 5 years. A higher score indicates better quality. RATIONALE: Cervical cancer is the 10th leading cause of cancer death in the United States, but it is highly preventable and can be treated successfully if it is detected early. The USPSTF recommends* screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. * Reference: The intent of the measure is to ensure that all women aged years receive a cervical cancer screening test during the measurement year or 2 years prior. ELIGIBLE POPULATION Measure Specifications All women 24 64* years of age as of December 31 of the measurement year. *Due to a 3 year look-back period, this measure includes screening for all women age 21 and older. NUMERATOR The number of women who were appropriately screened for cervical cancer, as identified in steps 1 and 2 below. Step 1: Identify women years of age as of December 31 of the measurement year who had cervical cytology during the measurement year or the two years prior to the measurement year. Step 2: From the women who did not meet step 1 criteria, identify women years of age as of December 31 of the measurement year who had cervical cytology (PAP) and a human papillomavirus (HPV) test with service dates four or less days apart during the measurement year or the four years prior to the measurement year and who were 30 years or older on the date of both tests. Procedure Codes & Code Descriptors Choose one of the following options: Performance Met CPT II code 3015F: Cervical cancer screening results documented and reviewed. OR Exclusion/Exception from Performance Measure CPT II code 3015F 1P: Cervical cancer screening not performed for medical reasons (as listed in exclusion criteria) OR Performance Not Met CPT II code 3015F 8P: Cervical cancer screening not performed, reason not specified. Step 3: The event from steps 1 and 2 will be summed to obtain the rate. BCBS, United Measure: Cervical Cancer Screening Page 92 of 199 Updated: 6/13/2016

93 Denominator Exclusions: 1.Evidence of Hysterectomy with no residual cervix Cervical agenesis Acquired absence of cervix 2. Documentation of complete, total or radical abdominal or vaginal hysterectomy meets the criteria for hysterectomy with no residual cervix. 3. Documentation of a vaginal pap smear in conjunction with documentation of hysterectomy meets exclusion criteria * Documentation of hysterectomy alone does not meet the criteria because it does not indicate that the cervix was removed. Exceptions: None Table 1: Codes to identify exclusions Description CPT HCPCS ICD-9-CM Diagnosis Absence of Cervix Value Set HEDIS 2016, Specification Manual 51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, , 58548, , , 58951, 58953, 58954, 58956, , V88.01, V88.03, ICD-9-CM Procedure Code See HEDIS 2016 manual ICD-10- CM and ICD 10- PCS See HEDIS 2016 manual Table 2: Codes to Identify Cervical Cancer Screening Description CPT HCPCS Cervical Cytology Value Set HEDIS 2016, Specification Manual , 88147, 88148, 88150, , , 88174, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 ICD-9-CM Procedure None ICD-10-CM Checked table Table 3: Codes to Identify Cervical Cancer Screening and HPV Test Description CPT HCPCS ICD-9-CM Procedure , 88147, 88148, G0123, G0124, G0141, G0143- Cervical 88150, , G0145, G0147, G0148, P3000, Cytology 88167, 88174, P3001, Q0091 Value Set HPV Value , 87624, Set ICD-10-CM None HEDIS 2016, Specification Manual MSSP & BCBS 2016 Measures Page 93 of 199 Updated: 6/13/2016 Cervical Cancer Screening

94 2016 BCBS ACO Reporting Data Collection Form Cervical Cancer Screening Target Population Age: Patients aged years Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient years of age? Yes Continue to Q2 Q2: Was the patient was seen for a visit in the measurement year? Yes Continue to Q3 No Stop No Stop Q3: Are there any medical reasons for excluding the patient from this measure? (e.g., Total hysterecomy and the reason is documented.) No Yes Continue to Q4 Stop. Do Not Answer Q 4. Go to Step 3 for Reporting Options Step 2 Did you meet the measure? Q4: Determine if cervical cancer screening is current during the measurement period (see guidelines above). Yes Not current Step 3 Reporting Options. Cervical cancer screening results documented and reviewed CPT II 3015F Documentation of medical reason(s) for not performing a cervical cancer screening (e.g., total hysterectomy) Cervical cancer screening results were not documented and reviewed, reason not otherwise specified CPT II 3015F - 1P CPT II 3015F - 8P For Practice Use: Form Completed by: Date: MSSP & BCBS 2016 Measures Page 94 of 199 Updated: 6/13/2016 Cervical Cancer Screening

95 Screening for High Blood Pressure and Follow-Up Documented Measure: MSSP Screening for High BP & Follow-Up Documented Domain: Preventive Care and Screening ACO 21 PREV- 11 PQRS NQF N/A Measure Steward: CMS ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP 2016 Measures Page 95 of 199 Updated: 6/13/2016 Screening for High BP & Follow-Up Documented

96 2016 MSSP ACO Measures Reporting Tracking Performance for Quality Improvement Screening for High Blood Pressure & Follow-Up Documented This measure looks at the percentage of patients aged 18 years and older seen during the measurement period who were screened for high blood pressure (BP) AND a recommended follow-up plan is documented based on the current blood pressure reading as indicated. A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: Hypertension is the most common reason for adult office visits other than pregnancy. It also has the highest utilization of prescription drugs. CLINICAL RECOMMENDATION STATEMENTS: The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults age 18 years and older. This is a grade A recommendation. Symptoms of elevated blood pressure usually do not occur until secondary problems arise such as with vascular diseases (myocardial infarction, stroke, heart failure and renal insufficiency) (Luehr D, et. al., 2012). Appropriate follow-up after blood pressure measurement is a pivotal component in preventing the progression of hypertension and the development of heart disease. Detection of marginally or fully elevated blood pressure by a specialty clinician warrants referral to a provider familiar with the management of hypertension and prehypertension. ELIGILBLE POPULATION Patients aged 18 years and older Measure Specifications + Seen for a visit during the measurement period NUMERATOR Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated if the blood pressure is prehypertensive or hypertensive DENOMINATOR Exclusions 1. Patient has an active diagnosis of hypertension Exceptions 1. Documentation of MEDICAL REASONS for not receiving screening for high blood pressure during measurement period Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient s health status. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated 2. Documentation of PATIENT REASONS Patient refuses to participate (either BP measurement or follow-up) Procedure Codes & Code Descriptors Choose one of the codes below: Performance Met HCPCS Code G8783: Normal blood pressure reading documented, follow-up not required Performance Met HCPCS Code G8950: Pre-Hypertensive or Hypertensive blood pressure reading documented, AND the indicated follow-up is documented OR Exclusion/Exception from Performance Measurement HCPCS Code G8784: Blood pressure reading not documented, documentation the patient is not eligible due to medical or patient reasons OR Exclusion/Exception from Performance Measurement HCPCS Code G8784: Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, documentation the patient is not eligible due to medical or patient reasons Performance Not Met HCPCS Code G8785: Blood pressure reading not documented, reason not given Performance Not Met HCPCS Code G8952: Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given MSSP 2016 Measures Page 96 of 199 Updated: 6/13/2016 Screening for High BP & Follow-Up Documented

97 Eligible Cases for Screening for High Blood Pressure and Follow-Up Documented Patients age 18 and older Patient encounter during the reporting period (CPT or HCPCS) + Seen during the measurement period Exclusions: Dx of hypertension, MEDICAL REASONS, Refusal AND CPT 90791, 90792, 90832, 90834, 90837, 90839, 90845, 90880, 92002, 92004, 92012, 92014, 96118, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99281, 99282, 99283, 99284, 99285, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99340, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, HCPCS D7140, D7210, G0101, G0402, G0438, G0439 STRATEGIES TO IMPROVE AND ENHANCE YOUR PERFORMANCE Although the recommended screening interval for a normal BP reading is every 2 years, to meet the intent of this measure, BP screening and follow-up must be performed once per measurement period. Use the most recent blood pressure. Both the systolic and diastolic blood pressure measurements are required for inclusion. If there are multiple blood pressures on the same date of service, use the most recent as the value as the representative blood pressure. Reported systolic and diastolic values should be from a single blood pressure reading. Provide recommended follow-up as indicated if the blood pressure is pre-hypertensive or hypertensive. The follow-up recommended should be appropriately linked to blood pressure management when reporting this measure, example: Patient referred to primary care provider for BP management. Definitions: Blood Pressure (BP) Classification: BP is defined by four (4) BP reading classifications: Normal, Pre-Hypertensive, First Hypertensive, and Second Hypertensive Readings. Recommended BP Follow-Up: The current Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) recommends BP screening intervals, lifestyle modifications and interventions based on the current BP reading as listed in the Recommended Blood Pressure Follow-Up Interventions listed below. Recommended Lifestyle Modifications: The current JNC 7 report outlines lifestyle modifications which must include one or more of the following as indicated: Weight Reduction Dietary Approaches to Stop Hypertension (DASH) Eating Plan Dietary Sodium Restriction Increased Physical Activity Moderation in alcohol (ETOH) Consumption MSSP 2016 Measures Page 97 of 199 Updated: 6/13/2016 Screening for High BP & Follow-Up Documented

98 Second Hypertensive Reading: Requires a BP reading of Systolic BP 140 mmhg OR Diastolic BP 90 mmhg during the current encounter AND a most recent BP reading within the last 12 months Systolic BP 140 mmhg OR Diastolic BP 90 mmhg Second Hypertensive BP Reading Interventions: The current JNC 7 report outlines BP follow-up interventions for a second hypertensive BP reading and must include one or more of the following as indicated: Anti-Hypertensive Pharmacologic Therapy Laboratory Tests Electrocardiogram (ECG) Recommended Blood Pressure Follow-up Interventions: Normal BP: No follow-up required for Systolic BP <120 mmhg AND Diastolic BP < 80 mmhg Pre-Hypertensive BP: Follow-up with rescreen every year with systolic BP of mmhg OR diastolic BP of mmhg AND recommended lifestyle modifications OR referral to Alternate/Primary Care Provider First Hypertensive BP Reading: Patients with one elevated reading of systolic BP >= 140 mmhg OR diastolic BP >= 90 mmhg: o Follow-up with rescreen 1 day and 4 weeks AND recommend lifestyle modifications OR referral to Alternative/Primary Care Provider Second Hypertensive BP Reading: Patients with second elevated reading of systolic BP >= 140 mmhg OR diastolic BP >= 90 mmhg: o Follow-up with Recommended lifestyle modifications AND one or more of the Second Hypertensive Reading Interventions OR referral to Alternative/Primary Care Provider MSSP 2016 Measures Page 98 of 199 Updated: 6/13/2016 Screening for High BP & Follow-Up Documented

99 PREV 11: Hypertension Screening and Follow-up Documented 2016 Description: Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented if indicated based on the current blood pressure (BP) reading. Denominator Exclusions: Active diagnosis of hypertension Denominator Exceptions: Medical reasons (BP measurement)or patient reasons (either BP measurement or follow up) What is the Quality Action? Completion of high blood pressure screening, which consists of a systolic and diastolic blood pressure reading. If the screening indicates pre-hypertension or hypertension, a follow-up plan is also required. Blood pressure classifications and the recommended follow-up plans are specified in the data guidance. Where may the Quality Action take place? Must take place in a healthcare setting. Who may perform the Quality Action? Any healthcare professional may perform a high blood pressure screening. Patient reported blood pressure readings, including readings directly from home monitoring devices, are not acceptable. The appropriate healthcare professional for providing the follow-up plan is dependent on the specific plan outlined for that patient. When must the Quality Action be performed? The blood pressure screening must take place during the measurement period. If more than one blood pressure screening is performed, use the most recent. If follow-up is necessary based on the result of the blood pressure screening, the recommended follow-up must be documented during the visit where the screening took place. Note: If the blood pressure is pre-hypertensive (SBP > 120 and <139 OR DBP >80 and <89) at a PCP encounter no additional follow-up would be needed, this would meet the intent of the measure, then select "Yes" to follow-up plan 22 What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: Date and values of the most recent systolic and diastolic blood pressure measurements. If there are multiple blood pressure measurements on the same date of service, use the lowest systolic and diastolic blood pressure on that date. Reported systolic and diastolic values should be from a single blood pressure reading; If a follow-up plan is required, documentation of discussion of the plan is also required. The follow-up plan must be specified as an intervention that pertains to the blood pressure measurement; or Documentation of the reason why the Quality Action is not performed due to an exception (see Data Guidance for specific medical or patient reason exceptions); or documentation of exclusion criteria. MSSP 2016 Measures Page 99 of 199 Updated: 6/13/2016 Screening for High BP & Follow-Up Documented

100 2016 MSSP Reporting Data Collection Form Screening for High Blood Pressure and Follow-Up Documented Target Population Age: Patients aged 18 years and older Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient 18 years of age or older? Yes Continue to Q2 No Stop Q2: Was the patient was seen for a visit in the measurement year? Yes Continue to Q3 No Stop Q3: Are there any exclusions for not screening the patient for high blood pressure? (Applicable Exclusions include Active Diagnosis of Hypertension or Medical Reason) No Continue to Q4 Yes Stop. Do not answer Q4. Go to Q5 Step 2 Did you meet the measure? Q4: Determine if the patient was screened for high blood pressure during the measurement period Note: Use most recent blood pressure Yes No Continue to Q6 Continue to Q5 Q5: Determine if there is documented medical or patient reason(s) for not screened for high blood pressure. (c) Medical Reasons: Select this option if the patient if the patient was not screened for high blood pressure for medical reasons (d) Patient Reasons: Select this option if the patient was not screened for high blood pressure patient reasons and it is documented (c) No Reason Documented If (a) or (b) or (c) are checked, Stop. Go to Step 3 for Reporting Options MSSP 2016 Measures Page 100 of 199 Updated: 6/13/2016 Screening for High BP & Follow-Up Documented

101 Q6: Determine if the most recent blood pressure is within normal parameters [<120 (systolic) AND < 80 (diastolic)] Yes Stop. Do Not Answer Follow Up Plan No Continue to Q7 Q7: If patient's most recent blood pressure was not within normal parameters, determine if a recommended follow-up plan was documented Yes Select this option if the recommended follow-up plan was documented based on the most recent blood pressure reading No Select this option if the recommended follow-up plan was not documented based on the most recent blood pressure reading Step 3 Reporting Options. Check One: Normal Blood Pressure Reading Documented, Follow-Up not Required HCPCS Code G8783 Pre-Hypertensive or Hypertensive Blood Pressure Reading Documented, AND Indicated Follow-Up Documented HCPCS Code G8950 Blood pressure reading not documented, documentation the patient is not eligible HCPCS Code G8784 Pre-Hypertensive or Hypertensive Blood Pressure Reading Documented, Indicated Follow- Up not Documented, Patient not Eligible HCPCS Code G8784 Blood pressure reading not documented, reason not given HCPCS Code G8785 Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given HCPCS Code G8952 For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 101 of 199 Updated: 6/13/2016 Screening for High BP & Follow-Up Documented

102 Hypertension: Controlling High Blood Pressure Measure: MSSP HTN Controlling High Blood Pressure Domain: At-Risk Population ACO 28 HTN-2 PQRS NQF 0018 Measure Developer: NCQA ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP 2016 Measures Page 102 of 199 Updated: 6/13/2016 Hypertension: Controlling High BP

103 2016 MSSP ACO Measures Reporting Tracking Performance for Quality Improvement Hypertension (HTN): Controlling High Blood Pressure This measure looks at the percentage of patients aged 18 through 85 years of age who had a diagnosis of hypertension (HTN) AND whose blood pressure (BP) was adequately controlled ( <140/90 mmhg) during the measurement year A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: Hypertension is a very significant health issue in the United States. Fifty million or more Americans have high blood pressure that warrants treatment, according to the National Health and Nutrition Examination Survey (NHANES) survey (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 2003). The United States Preventive Services Task Force (USPSTF) recommends that clinicians screen adults aged 18 and older for high blood pressure (United States Preventive Services Task Force 2007). The most frequent and serious complications of uncontrolled hypertension include coronary heart disease, congestive heart failure, stroke, ruptured aortic aneurysm, renal disease, and retinopathy. The increased risks of hypertension are present in individuals ranging from 40 to 89 years of age. For every 20 mmhg systolic or 10 mmhg diastolic increase in blood pressure, there is a doubling of mortality from both ischemic heart disease and stroke (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 2003). Better control of blood pressure has been shown to significantly reduce the probability that these undesirable and costly outcomes will occur. The relationship between the measure (control of hypertension) and the long-term clinical outcomes listed is well established. In clinical trials, antihypertensive therapy has been associated with reductions in stroke incidence (35-40 percent), myocardial infarction incidence (20-25 percent) and heart failure incidence (>50 percent) (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 2003). CLINICAL RECOMMENDATION STATEMENTS: The United States Preventive Services Task Force (2007) recommends screening for high blood pressure in adults age 18 years and older. This is a grade A recommendation. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2003): Treating systolic blood pressure and diastolic blood pressure to targets that are <140/90 mmhg is associated with a decrease in cardiovascular disease complications. ELIGILBLE POPULATION Measure Specifications Pts years + Diagnosis of Hypertension + Patient encounter during measurement period NUMERATOR Patients whose blood pressure at the most recent visit is adequately controlled (systolic BP < 140 mmhg and diastolic BP < 90 mmhg) during the measurement period DENOMINATOR Exclusions: 1. Documentation of MEDICAL REASON(S): 2. End Stage Renal Disease 3. Dialysis 4. Renal transplant 5. Pregnancy Exceptions: None Procedure Codes & Code Descriptors Choose Option A or B or C Checked all below codes 5 / 27 Performance Met or Performance Not Met Systolic pressure: Select one code: (A) HCPCS Code G8752: Most recent systolic BP < 140 mmhg HCPCS Code G8753: Most recent systolic BP 140 mmhg Diastolic pressure: Select one code: (A) HCPCS Code G8754: Most recent diastolic BP < 90 mmhg HCPCS Code G8755: Most recent diastolic BP 90 mmhg OR Exclusions/Exceptions from Performance Measurement (B) HCPCS Code G9231: Documentation of end stage renal disease (ESRD), dialysis, renal transplant or pregnancy. Performance Not Met (C) HCPCS Code G8756: No documentation of blood pressure measurement, reason not given MSSP 2016 Measures Page 103 of 199 Updated: 6/13/2016 Hypertension: Controlling High BP

104 Hypertension - Controlling High Blood Pressure : Eligible Cases Patients Yrs of age + Patient encounter during the reporting with: Diagnosis of Hypertension Checked: Diagnosis for hypertension (ICD-10-CM): I10 Encounter date in 2016 Exclusions: Medical Reasons AND And Patient Encounter During the Reporting Period (CPT or HCPCS): CPT Checked 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, or HCPCS Checked G0402, G0438, G0439 STRATEGIES TO IMPROVE AND ENHANCE YOUR PERFORMANCE Do not include blood pressure readings that meet the following criteria: a. Blood pressure readings from the patient's home (including readings directly from monitoring devices). b. Taken during an outpatient visit which was for the sole purpose of having a diagnostic test or surgical procedure performed (e.g., sigmoidoscopy, removal of a mole). c. Obtained the same day as a major diagnostic or surgical procedure (e.g., stress test, administration of IV contrast for a radiology procedure, endoscopy). To describe both systolic and diastolic BP values, each must be reported separately. If multiple blood pressure readings on the same day, use the lowest systolic and lowest diastolic blood pressure on that date. If a series of blood pressure readings are not on same day, you would use the most recent reading. You would use the lowest values regardless of position (sitting, standing, or laying down). You should take the most recent blood pressure reading of the measurement period regardless of provider type (Primary Care Visit or Specialty office visit), as long as the BP is documented in the medical record and isn't taken in an emergent or emergency or surgical setting. The diagnosis can be anytime documented in the patient's medical record up through the last day of the measurement period. If no blood pressure is recorded during the measurement period, the patient s blood pressure is assumed not controlled. MSSP 2016 Measures Page 104 of 199 Updated: 6/13/2016 Hypertension: Controlling High BP

105 HTN 2: Controlling High Blood Pressure 2016 Description: Percentage of patients years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmhg) during the measurement period. Denominator Exclusions: Dialysis or renal transplant before or during the measurement period ESRD Chronic kidney disease stage 5 Pregnancy during the measurement period Denominator Exceptions: None What is the Quality Action? Performance of a blood pressure reading and documentation of its result. A result of < 140/90 mm Hg is required for numerator inclusion. Where may the Quality Action take place? Must take place in a healthcare setting. Who may perform the Quality Action? Any qualified healthcare professional may take the patient s blood pressure. Patient reported blood pressure readings, including readings directly from home monitoring devices, are not acceptable. When must the Quality Action be performed? The blood pressure must be taken and the value recorded during the measurement period. If there is more than one blood pressure reading, use the most recent. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: The date and value of the most recent systolic and diastolic blood pressure readings. If there are multiple blood pressure readings on the same date of service, use the lowest systolic and lowest diastolic pressures on that date; or Documentation of exclusion criteria. MSSP 2016 Measures Page 105 of 199 Updated: 6/13/2016 Hypertension: Controlling High BP

106 2016 MSSP Reporting Data Collection Form Hypertension (HTN): Controlling High Blood Pressure Target Population Age: Patients aged years Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient years of age? Yes Continue to Q2 No Stop Q2: Was the patient was seen for a visit in the measurement year? Yes Continue to Q3 No Stop Q3: Are there any medical exclusions for excluding the patient from this measure? (Applicable denominator exclusions include: end stage renal disease (ESRD), patients undergoing dialysis, history of renal transplant, pregnancy, and chronic kidney disease (CKD), stage 5 and the reason is documented.) No Continue to Q4 Step 2 Did you meet the measure? Yes Stop and continue to Q5 Q4: Determine if the patient has a documented diagnosis of essential HTN? Yes Continue to Q6 Not Confirmed Stop Q5: Determine if there is documented medical for excluding the patient from this measure (e) Medical Reasons: Applicable denominator exclusions include: end stage renal disease (ESRD), patients undergoing dialysis, history of renal transplant, pregnancy, and chronic kidney disease (CKD) stage 5 and the reason is documented. (c) No Reason Documented If (a) or (b) are checked, do not answer Q6 and Q7. Go to Step 3 for Reporting Options MSSP 2016 Measures Page 106 of 199 Updated: 6/13/2016 Hypertension: Controlling High BP

107 Q6: Determine if the patient's most recent BP was documented during the measurement period Yes Continue to Q 7 No If selected - do not answer Q7. Go to Step 3 for Reporting Options Q7: If Most Recent BP = Yes, Provide the: Most Recent Date MM/DD/YYYY Most Recent Systolic BP mmhg Most Recent Diastolic BP mmhg / / mmhg mmhg Step 3 Reporting Options. Select (A) (B) or (C) reporting option below: (A) Submit Most Recent Blood Pressure Measurement Performed (Systolic and Diastolic) Systolic pressure: Select one code: Most recent systolic BP < 140 mmhg HCPCS Code G8752 Most recent systolic BP 140 mmhg HCPCS Code G8753 Diastolic pressure: Select one code: Most recent diastolic BP < 90 mmhg HCPCS Code G8754 Most recent diastolic BP 90 mmhg HCPCS Code G8755 (B) Patient not Eligible for Recommended BP Parameters for Documented Reasons Documentation of end stage renal disease (ESRD), dialysis, renal transplant or pregnancy (C.) Blood Pressure Measurement not Documented, Reason not Given HCPCS Code G9231 No documentation of blood pressure measurement, reason not given HCPCS Code G8756 For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 107 of 199 Updated: 6/13/2016 Hypertension: Controlling High BP

108 Diabetes: BP Control < 140/90 mmhg Measure: BCBS HMO BCBS Commercial Comprehensive Diabetes Care BP Control < 140/90 mmhg HEDIS Measure CPT II coding required: YES Click here to go to Table of Contents BCBS Measure: Diabetes and BP Control Page 108 of 199 Updated: 6/13/2016

109 2016 BCBS ACO Measures Reporting Tracking Performance for Quality Improvement Comprehensive Diabetes Care Blood Pressure Control < 140/90 mmhg This measure looks at the percentage of members aged years with diabetes who had the most recent BP level (taken during the measurement year) <140/90 mm Hg A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: Hypertension is common in people with diabetes and is itself a major risk factor for cardiovascular disease (CVD) and microvascular complications. In general, each reduction of systolic blood pressure by 10 mm Hg can reduce the risk for any complication related to diabetes by 12%. The intent of these measures is to promote hypertension management in adults with diabetes. Measure Specification DENOMINATOR Patients age at the end of the measurement year with a diagnosis of type 1 or type 2 diabetes (diagnosis of diabetes based on claims or pharmacy data). Inclusion Criteria between 1/1/2014 and 12/31/2015: Pateients with diabetes mellitus, based on at least one of the following criteria between 1/1/2014 and 12/31/2015: At least one ambulatory prescription for insulin or an oral hypoglycemic/ antihyperglycemic drug At least two outpatient visits, observation visits, ED visits, or non acute inpatient encounter on different dates of service with a diagnosis of diabetes At least one acute inpatient encounter with a diagnosis of diabetes NUMERATOR The most recent BP level (taken during the measurement year) <140/90 mm Hg If there is no BP reading during the measurement year or the BP is incomplete, this patient does not meet compliance If there are multiple BPs on the same date of service, use the lowest systolic and lowest diastolic BP on that date Do not include BP readings that meet the following criteria Taken during an acute inpatient stay or an ED visit. Taken during an outpatient visit which was for the sole purpose of having a diagnostic test or surgical procedure performed (e.g. sigmoidoscopy, removal of a mole). Obtained the same day as a major diagnostic or surgical procedure (e.g., stress test, administration of IV contrast for a radiology procedure, endoscopy). Reported by or taken by the member. Denominator Exclusions: 1. Gestational diabetes 2. Steroid induced diabetes without a face to face encounter with a diagnosis of diabetes 3. Death Procedure Codes & Code Descriptors Select one Systolic BP and one Diastolic BP option below: If not done, select not performed. Systolic BP (Choose one of the 3 codes below) G8752: Most recent systolic BP < 140 mmhg G8753 :Most recent systolic BP 140 mmhg Diastolic BP (Choose one of the 3 codes below) G8754: Most recent diastolic BP <90 mmhg G8755: Most recent diastolic BP 90 mmhg OR Exclusion/Exception from Performance Measurement HCPCS Code G9231: Documentation of end stage renal disease (ESRD), dialysis, renal transplant or pregnancy. (C.) Blood Pressure Measurement not Documented, Reason not Given HCPCS Code G8756: No documentation of blood pressure measurement, reason not given Exceptions: None BCBS Measure: Diabetes and BP Control Page 109 of 199 Updated: 6/13/2016

110 Table1: Codes to identify Diabetes Description Diabetes Value Set Diabetes mellitus without mention of complication ICD-9-CM Diagnosis ICD-10-CM See HEDIS 2016 spec manual Polyneuropathy in diabetes Diabetic retinopathy Diabetic cataract Diabetes Mellitus HEDIS 2016 Specification Manual Table 2: Codes to identify Visit Type Description CPT and HCPCS UBREV Outpatient Checked and added HCPCS: , , , , , , , , , 99411, 99412, 99420, 99429, 99455, 99456, HCPCS: G0402, G0438, G0439, G0463, T1015 Observation Checked , 0519, , , 0982, 0983 Non-acute inpatient Checked , 99315, 99316, 99318, , Acute inpatient Checked , , 99238, 99239, , , 0024, 0018, 0128, 0138, 0148, 0158, , 0199, 0524, 0525, , 0559, , 0669, , 0101, , 0119, , 0129, , 0139, , 0149, , 0159, 0160, 0164, 0167, 0169, , , 0219, , 0729, 0987 ED Checked: , 0456, 0459, 0981 HEDIS 2016 Specification Manual BCBS Measure: Diabetes and BP Control Page 110 of 199 Updated: 6/13/2016

111 Table 3: Prescriptions to Identify Members With Diabetes Description Prescription Alpha-glucosidase inhibitors Acarbose Miglitol Amylin analogs Antidiabetic combinations Insulin Pramlinitide Alogliptin-metformin Alogliptin-pioglitazone Canagliflozin-metformin Glimepiride-pioglitazone Glimepiride-rosiglitazone Glipizide-metformin Insulin aspart Insulin aspart-insulin aspart protamine Insulin detemir Insulin glargine Insulin glulisine Glyburide-metformin Linagliptin-metformin Metformin-pioglitazone Metformin-repaglinide Metformin-rosiglitazone Metformin-saxagliptin Meglitinides Nateglinide Repaglinide Glucagon-like peptide-1 (GLP1) agonists Sodium glucose cotransporter 2 (SGLT2) inhibitor Sulfonylureas Insulin isophane human Insulin isophane-insulin regular Insulin lispro Insulin lispro-insulin lispro protamine Insulin regular human Metformin-sitagliptin Sitagliptin-simvastatin Exenatide Liraglutide Albiglutide Canagliflozin Dapagliflozin Empagliflozin Chlorpropamide Glimepiride Glipizide Glyburide Thiazolidinediones Pioglitazone Rosiglitazone Dipeptidyl peptidase-4 (DDP-4) inhibitors Alogliptin Linagliptin Saxagliptin Sitaglipin Tolazamide Tolbutamide Note: Glucophage/metformin as a solo agent is not included because it is used to treat conditions other than diabetes; members with diabetes on these medications are identified through diagnosis codes only. NCQA will post a complete list of medications and NDC codes to by November 2, Source: HEDIS 2016 Table CDC-A: Prescriptions to Identify Members with Diabetes Table 4: Codes to identify Exclusions Description ICD-10-CM Diagnosis Diabetes Exclusion Value Set Steroid Induced See HEDIS 2016 specs See HEDIS 2016 specs Gestational diabetes See HEDIS 2016 specs Source: HEDIS 2016 Specification Manual BCBS Measure: Diabetes and BP Control Page 111 of 199 Updated: 6/13/2016

112 2016 BCBS ACO Reporting Data Collection Form COMPREHENSIVE DIABETES CARE High Blood Pressure Control < 140/90 mmhg Target Population Age: Patients aged years Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient years of age? Yes No Continue to Q2 Stop Q2: Determine if the patient has a documented history of DM during the measurement period or year prior to the measurement period. (see Detailed Denominator Criteria above) Yes No Continue to Q3 Stop Q3: Are there any medical exclusions for excluding the patient from this measure and the reason is documented (e.g., Diagnosis of polycystic ovaries, gestational diabetes or steroid induced diabetes? No Continue to Q4 Step 2 Did you meet the measure? Yes Stop. Patient will be excluded from denominator. Q4: Determine if the patient's most recent BP during the measurement period was recorded. Yes Continue to Q 5 No If selected - do not provide Date and BP values Q5: If yes to Q4, enter the following 3 values. Record the the date of the most recent BP in mm/dd/yyyy format Record the systolic BP value documented in mmhg Record the diastolic BP value documented in mmhg / / Step 3 Reporting Options. 5/27 check Select (A) (B) or (C) reporting option below: (A.) Submit Most Recent Blood Pressure Measurement Performed (Systolic and Diastolic) Systolic pressure: Select one code: Most recent systolic BP < 140 mmhg HCPCS Code G8752 Most recent systolic BP 140 mmhg HCPCS Code G8753 Diastolic pressure: Select one code: Most recent diastolic BP < 90 mmhg HCPCS Code G8754 BCBS Measure: Diabetes and BP Control Page 112 of 199 Updated: 6/13/2016

113 Most recent diastolic BP 90 mmhg HCPCS Code G8755 (B.) Patient not Eligible for Recommended BP Parameters for Documented Reasons Documentation of end stage renal disease (ESRD), dialysis, renal transplant or pregnancy (C.) Blood Pressure Measurement not Documented, Reason not Given HCPCS Code G9231 No documentation of blood pressure measurement, reason not given HCPCS Code G8756 BCBS Measure: Diabetes and BP Control Page 113 of 199 Updated: 6/13/2016

114 Heart Failure: Beta-Blocker Therapy for LVSD Measure: MSSP Heart Failure Beta-Blocker Therapy for LVSD Domain: At Risk Population ACO 31 HF-6 PQRS - 8 NQF 0083 Measure Steward: AMA/PCPI/ACC/AHA ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP 2016 Measures Page 114 of 199 Updated: 6/13/2016 Heart Failure: Beta-Blocker Therapy for LVSD

115 2016 MSSP Measure Reporting Tracking Performance for Quality Improvement Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) This measure looks at the percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed Beta-Blocker therapy either: OR within a 12 month period when seen in the outpatient setting at EACH hospital discharge A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: Beta-blockers are recommended for all patients with stable heart failure and left ventricular systolic dysfunction, unless contraindicated. Treatment should be initiated as soon as a patient is diagnosed with left ventricular systolic dysfunction and does not have low blood pressure, fluid overload, or recent treatment with an intravenous positive inotropic agent. Beta-blockers have been shown to lessen the symptoms of heart failure, improve the clinical status of patients, reduce future clinical deterioration, and decrease the risk of mortality and the combined risk of mortality and hospitalization. CLINICAL RECOMMENDATION STATEMENTS: Beta-blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol, and sustained release metoprolol succinate) are recommended for all stable patients with current or prior symptoms of heart failure with reduced ejection fraction (HFrEF), unless contraindicated. (Class I, Level of Evidence: A) (ACCF/AHA, 2013) Treatment with a beta blocker should be initiated at very low doses [see excerpt from guideline table below], followed by gradual increments in dose if lower doses have been well tolerated physicians, especially cardiologists and primary care physicians, should make every effort to achieve the target doses of the beta blockers shown to be effective in major clinical trials. (ACCF/AHA, 2013) Beta Blockers Commonly Used for the Treatment of Patients with [Heart Failure] with Low Ejection Fraction Beta Blockers Drug Initial Daily Dose(s) Maximum Doses(s) Bisoprolol 1.25 mg once 10 mg once Carvedilol mg twice 25 mg twice 50 mg twice for patients > 85 kg Metoprolol succinate extended release (metoprolol CR/XL) 12.5 to 25 mg once 200 mg once ended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotroshould be initiated at a low dose and only in stable patients. Caution should be used when initiating beta blockers in patients who have required inotropes during their hospital course. (Class I, Level of Evidence: B) (ACCF/AHA, 2013) MSSP 2016 Measures Page 115 of 199 Updated: 6/13/2016 Heart Failure: Beta-Blocker Therapy for LVSD

116 Reporting Criteria There are two reporting criteria for this measure: (1) All patients with a diagnosis of HF seen in the outpatient setting with two denominator eligible visits: Use Reporting Criteria 1. Report Annually. OR (2) All patients with a diagnosis of HF and discharged from hospital: Use Reporting Criteria 2. Report at each hospital discharge. Pt with Diagnosis of Heart Failure Seen in Outpatient Setting and had 2 denominator eligible visits Discharged from Hospital Reporting Criteria 1 (Once a Year) Reporting Criteria 2 (For EACH Discharge) MSSP 2016 Measures Page 116 of 199 Updated: 6/13/2016 Heart Failure: Beta-Blocker Therapy for LVSD

117 REPORTING CRITERIA 1: All patients with a diagnosis of HF seen in the outpatient setting DENOMINATOR (REPORTING CRITERIA 1): Patients aged 18 years on date of encounter AND Diagnosis for heart failure AND Seen in Outpatient setting AND Two Denominator Eligible Visits AND Left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely depressed left ventricular systolic function: G8923 FREQUENCY: Reported once in the measurement year for patients seen in the outpatient setting Patients who were prescribed beta-blocker therapy within a 12 month period when seen in the outpatient setting Definitions: Prescribed Outpatient Setting - May include prescription given to the patient for beta-blocker therapy at one or more visits in the measurement period OR patient already taking beta-blocker therapy as documented in current medication list. Beta-blocker Therapy - For patients with prior LVEF <40%, beta-blocker therapy should include bisoprolol, carvedilol, or sustained release metoprolol succinate. DENOMINATOR NOTE: LVEF < 40% corresponds to qualitative documentation of moderate dysfunction or severe LVSD Performance Met HCPCS Code G8450: Patients who were prescribed beta-blocker therapy within a 12 month period when seen in the outpatient setting Exclusion/Exception From Performance Measurement HCPCS Code G8451: Beta-Blocker Therapy for LVEF < 40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient declined, other patient reasons, or other reasons attributable to the healthcare system) Performance Not Met HCPCS Code G8452: Beta-blocker therapy not prescribed Eligible Cases for Criteria 1 (HF and seen in Outpatient Setting) Patients aged 18 years AND Diagnosis for HEART FAILURE: ICD-10-CM Diagnosis for heart failure (ICD-10-CM) : I11.0, I13.0, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9 AND AND AND Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, TWO Denominator Eligible visits during the measurement period Left Ventricular Ejection Fraction (LVEF) < 40% or documentation of moderately or severely depressed left ventricular systolic function: G8923 MSSP 2016 Measures Page 117 of 199 Updated: 6/13/2016 Heart Failure: Beta-Blocker Therapy for LVSD

118 REPORTING CRITERIA 2: All patients with a diagnosis of HF and discharged from hospital DENOMINATOR (REPORTING CRITERIA 2): Patients aged 18 years AND Diagnosis for heart failure AND Discharged from the hospital AND Left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely depressed left ventricular systolic function: G8923 FREQUENCY: At each hospital discharge Patients who were prescribed beta-blocker therapy at hospital discharge Definitions: Prescribed Inpatient Setting: May include prescription given to the patient for beta-blocker therapy at discharge OR beta-blocker therapy to be continued after discharge as documented in the discharge medication list. Beta-blocker Therapy For patients with prior LVEF < 40%, beta-blocker therapy should include bisoprolol, carvedilol, or sustained release metoprolol succinate. Performance Met HCPCS Code G8450: Beta-blocker therapy prescribed Exclusion/Exception from Performance Measurement HCPCS Code G8451: Beta-Blocker Therapy for LVEF < 40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient declined, other patient reasons, other reasons attributable to the healthcare system) Performance Not Met HCPCS Code G8452: Beta-blocker therapy not prescribed Eligible Cases for Criteria 2 (HF and Discharged from Hospital) Patients aged 18 years AND Diagnosis for HEART FAILURE Diagnosis for heart failure (ICD-10-CM): I11.0, I13.0, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9 AND Patient encounter during the reporting period (CPT): 99238, AND Left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely depressed left ventricular systolic function: G8923 MSSP 2016 Measures Page 118 of 199 Updated: 6/13/2016 Heart Failure: Beta-Blocker Therapy for LVSD

119 2016 MSSP Reporting Data Collection Form Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Target Population Age: Patients aged 18 years and older Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient 18 years of age or older? Yes Continue to Q2 No Stop Q2: Determine if the patient has a Acive Diagnosis of Heart Failure at any time in the patient s history up through the last day of the measurement period 2016 Yes No Continue to Q3 Stop Q3: Determine if the patient has LVSD (LVEF < 40%) or documented as moderate or severe) Yes Continue to Q4 Step 2 Did you meet the measure? No Stop Q4: Determine if the patient was prescribed Beta-Blocker therapy at any time during the measurement period Yes No If no, go to Q5 Q5: Determine if there is documented medical or patient reason(s) for not prescribing Beta-Blocker Therapy (a) Medical Reasons: Select this option if the patient was not prescribed Beta-Blocker for medical reasons and the reason is documented. (b) Patient Reasons: Select this option if the patient was not prescribed Beta-Blocker Therapy for patient reasons (c) System Reasons: Select this option if the patient was not prescribed Beta-Blocker Therapy for system reasons (d) No Reason Documented If (a) or (b) or (c) or (d) are checked, Stop. MSSP 2016 Measures Page 119 of 199 Updated: 6/13/2016 Heart Failure: Beta-Blocker Therapy for LVSD

120 REPORTING CRITERIA 2 REPORTING CRITERIA 1 Step 3 Reporting Options. Q 6: Determine the Reporting Criteria (1 or 2 ) To determine which code to use, choose which scenario is applicable to the patient: HF OUTPATIENT: Scenario A: Patient has HF INPATIENT: Scenario C: Patient has LVEF < 40% OR or documentation of moderately or severely depressed LVSD Two Denominator Eligible Visits (see Eligibility table) LVEF < 40% OR or documentation of moderately or severely depressed LVSD Patient encounter during the reporting period (see Eligibility table) Use Reporting Criteria 1 Use Reporting Criteria 2 REPORTING CRITERIA (OUTPATIENT) Patient has HF AND LVEF < 40% or documentation of moderately or severely depressed LVSD AND Two Denominator Eligible Visits Check One: Patients who were prescribed beta-blocker therapy within a 12 month period when seen in the outpatient setting Beta-Blocker Therapy for LVEF < 40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient declined, other patient reasons, or other reasons attributable to the healthcare system) HCPCS Code G8450 HCPCS Code G8451 Beta-blocker therapy not prescribed HCPCS Code G8452 REPORTING CRITERIA 2 (INPATIENT) Patient has HF AND LVEF < 40% or documentation of moderately or severely depressed LVSD AND Patient encounter during reporting period Check One: Beta-blocker therapy prescribed HCPCS Code G8450 Beta-Blocker Therapy for LVEF < 40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an HCPCS Code G8451 intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient declined, other patient reasons, other reasons attributable to the healthcare system) Beta-blocker therapy not prescribed HCPCS Code G8452 For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 120 of 199 Updated: 6/13/2016 Heart Failure: Beta-Blocker Therapy for LVSD

121 Diabetes: HbA1c Testing & HbA1c Control Measure: BCBS HMO United Commercial United Medicare Comprehensive Diabetes Care HbA1c Testing & HbA1c Control HEDIS Measure CPT II coding required: YES Click here to go to Table of Contents BCBS, United Measure: HbA1c Testing & HbA1c Control Page 121 of 199 Dated: 6/13/2016

122 2016 BCBS ACO Measures Reporting Tracking Performance for Quality Improvement Comprehensive Diabetes Care 2 Measures: HbA1c Testing & HbA1c Control These measures looks at the percentage of members aged years with diabetes (type 1 and type 2) who had: (a) HbA1c testing in the measurement year (b) HbA1c <8% A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement Report HbA1c between 7-9. CI Dept at IHP will follow-up with your practice for the exact HbA1c value if needed. RATIONALE: The serious complications of diabetes are well known: cardiovascular disease, nephropathy, retinopathy, and neuropathy. These microvascular and macrovascular complications can have devastating consequences on the health of people with diabetes. Studies have shown that, in general, every reduction in A1c level of 1% (e.g., from 8% to 7%) reduces the risk of developing microvascular complications by 40%. The ADA recommends a treatment goal of A1c <7%. The intent of these measures is to promote regular HbA1c testing and HbA1c control. Measure Specifications DENOMINATOR Patients age at the end of the measurement year with a diagnosis of type 1 or type 2 diabetes (diagnosis of diabetes based on claims or pharmacy data) Inclusion Criteria: Patients who meet the age requirement in the measurement year and meet at least one of the three event conditions that identify diabetes in either the measurement year or the year prior to the measurement year At least one ambulatory prescription for insulin or an oral hypoglycemic/ antihyperglycemic drug. At least two face-to-face encounters with different dates of service in an ambulatory setting or nonacute inpatient setting with a diagnosis of diabetes (ICD9 250.xx, 362.xx,366.41, 648.0). At least one face-to-face encounter in an inpatient or emergency room setting with a diagnosis of diabetes. NUMERATOR (a) HbA1c test during measurement year (b) HbA1c <8% - most recent DENOMINATOR Exclusions: *Change in 2016 Gestational diabetes Steroid induced diabetes *Please note, polycystic ovaries were removed as an exclusion in Exceptions: None Procedure Codes & Code Descriptors Performance Met CPT II Code 3044 F: Most recent HbA1c value < 7.0 % OR Exclusion/Exception from Performance Measure Exclusions: Gestational diabetes and steroid induced diabetes only. Polycystic ovaries no longer an exclusion. Exceptions: None OR Most recent HbA1c level % CPT Category II code 3045F: Most recent hemoglobin A1c (HbA1c) level % Per NCQA*, CPT Category II code 3045F indicates most recent hemoglobin A1c (HbA1c) level % and is not specific enough to denote numerator compliance for this indicator. For members with this code, the organization may elect to use other sources (laboratory data, hybrid reporting method) to determine if the HbA1c result was less than 8%. OR Performance Not Met CPT II Code 3046F: Most recent hemoglobin A1c level > 9.0% Performance Not Met CPT II 3046F-8P: Hemoglobin A1c not Performed, Reason not Otherwise Specified BCBS, United Measure: HbA1c Poor Control Page 122 of 199 Updated: 6/13/2016

123 Table1: Codes to identify Diabetes Description Diabetes Value Set Diabetes mellitus without mention of complication ICD-9-CM Diagnosis ICD-10-CM See HEDIS 2016 spec manual Polyneuropathy in diabetes Diabetic retinopathy Diabetic cataract Diabetes Mellitus HEDIS 2016 Specification Manual Table 2: Codes to identify Visit Type Description CPT and HCPCS UBREV Outpatient HCPCS: , , , , , , , , , 99411, 99412, 99420, 99429, 99455, 99456, HCPCS: G0402, G0438, G0439, G0463, T1015 Observation , 0519, , , 0982, 0983 Non-acute inpatient , 99315, 99316, 99318, , Acute inpatient , , 99238, 99239, , , 0024, 0018, 0128, 0138, 0148, 0158, , 0199, 0524, 0525, , 0559, , 0669, , 0101, , 0119, , 0129, , 0139, , 0149, , 0159, 0160, 0164, 0167, 0169, , , 0219, , 0729, 0987 ED , 0456, 0459, 0981 Source: HEDIS 2016 Specification Manual Table 3: Codes to Identify Diabetes Exclusions Description ICD-10-CM Diagnosis Diabetes Exclusion Value Set Steroid Induced See HEDIS 2016 specs See HEDIS 2016 specs Gestational diabetes See HEDIS 2016 specs Source: HEDIS 2016 Specification Manual BCBS, United Measure: HbA1c Poor Control Page 123 of 199 Updated: 6/13/2016

124 Table 4: Prescriptions to Identify Patients with Diabetes Description Prescription Alpha-glucosidase inhibitors Acarbose Miglitol Amylin analogs Antidiabetic combinations Insulin Pramlinitide Alogliptin-metformin Alogliptin-pioglitazone Canagliflozin-metformin Glimepiride-pioglitazone Glimepiride-rosiglitazone Glipizide-metformin Insulin aspart Insulin aspart-insulin aspart protamine Insulin detemir Insulin glargine Insulin glulisine Glyburide-metformin Linagliptin-metformin Metformin-pioglitazone Metformin-repaglinide Metformin-rosiglitazone Metformin-saxagliptin Meglitinides Nateglinide Repaglinide Glucagon-like peptide-1 (GLP1) agonists Sodium glucose cotransporter 2 (SGLT2) inhibitor Sulfonylureas Insulin isophane human Insulin isophane-insulin regular Insulin lispro Insulin lispro-insulin lispro protamine Insulin regular human Metformin-sitagliptin Sitagliptin-simvastatin Exenatide Liraglutide Albiglutide Canagliflozin Dapagliflozin Empagliflozin Chlorpropamide Glimepiride Glipizide Glyburide Thiazolidinediones Pioglitazone Rosiglitazone Tolazamide Tolbutamide Dipeptidyl peptidase-4 (DDP-4) inhibitors Source: HEDIS 2016 Specification Manual Alogliptin Linagliptin Saxagliptin Sitaglipin Table 4: Codes to identify HbA1c Tests CPT CPT Category II 83036, Checked: 3044F, 3045F, 3046F Source: HEDIS 2016 Specification Manual Table 5: Codes to identify HbA1c Levels and Compliance Most recent HbA1c level less than 7.0% (Numerator Compliant) CPT II 3044 F Most Recent Hemoglobin A1c Level between % (Not Specific enough*) CPT II 3045 F* Most Recent Hemoglobin A1c Level > 9.0% (Not Numerator Compliant) Hemoglobin A1c not Performed, Reason not Otherwise Specified (Not Numerator Compliant) CPT II 3046F CPT II 3046F-8P * Per HEDIS guidelines, CPT Category II code 3045F indicates most recent HbA1c (HbA1c) level 7.0% 9.0% and is not specific enough to denote numerator compliance for this indicator. For members with this code, the organization may use other sources (laboratory data, hybrid reporting method) to determine if the HbA1c result was <8%. Because providers assign the Category II code after reviewing test results, the date of service for the Category II code may not match the date of service for the HbA1c test found in other sources; if dates differ, use the date of service when the test was performed. BCBS, United Measure: HbA1c Poor Control Page 124 of 199 Updated: 6/13/2016

125 2016 BCBS ACO Reporting Data Collection Form COMPREHENSIVE DIABETES CARE HbA1c Testing & HbA1c Control Target Population Age: Patients aged years Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient years of age? Yes No Continue to Q2 Stop Q2: Determine if the patient has a documented history of DM during the measurement period or year prior to the measurement period (see Detailed Denominator Criteria above) Yes No Continue to Q3 Stop Q3: Are there any medical exclusions for excluding the patient from this measure and the reason is documented (e.g., Diagnosis of polycystic ovaries?, gestational diabetes or steroid induced diabetes? No Continue to Q4 Step 2 Did you meet the measure? Yes Stop. Patient will be excluded from denominator Q4: Determine if the patient had one or more HbA1c tests performed during the measurement period. Yes No Continue to Q 5 If selected - do not provide Date Drawn and HbA1c Value Q5: If yes to Q4, complete the following. Use the following priority ranking: i) Lab report draw date ii) Lab report date iii) Flow sheet documentation iv) Practitioner notes v) Other documentation Record the most recent date the blood was drawn for the Record the most recent HbA1c value OR if test was performed HbA1c in mm/dd/yyyy format but result is not documented, record "0" (zero) value / / Step 3 Reporting Options. Based on the values in Q6, Select one of the reporting options below: Most recent HbA1c level less than 7.0% CPT II 3044 F Most Recent Hemoglobin A1c Level between % CPT II 3045 F Most Recent Hemoglobin A1c Level > 9.0% CPT II 3046F Hemoglobin A1c not Performed, Reason not Otherwise Specified CPT II 3046F-8P * Per HEDIS guidelines, CPT Category II code 3045F indicates most recent HbA1c (HbA1c) level 7.0% 9.0% and is not specific enough to denote numerator compliance for this indicator. For members with this code, the organization may use other sources (laboratory data, hybrid reporting method) to determine if the HbA1c result was <8%. Because providers assign the Category II code after reviewing test results, the date of service for the Category II code may not match the date of service for the HbA1c test found in other sources; if dates differ, use the date of service when the test was performed. BCBS, United Measure: HbA1c Poor Control Page 125 of 199 Updated: 6/13/2016

126 Diabetes: Hemoglobin A1c Poor Control Measure: MSSP Diabetes: Hemoglobin A1c Poor Control Domain: At-Risk Population ACO 27 DM-2 PQRS 1 NQF 0059 Measure Developer: NCQA ACO submits data to CMS CPT II coding required: YES Diabetes Eye Exam (DM-7) and Diabetes HbA1c Poor Control measure (DM-2) are scored together as a Composite measure: ALL OR NONE SCORING Click here to go to Table of Contents BCBS, United Measure: HbA1c Poor Control Page 126 of 199 Updated: 6/13/2016

127 2016 MSSP ACO Measures Reporting Tracking Performance for Quality Improvement Diabetes: Hemoglobin A1c Poor Control This measure looks at the percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period For performance, a lower rate indicates better performance/control. Key: Performance Met Performance Not Met Excluded from Performance Measurement RATIONALE: Diabetes mellitus is a group of diseases characterized by high blood glucose levels caused by the body's inability to correctly produce or utilize the hormone insulin. It is recognized as a leading cause of death and disability in the U.S. and is highly underreported as a cause of death. Diabetes may cause life-threatening, life ending or life-altering complications, including poor circulation, nerve damage or neuropathy in the feet and eventual amputation. Nearly percent of diabetics suffer from mild or severe nervous system damage. Improved glycemic control, as evidenced by reduced levels of glycohemoglobin, correlates with a reduction in the development of microvascular complications in both Type 1 and Type 2 diabetes. In particular, the Diabetes Control and Complications Trial (DCCT) showed that for patients with Type 1 diabetes mellitus, important clinical outcomes such as retinopathy (an important precursor to blindness), nephropathy (which precedes renal failure), and neuropathy (a significant cause of foot ulcers and amputation in patients with diabetes) are directly related to level of glycemic control. ELIGILBLE POPULATION Measure Specifications All patients aged 18 through 75 years of age + Diabetes + Visit during the measurement period NUMERATOR: Patients whose most recent HbA1c level (performed during the measurement period) is > 9.0% A lower calculated performance rate for this measure indicates better clinical care or control. DENOMINATOR Exclusions: None Exceptions: None Eligible exclusions/exceptions have already been removed Procedure Codes & Code Descriptors All Codes C hecked 5 27 Choose one of the following Performance Met (want this number low) CPT II code 3046F: Most Recent Hemoglobin A1c Level > 9.0% Exclusion/Exceptions None: Eligible exclusions/exceptions have already been removed OR Performance Not Met Use CPT II code 3044F: Most recent hemoglobin A1c (HbA1c) level < 7.0% OR Use CPT II code 3045F: Most recent hemoglobin A1c (HbA1c) level 7.0 to 9.0% OR Performance Not Met CPT II code 3046F with 8P HbA1c was not performed during the performance period and the reason is not otherwise specified. BCBS, United Measure: HbA1c Poor Control Page 127 of 199 Updated: 6/13/2016

128 Diabetes: Hemoglobin A1c Poor Control Patient encounter during the reporting with: Patients yrs of AND Diagnosis of Diabetes age + Encounter date in 2016 Exclusions: None Diagnosis for diabetes (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, E13.36, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83 And Patient Encounter During the Reporting Period (CPT or HCPCS): CPT or HCPCS Patient encounter during reporting period (CPT or HCPCS): 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271, G0402, G0438, G0439 BCBS, United Measure: HbA1c Poor Control Page 128 of 199 Updated: 6/13/2016

129 DM 2: Hemoglobin A1c Poor Control 2016 Description: Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period. Denominator Exclusions: None Denominator Exceptions: None What is the Quality Action? Performance of an HbA1c test and documentation of its result. The patient is numerator compliant if the most recent HbA1c level is > 9.0% OR is missing a result OR if an HbA1c test was not done. Note - this is an inverse measure where a lower score indicates better quality. Where may the Quality Action take place? Must take place in a healthcare setting. Who may perform the Quality Action? Any qualified healthcare professional may obtain the HbA1c test and record its result. When must the Quality Action be performed? The HbA1c test must be performed, and its results documented, within the measurement period. more than one HbA1c test performed, use the most recent. If there is What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: A diagnosis of diabetes; and The date and value of the HbA1c test. BCBS, United Measure: HbA1c Poor Control Page 129 of 199 Updated: 6/13/2016

130 2016 MSSP Reporting Data Collection Form Diabetes Mellitus: Hemoglobin A1c Poor Control Target Population Age: Patients aged years Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient years of age? Yes Continue to Q2 No Stop Q2: Determine if the patient has a documented history of DM during the measurement period or year prior to the measurement period Yes Continue to Q3 No Stop Q3: Was the patient seen for a visit in the measurement year? Yes Continue to Q4 No Stop Step 2 Did you meet the measure? Q4: Determine if the patient had one or more HbA1c tests performed during the measurement period Yes No Continue to Q 5 If selected - do not provide Date Drawn and HbA1c Value Q5: If yes to Q4, complete the following. Use the following priority ranking: i) Lab report draw date ii) Lab report date iii) Flow sheet documentation iv) Practitioner notes v) Other documentation Record the most recent date the blood was drawn for the HbA1c in mm/dd/yyyy Record the most recent HbA1c value OR if test was performed but format result is not documented, record "0" (zero) value / / This information will be required at the time of GPRO submission and will be requested for the patients who are selected by CMS for sampling. Step 3 Reporting Options. Based on the values in Q5, Select one of the reporting option below: Most recent hemoglobin A1c (HbA1c) level < 7.0% CPT II 3044F Most recent hemoglobin A1c (HbA1c) level 7.0 to 9.0% CPT II 3045F Most Recent Hemoglobin A1c Level > 9.0% CPT II 3046F Hemoglobin A1c level was not performed during the performance period (12 months) CPT II 3046F - 8P For Practice Use: Form Completed by: Date: BCBS, United Measure: HbA1c Poor Control Page 130 of 199 Updated: 6/13/2016

131 Diabetes: Eye Exam Measure: MSSP United Medicare BCBS HMO Diabetes : Eye Exam Domain: At-Risk Population ACO 41 DM-7 PQRS 117 NQF 0055 Measure Developer: NCQA ACO submits data to CMS CPT II coding required: YES Diabetes Eye Exam (DM-7) and Diabetes HbA1c Poor Control measure (DM-2) are scored together as a Composite measure: ALL OR NONE SCORING Click here to go to Table of Contents MSSP 2016 Measures Page 131 of 199 Updated: 6/13/2016 Diabetes: Eye Exam

132 2016 MSSP, BCBS, United ACO Measures Reporting Tracking Performance for Quality Improvement Diabetes: Eye Exam This measure looks at the percentage of patients years of age with diabetes (type 1 and type 2) who had a retinal or dilated eye exam by an eye care professional during the measurement period OR a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period. For retinal or dilated eye exams performed 12 months prior to the measurement period, an automated* result must be available. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement A higher score indicates better quality. RATIONALE: Diabetes mellitus is a group of diseases characterized by high blood glucose levels caused by the body's inability to correctly produce or utilize the hormone insulin. It is recognized as a leading cause of death and disability in the U.S. Diabetes of either type may cause life-threatening, life-ending or life-altering complications, including glaucoma and blindness. Diabetic retinopathy is the most common diabetic eye disease and causes 21,000 24,000 new cases of blindness annually. The consensus among established clinical guidelines is that patients with both types of diabetes should have an initial dilated and comprehensive eye exam soon after diagnosis. Guidelines also recommend consultation with an ophthalmologist for treatment options if a patient has any level of macular edema or diabetic retinopathy (proliferative and nonproliferative) (American Diabetes Association 2009). ELIGILBLE POPULATION Measure Specification Yrs + Diabetes + Visit during the measurement period NUMERATOR: Patients who had a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement period OR a negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional (optometrist or ophthalmologist) in the year prior to the measurement period. For retinal or dilated eye exams performed 12 months prior to the measurement period, an automated result* must be available. DENOMINATOR Exclusions: None Exceptions: None Eligible exclusions/exceptions have already been removed Procedure Codes & Code Descriptors Choose one of the following Numerator Quality-Data Coding Performance Met CPT II code 2022F: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed OR Performance Met CPT II code 2024F: Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed: OR Performance Met CPT II code 2026F Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed: OR Performance Met CPT II code 3072F : Low risk for retinopathy (no evidence of retinopathy in the prior year)* *Note: This code can only be used if the claim/encounter was during the measurement period because it indicates that the patient had no evidence of retinopathy in the prior year. This code definition indicates results were negative; therefore an automated result is not required Exclusion/Exceptions from Performance Measurement Exclusions/Exceptions: None; Eligible exclusions/exceptions have already been removed OR Performance Not Met CPT II code 2022F with 8P or CPT II code 2024F with 8P or CPT II code 2026F: Retinal or Dilated Eye Exam not Performed, Reason not Otherwise Specified MSSP 2016 Measures Page 132 of 199 Updated: 6/13/2016 Diabetes: Eye Exam

133 Definitions: * Automated Result Electronic system-based data that includes results generated from test or procedures. For administrative data collection automated/electronic results are necessary in order to show that the exam during the 12 months prior was negative for retinopathy Diabetes Mellitus Eye Exam: Eligible Cases Patients Yrs of age + Encounter date in 2016 Exclusions: None AND Patient encounter during the reporting with: Diagnosis of Diabetes Diagnosis for diabetes (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, E13.36, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83 And Patient Encounter During the Reporting Period (CPT or HCPCS): CPT or HCPCS Patient encounter during the reporting period (CPT or HCPCS): 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439 MSSP 2016 Measures Page 133 of 199 Updated: 6/13/2016 Diabetes: Eye Exam

134 DM-7: Eye Exam 2016 DM-7 is one of two component measures comprising the DM Composite Description: Percentage of patients years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period. Denominator Exclusions: None Denominator Exceptions: None What is the Quality Action? Performance of a retinal or dilated eye exam. Retinal imaging is also acceptable if reviewed by an appropriate professional as described below. Who may perform the Quality Action? The eye exam must be performed by or results reviewed by an ophthalmologist or optometrist. When must the Quality Action be performed? The retinal or dilated eye exam can occur during the measurement period OR a negative retinal exam (no evidence of retinopathy) in the year prior to the measurement period. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: A diagnosis of diabetes; and If the eye exam was performed during the measurement period, the date of the exam; or if the eye exam was performed the year prior to the measurement period, the date and result of the eye exam; or If retinal imaging was performed, the date imaging was performed and evidence that it was reviewed by an eye care professional. What are the documentation requirements relative to the Quality Action? (cont.) NOTE: The measure permits the use of retinal imaging provided it includes the date the fundus photography was performed and evidence that an eye care professional (optometrist or ophthalmologist) reviewed the results. Alternatively, results may be read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist. For example, if an endocrinologist or PCP performs the appropriate imaging in their office and the results are reviewed by an eye care professional (optometrist or ophthalmologist) during the measurement period or the year prior to the measurement period (if negative for retinopathy) then it is eligible for use in reporting. MSSP 2016 Measures Page 134 of 199 Updated: 6/13/2016 Diabetes: Eye Exam

135 2016 MSSP Reporting Data Collection Form Diabetes Mellitus: Eye Exam Target Population Age: Patients aged years Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient years of age? Yes Continue to Q2 No Stop Q2: Determine if the patient has a documented history of DM during the measurement period or year prior to the measurement period Yes Continue to Q3 No Stop Q3: Was the patient seen for a visit in the measurement year? Yes Continue to Q4 No Stop Step 2 Did you meet the measure? Q4: Determine if patient was screened for diabetic retinal disease identified by one of the following: A retinal or dilated eye exam by an eye care professional during the measurement period OR A negative retinal exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement period. Note: The eye exam must be performed by an ophthalmologist or optometrist Yes No Note: Automated Result is defined as Electronic system-based data that includes results generated from test or procedures. For administrative data collection automated/electronic results are necessary in order to show that the exam during the12 months prior was negative for retinopathy Step 3 Reporting Options. Based on the values in Q4, Select one of the reporting option below: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed Low risk for retinopathy (no evidence of retinopathy in the prior year)* *Note: This code can only be used if the claim/encounter was during the measurement period because it indicates that the patient had no evidence of retinopathy in the prior year. This code definition indicates results were negative; therefore an automated result is not required. Retinal or Dilated Eye Exam not Performed, Reason not Otherwise Specified CPT II code 2022F CPT II code 2024F CPT II code 2026F CPT II code 3072F CPT II code 2022F with 8P or CPT II code 2024F with 8P or CPT II code 2026F with 8P For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 135 of 199 Updated: 6/13/2016 Diabetes: Eye Exam

136 Diabetes: Attention to Nephropathy Measure: BCBS HMO United Medicare United Commercial Diabetes: Attention to Nephropathy PQRS 119 NQF 0062 CPT II coding required: YES Click here to go to Table of Contents. BCBS QIPP, United Measures Page 136 of 199 Updated: 6/13/2016 Diabetes: Attention to Nephropathy

137 2016 BCBS ACO Measures Reporting Tracking Performance for Quality Improvement Diabetes: Attention to Nephropathy This measure looks at the percentage of patients years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period A higher rate indicates better performance/control. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: Diabetes mellitus (diabetes) is a group of diseases characterized by high blood glucose levels caused by the body's inability to correctly produce or utilize the hormone insulin. It is recognized as a leading cause of death and disability in the U.S. and is highly underreported as a cause of death (). Diabetes may cause life-threatening, life-ending or life-altering complications, including endstage kidney disease. Diabetes is the primary cause of kidney failure, accounting for 44 percent of newly diagnosed cases in Clinical guidelines recommend regular testing to evaluate urine albumin excretions and serum creatinine and the estimated glomerular filtration rate derived from serum creatinine, in addition to comparing measurements when screening for chronic kidney disease. CLINICAL RECOMMENDATION STATEMENTS: Perform an annual test to assess urine albumin excretion in type 1 diabetic patients with diabetes duration of >=5 years and in all type 2 diabetic patients, starting at diagnosis. Measure serum creatinine at least annually in all adults with diabetes regardless of the degree of urine albumin excretion. The serum creatinine should be used to estimate GFR and stage the level of chronic kidney disease (CKD), if present. In the treatment of the non-pregnant patient with micro- or macroalbuminuria, either ACE inhibitors or ARBs should be used. (References: National Institute of Diabetes and Digestive and Kidney Diseases 2011, American Diabetes Association 2009; American Association of Clinical Endocrinologists 2007) Target Population ELIGILBLE POPULATION All patients aged years of age + Diagnosis of Diabetes Mellitus + Visit during the measurement period NUMERATOR: The percentage of patients years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period DENOMINATOR Exclusions: None Exceptions: None Eligible exclusions/exceptions have already been removed Choose one of the following Coding Options (A) Performance Met Procedure Codes & Code Descriptors CPT II code 3060F : Positive microalbuminuria test result documented and reviewed: OR CPT II code 3061F: Negative microalbuminuria test result documented and reviewed: OR CPT II code 3062F: Positive macroalbuminuria test result documented and reviewed: OR CPT II Code 3066F:Documentation of treatment for nephropathy (e.g., patient receiving dialysis, patient being treated for ESRD, CRF, ARF, or renal insufficiency, any visit to a nephrologist): OR HCPCS code G8506: Patient receiving angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy: Exclusion/Exception from Performance Measurement None Performance Not Met 3060F or 3061F or 3062F with 8P: Nephropathy screening was not performed, reason not otherwise specified. BCBS QIPP, United Measures Page 137 of 199 Updated: 6/13/2016 Diabetes: Attention to Nephropathy

138 Diabetes: Attention to Nephropathy: Eligible Patients Patient encounter during the reporting with: Patients YRS of age + Encounter date in measurement period Exclusions: None AND Diagnosis of Diabetes Diagnosis for diabetes (ICD-10-CM) :E08.21, E08.22, E08.29, E09.21, E09.22, E09.29, E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, E13.36, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83 And Patient Encounter During the Reporting Period (CPT or HCPCS): CPT or HCPCS Patient encounter during the reporting period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439 BCBS QIPP, United Measures Page 138 of 199 Updated: 6/13/2016 Diabetes: Attention to Nephropathy

139 2016 MSSP Reporting Data Collection Form Diabetes: Attention to Nephropathy Target Population Age: Patients aged years Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient years of age? Yes No Continue to Q2 Stop Q2: Determine if the patient has a documented history of DM during the measurement period or year prior to the measurement period (see Detailed Denominator Criteria above) Yes No Continue to Q3 Stop Step 2 Did you meet the measure? Q3: Determine if the patient had a nephropathy screening test or evidence of nephropathy during the measurement period. Yes Choose one of the reporting options blow No Choose the reporting option below to report that nephropathy screening was not performed Step 3 Reporting Options. Based on the values in Q3, Select one of the reporting options below: Positive microalbuminuria test result documented and reviewed CPT II code: 3060F Negative microalbuminuria test result documented and reviewed CPT II code 3061F Positive macroalbuminuria test result documented and reviewed CPT II code 3062F Documentation of treatment for nephropathy (e.g., patient receiving dialysis, patient being treated for ESRD, CRF, ARF, or renal insufficiency, any visit to a nephrologist) Patient receiving angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy NEPHROPATHY SCREENING WAS NOT PERFORMED: Append a reporting modifier (8P) to CPT Category II code 3060F or 3061F or 3062F CPT II code 3066F HCPCS code G8506 CPT II code: 3060F -8P or 3061F -8P or 3062F - 8P BCBS QIPP, United Measures Page 139 of 199 Updated: 6/13/2016 Diabetes: Attention to Nephropathy

140 Diabetes: Screening for Depression Measure: BCBS Diabetes Screening for Depression CPT II coding required: YES Click here to go to Table of Contents BCBS Measure Page 140 of 199 Updated: 6/13/2016 Diabetes: Screening for Depression

141 2016 BCBS HMO QI Measure Reporting Tracking Performance for Quality Improvement Diabetes Mellitus: Screening for Depression A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE:CLINICAL RECOMMENDATION STATEMENTS: Measure Specifications Procedure Codes & Code Descriptors ELIGILBLE POPULATION All patients aged years of age + Diagnosis of Diabetes Mellitus + Visit during the measurement period NUMERATOR Number of patients who were screened for depression using a standardized screening tool DENOMINATOR Exclusions: *Change in 2016 Gestational diabetes Steroid induced diabetes Diagnosis of depression since 1/1/2015 *Please note, polycystic ovaries were removed as an exclusion in Exceptions: None Performance Met HCPCS Code G8431: Screening for clinical depression documented as positive AND follow up plan documented OR HCPCS Code G8510: Screening for clinical depression documented as negative, follow up plan not required Exclusion/Exception from Performance Measurement HCPCS Code G8433: Screening for clinical depression not documented, documentation states patient not eligible per exclusion definitions Exclusions: *Gestational diabetes, steroid induced diabetes, diagnosis of depression Exclusion/Exception from Performance Measurement HCPCS Code G8940: Screening for clinical depression documented as positive, follow up plan not documented, patient not eligible per exclusion definitions Exclusions: *Gestational diabetes, steroid induced diabetes, diagnosis of depression Performance Not Met HCPCS Code G8432: Screening for clinical depression not documented, reason not given Performance Not Met HCPCS Code: G8511: Screening for clinical depression documented as positive, follow up plan not documented, reason not given BCBS Measure Page 141 of 199 Updated: 6/13/2016 Diabetes: Screening for Depression

142 2016 BCBS Measure Reporting Data Collection Form Diabetes Mellitus: Screening for Depression Target Population Age: Patients aged years Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient years of age with a visit during the measurement period? Yes No Continue to Q2 Stop Q2: Determine if the patient has a documented history of DM during the measurement period or year prior to the measurement period Yes No Continue to Q3 Stop Q3: Are there any medical exclusions for excluding the patient from this measure and the reason is documented (e.g., Diagnosis, gestational diabetes or steroid induced diabetes? No Yes Continue to Q4 Stop Step 2 Did you meet the measure? Q4: Determine if the patient was screened with a standardized depression screening tool? Yes Continue to Q 5 Step 3 Reporting Options. No Go to Step 3 Based on the values in Q4, Select one of the reporting options below: Screening for clinical depression is documented as being positive AND a follow-up plan is documented Screening for clinical depression is documented as negative, a follow-up plan is not required Screening for clinical depression not documented, documentation stating the patient is not eligible Screening for clinical depression documented as positive, a follow-up plan not documented, documentation stating the patient is not eligible Clinical depression screening not documented, Reason not given Screening for Clinical Depression Documented as Positive, Follow-Up Plan not Documented, Reason not Given HCPCS Code G8431 HCPCS Code G8510 HCPCS Code G8433 HCPCS Code G8940 HCPCS Code G8432 HCPCS Code G8511 For Practice Use: Form Completed by: Date: BCBS Measure Page 142 of 199 Updated: 6/13/2016 Diabetes: Screening for Depression

143 ACE Inhibitor or ARB Therapy Diabetes or LVSD (LVEF < 40%) Measure: MSSP Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) Domain: At Risk Population ACO 33 CAD -7 PQRS -118 NQF 0066 Measure Steward: AMA/PCPI/ACC/AHA ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP 2016 Measures Page 143 of 199 Updated: 6/13/2016 ACE/ARB for Pts with CAD & Diabetes or CAD & LVSD

144 2016 MSSP ACO Measures Reporting Tracking Performance for Quality Improvement Coronary Artery Disease (CAD): ACE/ARB for Patients with CAD and Diabetes or CAD and LVSD This measure looks at the percentage of patients aged 18 years and older with a diagnosis of Coronary Artery Disease (CAD) seen within a 12 month period who also have Diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy. A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: Non-adherence to cardioprotective medications is prevalent among outpatients with coronary artery disease and can be associated with a broad range of adverse outcomes, including all-cause and cardiovascular mortality, cardiovascular hospitalizations, and the need for revascularization procedures. In the absence of contraindications, ACE inhibitors or ARBs are recommended for all patients with a diagnosis of coronary artery disease and diabetes or reduced left ventricular systolic function. ACE inhibitors remain the first choice, but ARBs can now be considered a reasonable alternative. Both pharmacologic agents have been shown to decrease the risk of death, myocardial infarction, and stroke. Additional benefits of ACE inhibitors include the reduction of diabetic symptoms and complications for patients with diabetes. CLINICAL RECOMMENDATION STATEMENTS: 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease (SIHD) Reporting Criteria There are two reporting criteria for this measure: (1) Patients who are 18 years and older with a diagnosis of CAD with LVEF < 40% (without Diabetes) OR (2) Patients who are 18 years and older with a diagnosis of CAD who have Diabetes CAD + LVSD Reporting Criteria 1 CAD + Diabetes Reporting Criteria 2 CAD + Diabetes + LVSD Reporting Criteria 2 MSSP 2016 Measures Page 144 of 199 Updated: 6/13/2016 ACE/ARB for Pts with CAD & Diabetes or CAD & LVSD

145 REPORTING CRITERIA 1: All patients with a diagnosis of CAD with LVEF < 40% (without a diagnosis of Diabetes) DENOMINATOR (REPORTING CRITERIA 1): Patients 18 years of age and older AND Diagnosis of CAD with LVEF <40% AND Without Diagnosis of Diabetes EXCEPTIONS: Documentation of MEDICAL / PATIENT / SYSTEM REASON(S) If multiple diagnostic studies were performed on the same day to measure ejection fraction, use the following hierarchy to determine if LVSD is present: cardiac catheterization echocardiogram MUGA or other cardiac scan If you cannot confirm LVSD because there are no cardiac reports available, answer No. Prescribed may include prescription given to the patient for ACE inhibitor or ARB therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB therapy as documented in the current medication list. Document in medical record if patient is already taking ACE inhibitor or ARB therapy. If the medication was started anytime during the measurement period, then answer yes. If there are medical reasons to exclude a patient from this measure, these must be documented in the current medical record. DENOMINATOR Exclusions: None Exceptions: 1. Documentation of MEDICAL REASON(S) for not prescribing ACE inhibitor or ARB therapy (e.g., allergy, intolerance, pregnancy, renal failure due to ACE inhibitor, diseases of the aortic or mitral valve, other medical reasons) 2. Documentation of PATIENT REASON(S) for not prescribing ACE inhibitor or ARB therapy (e.g., patient declined, other patient reasons) 3. Documentation of SYSTEM REASON(S) for not prescribing ACE inhibitor or ARB therapy (e.g., lack of drug availability, other reasons attributable to the healthcare system) Performance Met HCPCS Code G8935: Clinician prescribed angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy Exclusion/Exception From Performance Measurement HCPCS Code G8936: Clinician documented that patient was not an eligible candidate for angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy Performance Not Met HCPCS Code G8937: Clinician did not prescribe angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy, reason not given MSSP 2016 Measures Page 145 of 199 Updated: 6/13/2016 ACE/ARB for Pts with CAD & Diabetes or CAD & LVSD

146 Eligible Cases for Reporting Criteria A : ACE/ARB for Patients with CAD and LVSD Patients aged 18 years AND Diagnosis for coronary artery disease (active or history of): Diagnosis for coronary artery disease(icd-10-cm): I20.0, I20.1, I20.8, I20.9, I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I22.0, I22.1, I22.2, I22.8, I22.9, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.2, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750, I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.83, I25.89, I25.9, Z95.1, Z95.5, Z98.61 AND Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, AND Seen for 2 Denominator Eligible visits during the measurement period AND Left Ventricular Ejection Fraction (LVEF) < 40% or documentation of moderately or severely depressed left ventricular systolic function: G8934 EXCEPTIONS: Documentation of MEDICAL PATIENT/ SYSTEM REASON(S) for not prescribing ACE inhibitor or ARB therapy MSSP 2016 Measures Page 146 of 199 Updated: 6/13/2016 ACE/ARB for Pts with CAD & Diabetes or CAD & LVSD

147 REPORTING CRITERIA 2: All patients with a diagnosis of CAD who have Diabetes DENOMINATOR (REPORTING CRITERIA 2): Patients 18 years and older And Diagnosis of CAD And Diabetes Or Diagnosis of CAD And Diabetes And LVSD NOTE Only patients who had at least two denominator eligible visits during the reporting period will be counted for Reporting Criteria 1 and 2 of this measure. EXCEPTIONS: Documentation of MEDICAL / PATIENT / SYSTEM REASON(S) for not prescribing ACE inhibitor or ARB therapy To confirm whether a CAD patient also has DM, the patient should have a documented history of diabetes in the measurement period or the year prior to the measurement period. LVSD is defined as the patient ever having an LVEF < 40% OR having an LVEF documented as moderate or severe Prescribed may include prescription given to the patient for ACE inhibitor or ARB therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB therapy as documented in the current medication list Document in medical record if patient is already taking ACE inhibitor or ARB therapy If the medication was started anytime during the measurement period, then answer yes. If there are medical reasons to exclude a patient from this measure, these must be documented in the current medical record. DENOMINATOR Exclusions: Exceptions: 1. Documentation of MEDICAL REASON(S) for not prescribing ACE inhibitor or ARB therapy (e.g., allergy, intolerance, pregnancy, renal failure due to ACE inhibitor, diseases of the aortic or mitral valve, other medical reasons) 2. Documentation of PATIENT REASON(S) for not prescribing ACE inhibitor or ARB therapy (e.g., patient declined, other patient reasons) 3. Documentation of SYSTEM REASON(S) for not prescribing ACE inhibitor or ARB therapy (e.g., lack of drug availability, other reasons attributable to the healthcare system) Performance Met HCPCS Code G8473: Clinician prescribed angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy Excluded From Performance Measurement HCPCS Code G8474: Clinician documented that patient was not an eligible candidate for angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy Performance Not Met HCPCS Code G8475: Clinician did not prescribe angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy, reason not given MSSP 2016 Measures Page 147 of 199 Updated: 6/13/2016 ACE/ARB for Pts with CAD & Diabetes or CAD & LVSD

148 Eligible Cases for Reporting Criteria B : ACE/ARB for Patients with CAD and Diabetes Patients aged 18 years AND AND AND AND Diagnosis for Coronary Artery Disease: ICD-9-CM Diagnosis for coronary artery disease(icd-10-cm): I20.0, I20.1, I20.8, I20.9, I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I22.0, I22.1, I22.2, I22.8, I22.9, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.2, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750, I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.83, I25.89, I25.9, Z95.1, Z95.5, Z98.61 Diagnosis for DIABETES Diagnosis for diabetes (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, E13.36, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9 Patient encounter during the reporting period (CPT) 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, Seen for 2 Denominator Eligible visits during the measurement period EXCEPTIONS: Documentation of MEDICAL/PATIENT/ SYSTEM REASON(S) for not prescribing ACE inhibitor or ARB therapy MSSP 2016 Measures Page 148 of 199 Updated: 6/13/2016 ACE/ARB for Pts with CAD & Diabetes or CAD & LVSD

149 CAD-7: ACE Inhibitor or ARB Therapy Diabetes or LVEF <40% 2016 Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy. Denominator Exclusions: None Denominator Exceptions: Medical reasons, patient reasons, or system reasons What is the Quality Action? Prescription of either an ACE inhibitor or ARB therapy. Where may the Quality Action take place? Must take place in a healthcare setting. Who may perform the Quality Action? Any prescribing healthcare professional may prescribe ACE inhibitor or ARB therapy. When must the Quality Action be performed? The prescription of an ACE inhibitor or ARB therapy must be documented as either initiated or continuing during the measurement period. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: A diagnosis of coronary artery disease or history of cardiac surgery; and A diagnosis of diabetes and/or LVEF < 40% (or documentation of moderate or severe) at anytime in their history, up through the last day of the measurement period; and An active prescription for an ACE inhibitor or ARB therapy anytime during the measurement period; or Documentation of the reason why the Quality Action is not performed due to an exception (see Data Guidance for specific medical, patient or system reason exceptions). MSSP 2016 Measures Page 149 of 199 Updated: 6/13/2016 ACE/ARB for Pts with CAD & Diabetes or CAD & LVSD

150 2016 MSSP Reporting Data Collection Form ACE/ARB for Patients with CAD and Diabetes or CAD and LVSD Target Population Age: Patients aged 18 years and older Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the patient 18 years of age or older? Yes Continue to Q2 No Stop Q2: Determine if the patient has a diagnosis of CAD (active or history of) at any time up through the last day of the measurement year. Yes Continue to Q3 No Stop Q3: Determine if the patient has LVSD (Current or prior LVEF < 40% or documented as moderate or severe) OR has diabetes Yes Continue to Q4 No Stop Step 2 Did you meet the measure? Q4: If the patient has LVSD and/or diabetes, determine if ACE inhibitor or ARB therapy was prescribed at any time during the measurement period Yes Continue to Q6 No If, go to Q5 Q5: Determine if there is documented medical or patient reason(s) for not prescribing ACE or ARB Therapy a. Medical Reasons: Select this option if the patient was not prescribed ACE Inhibitor or ARB Therapy for medical reasons and the reason is documented. b. Patient Reasons: Select this option if the patient was not prescribed ACE Inhibitor or ARB Therapy for medical reasons c. System Reasons: Select this option if the patient was not prescribed ACE Inhibitor or ARB Therapy for system reasons d. No Reason Documented If (a) or (b) or (c) or (d) are checked, Stop. MSSP 2016 Measures Page 150 of 199 Updated: 6/13/2016 ACE/ARB for Pts with CAD & Diabetes or CAD & LVSD

151 REPORTING CRITERIA 2 REPORTING CRITERIA 1 Step 3 Reporting Options. Q 6: Determine the Reporting Criteria (1 or 2 ) To determine which code to use, choose which scenario is applicable to the patient: Scenario A: Patient has Scenario B: Patient has Scenario C: Patient has CAD CAD CAD LVSD (LVEF < 40%) Patient has Diabetes Patient has Diabetes But does not have Diabetes Patient does not have LVSD Patient has LVSD Use Use Use Reporting Criteria 1 Below Reporting Criteria 2 Below Reporting Criteria 2 Below REPORTING CRITERIA 1 Patient has CAD with LVSD (LVEF < 40% ) without a Diagnosis of Diabetes Check One: Clinician prescribed angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy Clinician documented that patient was not an eligible candidate for angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy Clinician did not prescribe angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy, reason not given HCPCS Code G8935 HCPCS Code G8936 HCPCS Code G8937 REPORTING CRITERIA 2 Patient has CAD with a Diagnosis of Diabetes If patient with CAD has both Diabetes and LVSD, use this criteria 2. Check One: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy prescribed Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy not prescribed for reasons documented by the clinician Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy not prescribed, reason not given HCPCS Code G8473 HCPCS Code G8474 HCPCS Code G8475 For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 151 of 199 Updated: 6/13/2016 ACE/ARB for Pts with CAD & Diabetes or CAD & LVSD

152 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Measure: MSSP Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Domain: Preventive Health ACO 42 PREV 13 PQRS Measure Developer: NCQA ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP 2016 Measures Page 152 of 199 Updated: 6/13/2016 Statin Therapy for Cardiovascular Disease

153 2016 MSSP ACO Measures Reporting Tracking Performance for Quality Improvement Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Percentage of the following patients all considered at high risk of cardiovascular events who were prescribed or were on statin therapy during the measurement period: Adults aged 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR Adults aged 21 years with a fasting or direct low-density lipoprotein cholesterol (LDL-C) level 190 mg/dl; OR Adults aged years with a diagnosis of diabetes with a fasting or direct LDL-C level of mg/dl A higher score indicates better quality. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: The evidence demonstrated that cholesterol management recommendations should be based on a treatment strategy to incorporate optimal doses of statin therapy rather than on achievement of a target LDL-C level; however, it is important to monitor LDL cholesterol levels. The 2013 ACC/AHA guidelines identify four major statin benefit categories: 1. Secondary prevention in individuals with clinical ASCVD 2. Primary prevention in individuals with primary elevations (i.e., initial readings) of LDL-C >=190 mg/dl 3. Primary prevention in individuals with diabetes ages 40 to 75 years who have LDL-C 70 to 189 mg/dl 4. Primary prevention in individuals ages 40 to 75 years without diabetes but with estimated 10-year ASCVD risk >=7.5%, and LDL-C 70 to 189 mg/dl. The first three of these four categories were deemed high risk in the 2013 ACC/AHA guidelines, so this measure of statin therapy focuses on patients in those high-risk categories. CLINICAL RECOMMENDATION STATEMENTS: The addition of statin therapy reduces the risk of cardiovascular events (such as stroke and myocardial infarction) among high-risk individuals, defined as follows: individuals with clinical ASCVD, with LDL-C >= 190 mg/dl, or with or with diabetes and LDL-C mg/dl (Stone et al. 2013). Measure Specifications ELIGILBLE POPULATION Criteria 1 Adults aged 21 years + Previously diagnosed or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); + Patient encounter during measurement period OR Criteria 2 Adults aged 21 years + Any fasting or direct LDL-C lab test result > or = to 190 mg/dl + Patient encounter during measurement period OR Criteria 3 Adults aged years + Diabetes, Type 1 or Type 2 diagnosis + Highest fasting or direct LDL-C lab test result of mg/dl in the measurement period or two years prior to the beginning of the measurement period AND Patient encounter during the measurement period NUMERATOR Patients who are statin therapy users during the measurement period or who receive an order (prescription) to receive statin therapy at any point during the measurement period DENOMINATOR Exclusions: None Exceptions: Medical Reasons, see details above right column Procedure Codes & Code Descriptors All Criteria Utilize Measurement Codes Below Performance Met HCPCS Code G9664: Patients who are currently statin therapy users or received an order (prescription) for statin therapy OR Exclusions/Exceptions from Performance Measurement HCPCS Code G9667: Documentation of medical reason(s) for not currently being a statin therapy user or receive an order (prescription) for statin therapy (e.g., patient with adverse effect, allergy or intolerance to statin medication therapy, patients who have an active diagnosis of pregnancy or who are breastfeeding, patients who are receiving palliative care, patients with active liver disease or hepatic disease or insufficiency, patients with end stage renal disease (ESRD), and patients with diabetes who have a fasting or direct LDL- C laboratory test result < 70 mg/dl and are not taking statin therapy) Performance Not Met HCPCS Code G9665: Patients who are not currently statin therapy users or did not receive an order (prescription) for statin therapy MSSP 2016 Measures Page 153 of 199 Updated: 6/13/2016 Statin Therapy for Cardiovascular Disease

154 Definitions: Clinical Atherosclerotic Cardiovascular Disease (ASCVD) Defined as - Acute Coronary Syndromes History of Myocardial Infarction Stable or Unstable Angina Coronary or other Arterial Revascularization Stroke or Transient Ischemic Attack (TIA) Peripheral Arterial Disease of Atherosclerotic Origin Lipoprotein Density Cholesterol (LDL-C) - A fasting or direct LDL-C laboratory test performed and test result documented in the medical record Statin Therapy for Prevention and Treatment of Cardiovascular Disease Criteria 1 & 2 Patients aged 21 years + Criteria 1: Previous dx of ASCVD OR Criteria 2: LDL-C 190 mg/dl. OR Criteria 3: Patients aged 40 to 75 years with Type 1 or Type 2 diabetes and an LDL-C result of mg/dl + Encounter date in 2016 Exclusions: Medical Reasons AND Patient encounter during the reporting with: Criteria 1: Previously diagnosed or have an active diagnosis of ASCVD G9662 Criteria 2: Any fasting or direct LDL-C laboratory test result 190 mg/dl G9663 Criteria 3: Patients with Type 1 or Type 2 diabetes and an LDL-C result of mg/dl recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period Patients with Type 1 or Type 2 diabetes E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, E13.36, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83 AND The highest fasting or direct LDL-C laboratory test result of mg/dl in the measurement period or two years prior to the beginning of the measurement period: G9666 And Patient Encounter During the Reporting Period (CPT or HCPCS): CPT or HCPCS 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0438, G0439 Medical Performance Exclusion Codes (for all criteria) Active Liver or Hepatic Disease or Insufficiency The following codes are included in the Medical Performance Exclusion (G9667) to define liver disease: B17.0, B17.2, B17.8, B17.10, B17.11, B18.2, B18.8, B18.9, B19.0, B19.20, B19.21, K70.0, K70.9, K70.30, K70.31, K70.40, K70.41, K71.3, K71.4, K71.9, K71.10, K71.11, K71.50, K71.51, K72.00, K72.01, K72.10, K72.11, K72.90, K72.91, K73.0, K73.2, K73.8, K73.9, K74.0, K74.1, K74.2, K74.3, K74.4, K74.5, K74.60, K74.69, K75.4, K76.0, K76.2, K76.3, K76.7, K76.9, K76.89, O MSSP 2016 Measures Page 154 of 199 Updated: 6/13/2016 Statin Therapy for Cardiovascular Disease

155 Table 1 - Sample (List is NOT inclusive of all agents) Statin Medication Therapy List: Generic Name Brand or Trade Name Medication Type, If Applicable Atorvastatin Lipitor Statin Fluvastatin Lescol XL or Lescol Statin Lovastatin (Mevinolin) Mevacor or Altoprev Statin Pitavastatin Livalo N/A Pravastatin Sodium Pravachol Statin Rosuvastatin Calcium Crestor Statin Simvastatin Zocor Statin Amlodipine Besylate/Atorvastatin Caduet Combination Calcium Ezetimibe/Simvastatin Vytorin Combination Niacin/Lovastatin Advicor Combination Niacin/Simvastatin Simcor Combination Sitagliptin/Simvastatin Juvisync Diabetes Combination Sitagliptin Phosphate/Simvastatin Juntadueto Diabetes Combination Source 2016 PQRS Specification # 438 MSSP 2016 Measures Page 155 of 199 Updated: 6/13/2016 Statin Therapy for Cardiovascular Disease

156 PREV 13: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease 2016 Description: Percentage of the following patients all considered at high risk of cardiovascular events who were prescribed or were on statin therapy during the measurement period: Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR Adults aged >=21 years with a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dl; OR Adults aged years with a diagnosis of diabetes with a fasting or direct LDL-C level of mg/dl Denominator Exclusions: None Denominator Exceptions: Medical reasons What is the Quality Action? Prescription of statin therapy. Who may perform the Quality Action? Any eligible professional with prescribing authority may prescribe statin therapy. When must the Quality Action be performed? The prescription of statin therapy must be documented as either initiated or continuing during the measurement period. What are the documentation requirements relative to the Quality Action? An active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); or A fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dl(any time prior to the end of the measurement period) or Adults aged years with a diagnosis of diabetes with a fasting or direct LDL-C level of mg/dl(during the measurement period or two years prior); AND An active prescription for statin therapy anytime during the measurement period; or Documentation of the reason why the Quality Action is not performed due to an exception (see Data Guidance for specific medical reason exceptions). MSSP 2016 Measures Page 156 of 199 Updated: 6/13/2016 Statin Therapy for Cardiovascular Disease

157 2016 MSSP Reporting Data Collection Form Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Target Population: Three Criteria Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Criteria 1 : Is the patient 21 years of age or older and diagnosed with clinical atherosclerotic cardiovascular disease (CAVD) OR Criteria 2: Is the patient 21 years of age or older and has a fasting or direct low density lipoprotein cholesterol (LDL-C) level greater than or equal to 190 mg/dl OR Criteria 3: Is the patient aged with a diagnosis of diabetes with a fasting or direct LDL-C level of mg / dl? Yes No Continue to Q2 Stop Step 2 Did you meet the measure? Q4: Is the patient currently on statin therapy or received an order (prescription) for statin therapy? Yes No Continue to Q6 If, go to Q5 Step 3 Reporting Options. Performance Met: Pt is currently statin therapy user or received a prescription for statin therapy. Medical Performance Exclusion: Documentation of medical reasons for not currently being a statin therapy user or receive prescription for statin therapy Performance Not Met: Patients who are not currently statin therapy users or did not receive a prescription for statin therapy G9664 G9667 G9665 For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 157 of 199 Updated: 6/13/2016 Statin Therapy for Cardiovascular Disease

158 IVD: Use of Aspirin or Another Antithrombotic Measure: MSSP IVD Use of Aspirin or Another Antithrombotic Domain: At Risk Population ACO 30 IVD - 2 PQRS NQF 0068 Measure Steward: NCQA ACO submits data to CMS CPT II coding required: YES Click here to go to Table of Contents MSSP 2016 Measures Page 158 of 199 Updated: 6/13/2016 IVD Use of ASA or Another Antithrombotic

159 2016 BCBS ACO Measures Reporting Tracking Performance for Quality Improvement Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic This measure looks at the percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period. A higher rate indicates better performance / control. Key: Performance Met Performance Not Met Exclusion/Exception from Performance Measurement RATIONALE: Coronary heart disease (CHD) is a major cause of death in the United States in 2004, it was an underlying or contributing cause of death for 451,300 people (1 of every 5 deaths). Acute myocardial infarction (AMI) was an underlying or contributing cause of death for 156,000 people In addition, nearly 16 million people (or 7.3 percent of the American population) had CHD in The cost of cardiovascular diseases and stroke in the United States for 2008 was estimated at $448.5 billion. This figure includes health expenditures (direct costs such as the cost of physicians and healthcare practitioners, hospital and nursing home services, medications, home health care and other medical durables) and lost productivity resulting from morbidity and mortality (indirect costs). AMI accounts for 18 percent of hospital discharges and 28 percent of deaths due to heart disease. Research has shown that costs associated with cardiovascular disease for hospitals are easily $156 billion. (References: American Heart Association 2008 and National Heart, Lung, and Blood Institute). Aspirin treatments reduce MI in men (127 events per 100,000 person-years) and women (17 events per 100,000 person-years) (Grieving et al. 2008). While studies have shown warfarin to be more effective, aspirin is a safer, more convenient, and less expensive form of therapy (Patrono et al. 2004). Aspirin therapy has been shown to directly reduce the odds of cardiovascular events among men by 14 percent and among women by 12 percent (Berger et al. 2006). Aspirin use has been shown to reduce the number of strokes by 20 percent, MI by 30 percent, and other vascular events by 30 percent (Weisman and Graham 2002). ELIGILBLE POPULATION 18 years AND Measure Specifications Active Diagnosis of Ischemic Vascular Disease, OR who were discharged alive for Acute Myocardial Infarction (AMI), Coronary Artery Bypass Graft (CABG) or Percutaneous Coronary Interventions (PCI) in the 12 months prior to the measurement period AND Patient encounter during reporting period NUMERATOR Patients who have documentation of use of aspirin or another antithrombotic therapy during the measurement period. DENOMINATOR Exclusions: None listed. Exclusions need to be approved by CMS in the form of a response to a Quality Net Help Desk inquiry. Exceptions: None Procedure Codes & Code Descriptors Performance Met G8598: Aspirin or another antithrombotic therapy used Exclusion/Exception from Performance Measurement CMS approved from quality net help desk only Performance Not Met G8599: Aspirin or another antithrombotic therapy not used, reason not given REPORTING FREQUENCY: This measure is to be reported a minimum of once per reporting period for patients with IVD seen during the reporting period. MSSP 2016 Measures Page 159 of 199 Updated: 6/13/2016 IVD Use of ASA or Another Antithrombotic

160 IVD: Use of Aspirin or Another Antithrombotic: Eligible Cases 18 years AND Diagnosis of Ischemic Vascular Disease, or who were discharged alive for Acute Myocardial Infarction (AMI), Coronary Artery Bypass Graft (CABG) or Percutaneous Coronary Interventions (PCI) AND Patient encounter during reporting period Exclusions: None AND Diagnosis of IVD or Diagnosis of AMI Diagnosis for Ischemic Vascular Disease Diagnosis for Ischemic Vascular Disease (ICD-10-CM): I20.0, I20.1, I20.8, I20.9, I21.11, I21.19, I21.21, I21.29, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750, I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.89, I25.9, I63.00, I63.011, I63.012, I63.019, I63.02, I63.031, I63.032, I63.039, I63.09, I63.10, I63.111, I63.112, I63.119, I63.12, I63.131, I63.132, I63.139, I63.19, I63.20, I63.211, I63.212, I63.219, I63.22, I63.231, I63.232, I63.239, I63.29, I63.30, I63.311, I63.312, I63.319, I63.321, I63.322, I63.329, I63.331, I63.332, I63.339, I63.341, I63.342, I63.349, I63.39, I63.40, I63.411, I63.412, I63.419, I63.421, I63.422, I63.429, I63.431, I63.432, I63.439, I63.441, I63.442, I63.449, I63.49, I63.50, I63.511, I63.512, I63.519, I63.521, I63.522, I63.529, I63.531, I63.532, I63.539, I63.541, I63.542, I63.549, I63.59, I63.6, I63.8, I63.9, I65.01, I65.02, I65.03, I65.09, I65.1, I65.21, I65.22, I65.23, I65.29, I65.8, I65.9, I66.01, I66.02, I66.03, I66.09, I66.11, I66.12, I66.13, I66.19, I66.21, I66.22, I66.23, I66.29, I66.3, I66.8, I66.9, I70.1, I70.201, I70.202, I70.203, I70.208, I70.209, I70.211, I70.212, I70.213, I70.218, I70.219, I70.221, I70.222, I70.223, I70.228, I70.229, I70.231, I70.232, I70.233, I70.234, I70.235, I70.238, I70.239, I70.241, I70.242, I70.243, I70.244, I70.245, I70.248, I70.249, I70.25, I70.261, I70.262, I70.263, I70.268, I70.269, I70.291, I70.292, I70.293, I70.298, I70.299, I70.92, I74.01, I74.09, I74.10, I74.11, I74.19, I74.2, I74.3, I74.4, I74.5, I74.8, I74.9, I75.011, I75.012, I75.013, I75.019, I75.021, I75.022, I75.023, I75.029, I75.81, I75.89 Diagnosis for acute myocardial infarction Diagnosis for acute myocardial infarction (ICD-10-CM) I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4 AND Patient encounter during the reporting period (CPT or HCPCS) CPT 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, OR Patient encounter during the reporting period (CPT) - Procedure HCPCS G0402, G0438, G , 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536, 92920, 92924, 92928, 92933, 92937, 92941, MSSP 2016 Measures Page 160 of 199 Updated: 6/13/2016 IVD Use of ASA or Another Antithrombotic

161 IVD 2: Use of Aspirin or Another Antithrombotic 2016 Description: Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period. Denominator Exclusions: None Denominator Exceptions: None What is the Quality Action? Prescription of aspirin or another antithrombotic. Where may the Quality Action take place? Must take place in a healthcare setting. Who may perform the Quality Action? Any prescribing healthcare professional may prescribe the use of aspirin or another antithrombotic. In addition to aspirin, antithrombotic medications may include: clopidogrel, combination of aspirin and extended release dipyridamole, Prasugrel, Ticagrelor, or Ticlopidine. When must the Quality Action be performed? The prescription for aspirin or another antithrombotic must be either initiated or continued during the measurement period. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: An active diagnosis of ischemic vascular disease or discharged alive for AMI, CABG or PCI; and An active prescription for aspirin or another antithrombotic anytime during the measurement period. MSSP 2016 Measures Page 161 of 199 Updated: 6/13/2016 IVD Use of ASA or Another Antithrombotic

162 2016 MSSP Reporting Data Collection Form Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Target Population Age: Patients aged 18 years of age or older. Patient Name: DOB: (First) (M.I.) (Last) mm / dd / yyyy Gender: M F Medical Record Number: Date of Service : mm / dd / yyyy Step 1 Determine if the patient is eligible for this measure? Q1: Is the Is the patient > 18 years of age? Yes Continue to Q2 No Stop Q2: Was the patient was seen for a visit in the measurement year? Yes Continue to Q3 No Stop Q3: Determine if the patient was discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period. Yes Not Confirmed Continue to Q4 Stop Step 2 Did you meet the measure? Q4: Determine if the patient has documented use of aspirin or another antithrombotic during the measurement period (Oral antithrombotic therapy consists of aspirin, clopidogrel, combination of aspirin and extended release dipyridamole, prasugrel, ticagrelor or ticlopidine) Yes Step 3 Reporting Options. Based on the values in Q4, Select reporting option (A) or (B) below: A.. Aspirin or Another Antithrombotic Therapy Used Aspirin or another antithrombotic therapy used HCPCS Code G8598 B.. Aspirin or Another Antithrombotic Therapy not Used, Reason not Given Aspirin or another antithrombotic therapy not used, reason not given HCPCS Code G8599 No For Practice Use: Form Completed by: Date: MSSP 2016 Measures Page 162 of 199 Updated: 6/13/2016 IVD Use of ASA or Another Antithrombotic

163 VI. Other ACO Measures: Not Requiring CPT II Coding Other ACO Measures CPT II Coding Not Required Complete and accurate use of Billing Codes is essential for measure compliance Click here to go to Table of Contents Measures Not Requiring CPT II Codes Page 163 of 199 Updated: 6/13/2016

164 Childhood Immunizations MMR Measure: BCBS Commercial BCBS HMO Childhood Immunization MMR Click here to go to Table of Contents BCBS Measure: Page 164 of 199 Updated: 6/13/2016 Childhood Immunization Status - MMR

165 2016 BCBS ACO Measures Reporting Tracking Performance for Quality Improvement Childhood Immunization Status This measure looks at the percentage of children 2 years of age with evidence of receiving MMR Vaccine (measles, mumps and rubella vaccine) on or before the child s second birthday. A higher score indicates better quality. RATIONALE: Measles, mumps, and rubella are serious diseases. Measles, mumps, and rubella (MMR) vaccine can protect children from all three of these diseases. The intent of the measure is to have the recommended childhood immunizations on or before the child s second birthday. ELIGIBLE POPULATION Meausure Specification Procedure Codes & Code Descriptors CPT II codes - N/A Children who turn 2 years of age during the measurement year. NUMERATOR Data will be abstracted from Practice Billing Children 2 years of age who had at least one MMR (measles, mumps and rubella) vaccine with the date of service falling on or before the child s second birthday. For MMR, count any of the following : Evidence of the antigen or combination vaccine, or Documented history of the illness, or A seropositive test result for each antigen Any of the following with a date of service on or before the child s second birthday meet criteria: At least one Measles, Mumps and Rubella (MMR) Vaccine Administered. At least one Measles and Rubella Vaccine Administered and at least one Mumps Vaccine Administered on the same date of service or on different dates of service. At least one Measles Vaccine Administered and at least one Mumps Vaccine Administered and at least one Rubella Vaccine Administered on the same date of service or on different dates of service. History of Measles, Mumps or Rubella illness. DENOMINATOR Exclusions: Must have been documented on or before the child s second birthday. 1. Immunodeficiency (Disorders of the Immune System) 2. HIV 3. Lymphoreticular cancer, Multiple myeloma or Leukemia (Malignant Neoplasm of Lymphatic Tissue) 4. Anaphylactic reaction to neomycin. Exceptions: BCBS Measure: Page 165 of 199 Updated: 6/13/2016 Childhood Immunization Status - MMR

166 Table 1: Codes to identify exclusions Description CPT HCPCS Disorders of the immune system ICD-9-CM Procedure ICD -10-CM 279 Refer to Hedis spec HIV 042, V08 Checked: B20, Z21, O42, V08 Lymphoreticular cancer, ( Hedis: Refer to Hedis spec malignant neoplasm of lymphatic tissue) 203 Refer to Hedis spec Multiple myeloma Refer to Hedis spec Leukemia Anaphylactic reaction to neomycin Anaphylactic reaction to the vaccine or its components Source HEDIS 2016 Specification Manual Checked, T80.52XA, T80.52XD, T80.52XS Any of the following with a date of service on or before the child s second birthday meet criteria At least one MMR vaccination (Measles, Mumps and Rubella (MMR) Vaccine Administered) At least one measles and rubella vaccination (Measles/Rubella Vaccine Administered) AND at least one mumps vaccination (Mumps Vaccine Administered) on the same date of service or on different dates of service. At least one measles vaccination (Measles Vaccine Administered) AND at least one mumps vaccination (Mumps Vaccine Administered) AND at least one rubella vaccination (Rubella Vaccine Administered) on the same date of service or on different dates of service. History of Measles, Mumps or Rubella illness documented Table 2: Codes to identify MMR vaccination status or history of illness Description CPT Vaccine Administration ICD-9-CM Procedure MMR Vaccine 90707, Administration of MMR Vaccine Measles and Rubella Measles Administration of Measles Vaccine Mumps Administration of Mumps Vaccine ICD-10 Diagnosis Code for History of Illness B05.0-B05.4, B05.81, B05.89, B05.9 B26.0-B26.3, B B26.85, B26.89, B26.9 BCBS Measure: Page 166 of 199 Updated: 6/13/2016 Childhood Immunization Status - MMR

167 Rubella Administration of Rubella Vaccine Source HEDIS 2016 Specifications Manual B06.00-B06.02, B06.09, B06.81, B06.82, B06.89, B06.9 For immunization evidence obtained from the medical record, HEDIS guidelines state the following: Count members where there is evidence that the antigen was rendered from one of the following: A note indicating the name of the specific antigen and the date of the immunization. A certificate of immunization prepared by an authorized health care provider or agency including the specific dates and types of immunizations administered. For documented history of illness or a seropositive test result, there must be a note indicating the date of the event, which must have occurred by the member s second birthday. For combination vaccinations that require more than one antigen (i.e., MMR), the organization must find evidence of all the antigens. STRATEGIES TO IMPROVE AND ENHANCE YOUR PERFORMANCE To improve your scores on this measure: Please note that documenting the member is 'up-to-date' with immunizations, without listing the antigen name and dates, does not meet HEDIS documentation requirements. Ensure proper documentation in the medical record. Have a place in the chart for easy identification of childhood immunizations. Train staff to prep the chart in advance of the visit and identify immunizations that are due. Ensure that the vaccinations are being given according to the schedule. The Advisory Committee on Immunization Practices (ACIP) recommends a two-dose vaccine schedule for measles, mumps, rubella and varicella vaccines for children, with the first dose at age months and the second at age 4-6 years. (Source: Recommend immunizations to parents. Parents are more likely to agree with vaccinations when supported by the provider. Address common misconceptions about vaccinations. Institute a system for patient reminders. Some vaccines will have been given before the patient established cared with you. Include these on the member s vaccination record, even if your office did not provide the vaccine. All medical record entries must be dated by the child's second birthday. Document any parent refusal for immunizations, as well as anaphylactic reactions. If there is a contraindication to vaccine, document it. BCBS Measure: Page 167 of 199 Updated: 6/13/2016 Childhood Immunization Status - MMR

168 Childhood Immunization - Combination 10 Measure: BCBS HMO Childhood Immunization (Combination 10) HEDIS Measure Click here to go to Table of Contents BCBS, United Measure: Page 168 of 199 Updated: 6/13/2016 Immunizations for Combo 10

169 Childhood Immunization (Combination 10) This measure looks at the percentage of members turning 2 yrs. of age who received the combination 10 including: 4 DTaP, 3 IPV, 1 MMR, 3 HiB, 3 HepB, 1 VZV,4 PCV by their second birthday. The measure calculates a combination rate for reporting. Combination Vaccinations for Childhood Immunization Status Combination DTaP IPV MMR HiB HepB VZV PCV HepA RV Influenza Combination 10 Table 1: Codes for the vaccines in Combination 10 are included in the following table and indicated by : Immunization CPT HCPCS ICD-9-CM diagnosis ICD-9-CM Procedure ICD-10-CM Procedure DTaP 90698, 90700, , IPV 9068, 90713, MMR 90707, Measles and rubella 9078 Measles Mumps Rubella HiB , 90698, 90721, 070.2, 070.3, V Hepatitis B** 90723, 90740, G , 90747, VZV S90710, , 053 Pneumococcal 90669, G0009 conjugate Hepatitis A Rotavirus (2 doses) 90681, Rotavirus (3 doses) Influenza 90630, 90673, 90655, 90657, 90661, 90662, G BCBS, United Measure: Page 169 of 199 Updated: 6/13/2016 Immunizations for Combo 10

170 Source BCBS HMO Specifications for 2016 Childhood Immunization QI Projects BCBS, United Measure: Page 170 of 199 Updated: 6/13/2016 Immunizations for Combo 10

171 Source BCBS HMO Specifications for 2016 Childhood Immunization QI Projects Exclusions: An organization that excludes contraindicated children may do so only if the administrative data do not indicate that the contraindicated immunization was rendered. The exclusion must have occurred by the second birthday. Organizations should look for exclusions as far back as possible in the member s history and use the codes in Table CIS-B to identify allowable exclusions. Codes to identify Childhood Immunizations Immunization Description ICD-9-CM Diagnosis Code ICD 10 Any particular vaccine Anaphylactic reaction to See Hedis spec manual vaccine or its components DTaP Encephalopathy.Progressive * with (E948.4 or See Hedis spec manual neurologic disorder, including infantile spasm and uncontrolled epilepsy E948.5 or E948.6) IPV Anaphylactic reation to See Hedis spec manual streptomycin, polymixin B or neomycin MMR, VZV, and influenza Immunodeficiency, including 279 See Hedis spec manual genetic (congenital) immunodeficiency syndromes MMR, VZV and influenza HIV disease; asymptomatic 042, V08 See Hedis spec manual HIV MMR, VZV and influenza Multiple myeloma 203 See Hedis spec manual MMR, VZV, and influenza Leukemia See Hedis spec manual MMR, VZV, and influenza Lymphoreticular cancer See Hedis spec manual MMR, VZV, and influenza Anaphylactic reaction to See Hedis spec manual neomycin Hepatitis B Anaphylactic reaction to common baker s yeast See Hedis spec manual BCBS, United Measure: Page 171 of 199 Updated: 6/13/2016 Immunizations for Combo 10