Provider Gaps in Care Technical Specifications and Billing Guide. Working with our Providers to enhance the Quality of Care provided to our Members

Transcription

1 Provider Gaps in Care Technical Specifications and Billing Guide Working with our Providers to enhance the Quality of Care provided to our Members

2 Table of Contents Disclaimer 3 What is HEDIS 3 Annual HEDIS Timeline 4 Tips and Best Practice 5 Regarding HIPAA 5 The Importance of Documentation 6 Quality Measures Childhood Immunization Status (CIS) 7 Immunizations for Adolescents (IMA) 10 Lead Screening in Children (LSC) 11 Well-Child Visits in the First 15 Months of Life (W15) 12 Well-Child Visits in the Third, Fourth, Fifth, and Sixth years of Life (W34) 13 Adolescent Well-Care Visits (AWC) 14 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) 15 Adult BMI Assessment (ABA) 17 Chlamydia Screening in Women (CHL) 19 Breast Cancer Screening (BCS) 21 Cervical Cancer Screening (CCS) 23 Controlling High Blood Pressure (CBP) 25 Comprehensive Diabetes Care - HbA1c Results (CDC - HbA1c) 27 CDC Comprehensive Diabetes Care - Monitor for Nephropathy (CDC - Neph) 28 CDC Comprehensive Diabetes Care - Dilated Retinal Eye Exam (CDC - DRE) 31 CDC Comprehensive Diabetes Care - Blood Pressure Less Than 140/90 (CDC - BP) 32 Annual Dental Visit (ADV) 33 Frequency of Ongoing Prenatal Care (FPC) 34 Prenatal and Postpartum Care (PPC) 38 Follow-Up Care for Children Prescribed ADHD Medication (ADD) 42 Follow-Up After Hospitalization for Mental Illness (FUH) 44 Antidepressant Medication Management (AMM) 46 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) 47 Pharmacotherapy Management of COPD Exacerbation (PCE) 49 Medication Management for People With Asthma (MMA) 50 Appropriate Testing for Children With Pharyngitis (CWP) 51 Appropriate Treatment for Children With Upper Respiratory Infection (URI) 52 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAB) 53 Care for Older Adults (COA) 54 Colorectal Cancer Screening (COL) 55 Use of High-Risk Medications in the Elderly (DAE) 57 Use of Imaging Studies for Low Back Pain (LBP) 59 Osteoporosis Management in Women Who Had a Fracture (OMW) 60 Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) 61 Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) 62

3 Disclaimer This material serves as a tool to assist providers, their clinical team, and billing staff with information to improve HEDIS performance. HEDIS 2016 Volume 2 Technical Specifications for Health Plans was used to generate this Provider Billing Guide. The Technical Specifications were current at the time of publication. HEDIS indicators have been designed by NCQA to standardize performance measurement and do not necessarily represent the ideal standard of care. Information contained in this report is based on claims data only. What is HEDIS? HEDIS is a registered trademark of the National Quality Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) NCQA defines HEDIS as a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of health care plans. HEDIS is a registered trademark of the National Committee for Quality Assurance. HEDIS is a performance measurement tool that is coordinated and administered by NCQA and used by the Centers for Medicare & Medicaid Services (CMS) for monitoring the performance of managed care organizations. Results from HEDIS data collection serve as measurements for quality improvement processes, educational initiatives, and preventive care programs. All managed care companies who are NCQA accredited perform HEDIS reviews the same time each year. HEDIS consists of 88 measures across seven domains of care that address important health issues. HEDIS is a retrospective review of services and performance of care from the prior calendar year. There are two types of HEDIS data collected: Administrative data comes from submitted claims and encounters Hybrid data comes from chart collection/review and submitted claims and encounters 3

4 Annual HEDIS Timeline Feb - Early May Quality Department staff collects and reviews HEDIS data (on-site provider office visits and faxing chart collection occurs) June HEDIS results are audited and reported to NCQA October **HEDIS is a retrospective process HEDIS 2017 = Calendar Year 2016 Data** NCQA releases Quality Compass (national benchmarks) for Medicaid HEDIS Medical Record Review Process: Data collection methods include: fax, mail, on-site visits for larger requests, and remote electronic medical record (EMR) system access, if available. Medical record fax requests include a list showing each member's respective measure(s) and the description of the information needed from the medical record. A turnaround time of 3-5 days is appreciated. If selected for on-site chart review, the office will be contacted to schedule a mutually agreeable time for the review. The list charts needing review will be provided ahead of time. 4

5 Tips and Best Practices General tips and information that can be applied to most HEDIS measures: 1. Use your Gaps in Care member roster to outreach to patients win need of services/procedures or are new to your practice. 2. Take advantage of this guide, coding information, and the on-line resources that can assist the practice with HEDIS measure understanding, compliance, and requirements. 3. You can provide evidence of completed HEDIS services by faxing the supporting chart documentation to the Quality Management Department at Assign a staff member to serve as a point of contact with Aetna Better Health and the Quality Management staff. HIPAA Under the Health Information Portability and Accountability Act (HIPAA) Privacy Rule, data collection for HEDIS is permitted, and the release of this information requires no special patient consent or authorization. Please be assured our members personal health information is maintained in accordance with all federal and state laws. HEDIS results are reported collectively without individual identifiers or outcomes. All of the health plans contracted providers records are protected by these laws. 1. HEDIS data collection and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities. 2. The records you provide us during this process helps us to validate the quality of care our members receive. 5

6 Importance of Documentation Common reasons members may still appear on a Gaps in Care report: 1. Missing information or incomplete services (i.e. Tdap shot administered but no Meningococcal vaccine for adolescent immunization measure). 2. Service provided without claim/encounter data submitted. 3. Lack of follow through by patient to obtain the recommended service (i.e. diabetic eye exam to check for retinopathy). 4. Service provided but outside of the required HEDIS time frame or anchor date (i.e. Lead screening performed after age 2). 5. Failure to document or code exclusion criteria for a measure. Minimal Documentation Requiements: All records must include: 1. The patient's name on every page. 2. The patient's date of birth on at least 1 page. 3. The required information for each applicable measure listed on the following pages. 6

7 CIS - Childhood Immunization Status The percentage of children turning 2 years of age in 2016 who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (Hep B), one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates. Common Chart Deficiencies and Tips: 1. Vaccinations for DTaP, IPV, HiB, or PCV given before 42 days after birthday do not count towards vaccine compliance 2. Participate in State Immunization registries, where available 3. Devote time during each visit to review immunization record and look for opportunities to catch-up on missing immunizations 4. Document date of first hepatitis B vaccination if given at hospital and note the hospital 5. If available, record date and immunization(s) provided at the health department # in HCPCS ICD-9 CM ICD-10 CM Series DTaP , 90700, 90721, IPV MMR , 90713, , Any Combination of the following to satisfy recommendation of 1 MMR Measles Only Mumps Only Rubella Only Measles and Rubella , , , 055.8, , , , , 072.8, , , , , , 056.8, B05.0-B05.4, B B05.9 B26.0-B26.3, B B26.9 B06.00-B06.02, B06.81-B06.9

8 CIS - Childhood Immunization Status Hib Hepatitis B VZV Influenza # in Series DTaP - Encephalopathy with Adverse-Effect 3 HCPCS ICD-9 CM ICD-10 CM 90723, 90740, 90744, 3 G , , 90698, 90721, , , 90657, 90661, 90662, 90673, G0008 ICD-9 CM E948.4, E948.5, E , 279, V08, , , V , 053 Pneumococcal , G0009 Conjugate Hepatitis A , Rotavirus 2-dose or 3-dose vaccinations satisfy Rotavirus recommendations. Exclusion: Exclude children who had a contraindication for a specific vaccine. Exclusion Any particular vaccine - Anaphylactic Reaction MRR, VZV and Influenza Exclusion MRR, VZV and Influenza IPV Rotavirus 2-dose Rotavirus 3-dose Hepatitis B Measure Exclusion Criteria: HCPCS B16.0-B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, Z22.51 B01.0, B01.11-B01.2, B01.81-B01.9, B02.0, B02.1, B B02.29, B B15.0, B15.9 ICD-10 CM T80.52XA, T80.52XD, T80.52XS G04.32 WITH T50.A15A, T50.A15D, T50.A15S D81.0-D81.2, D81.4, D81.6, D81.7, D81.89, D81.9, D82.0- D82.9, D83.0-D83.9, D84.0- D84.9, D89.3, D D89.9, B20, Z21, C81.00-C86.6, C86.2- C94.32, C94.80-C96.Z General Exclusion Criteria Anaphylactic reaction to neomycin Anaphylactic reaction to streptomycin, polymyxin B, or neomycin Anaphylactic reaction to common baker's yeast 8

9 CIS - Childhood Immunization Status Medical Record Documentation Progress/Office Notes Logs/Procedure Results Immunization records/logs State immunization registry printout Documentation of history or seropositive test for MMR, hepatitis A, hepatitis B and/or chicken pox 9

10 IMA - Immunizations for Adolescents The percentage of adolescents turning 13 years of age in 2016 who had one dose of meningococcal conjugate vaccine (MCV), one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td), and three doses of the human papillomavirus (HPV) vaccine by their 13th birthday. Common Chart Deficiencies and Tips: 1. Participate in State Immunization registries, where available 2. Devote time during each visit to review immunization record and look for opportunities to catch-up on missing immunizations 3. If available, record date and immunization(s) provided at the health department in the medical record 4. Administer Tdap between the 10th and 13th birthday and meningococcal between the 11th and 13th birthday. 5. Less than 3 HPV doses administered 6. Final dose administered after the adolescent turns 13. Tdap/Td Tetanus and Diphtheria Meningococcal HPV 90714, 90715, and Measure Exclusion Criteria: Exclusion: Exclude children who had a contraindication for a specific vaccine. Exclusion ICD-9 CM ICD-10 CM Anaphylactic Reaction 999.4, T80.52XA, T80.52XD, T80.52XS Immunization records/logs State immunization registry printout Medical history Medical Record Documentation Worksheets/Lists/Logs 10

11 LSC - Lead Screening in Children The percentage of children turning 2 years of age in 2016 who had one or more capillary or venous lead blood test for lead poisoning by their second birthday. Common Chart Deficiencies and Tips: 1. Lead screening is considered late if performed after the child turns 2 years of age 2. A lead risk assessment does not satisfy the venous blood lead requirement regardless of the risk score 3. Options exist for in-office lead testing, including blood lead analyzer and MedTox filter paper testing LOINC Lead Tests , , , , , , , , Medical Record Documentation Worksheets/Lists/Logs Logs/Procedure Results Well-care flow sheets EPDST Preventive forms Health maintenance forms Immunization record All lead test results (value and DOS) must be documented. 11

12 W15 - Well-Child Visits in the First 15 Months of Life The percentage of members who turned 15 months old in 2016 and who had the following number of well-child visits with a PCP during their first 15 months of life: No well-child visits One well-child visit Two well-child visits Three well-child visits Four well-child visits Five well-child visits Six well-child visits The comprehensive well care visit includes: Health history Physical developmental history Mental developmental history Complete physical exam Health education/anticipatory guidance (age appropriate) Common Chart Deficiencies and Tips: 1. Missing or undocumented anticipatory guidance 2. Sick visit in calendar year without well-child visit 3. Turn a sick visit into a well-child visit Office Visit , , HCPCS G0439, G0438 ICD-9 CM V20.2, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 ICD-10 CM Z00.00-Z00.129, Z00.5, Z00.8, Z02.0-Z02.9 Medical Record Documentation Progress/Office Notes Worksheets/Lists/Logs Progress/office notes from member s date of birth up to 15 months of age. Don t include services rendered during an inpatient or ER visit day care exams and state, sports or camp physicals Developmental checklists Physical exam Anticipatory guidance/health education 12

13 W34 - Well-Child Visits in the Third, Fourth, Fifth, and Sixth years of Life The percentage of members 3 6 years of age who had one or more well-child visits with a PCP in The comprehensive well care visit includes: Health history Physical developmental history Mental developmental history Complete physical exam Health education/anticipatory guidance (age appropriate) Common Chart Deficiencies and Tips: 1. Missing or undocumented anticipatory guidance 2. Sick visit in calendar year without well-child visit 3. Turn a sick visit into a well-child visit HCPCS ICD-9 CM ICD-10 CM Office Visit 2016 progress/office notes , , Well-child visit must occur with a PCP, but the PCP doesn t have to be the practitioner assigned to the child. Don t include services rendered during an inpatient or ER visit. G0439, G V20.2, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Medical Record Documentation Progress/Office Notes Worksheets/Lists/Logs Z00.00-Z00.129, Z00.5, Z00.8, Z02.0-Z02.9 Day care exams and state, sports or camp physicals Developmental checklists Physical exam Anticipatory guidance/health education

14 AWC - Adolescent Well-Care Visits The percentage of enrolled members years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during The comprehensive well care visit includes: Health history Physical developmental history Mental developmental history Complete physical exam Health education/anticipatory guidance (age appropriate) Common Chart Deficiencies and Tips: 1. Missing or undocumented anticipatory guidance 2. Sick visit in calendar year without well-child visit 3. Turn a sick visit into a well-child visit 4. Schedule next visit at end of each appointment HCPCS ICD-9 CM ICD-10 CM Office Visit , , G0439, G0438 V20.2, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Medical Record Documentation Progress/Office Notes Worksheets/Lists/Logs 2016 progress/office notes Services must include: Health history Physical developmental history Mental development history Physical exam Anticipatory guidance/health education (AG/HE) Z00.00-Z00.129, Z00.5, Z00.8, Z02.0-Z02.9 Medical, surgical and/or social history Developmental assessments Well-care flow sheets Physical exam and review of systems Assessments and plan of care Sports or camp physicals Anticipatory guidance and/or health education forms/lists SOAP note 14

15 WCC - Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents The percentage of members 3 17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition, and counseling for Physical activity in Common Chart Deficiencies and Tips: 1. BMI percentile or BMI percentile plotted on growth chart for members 3-17 years of age 2. Must include documentation indicating counseling HCPCS ICD-9 CM ICD-10 CM UB Revenue Office /Other Outpatient Service BMI, BMI Percentile , , , , , , , , , 99420, 99429, G0402, G0438, G0439, G0463, T1015 V85.51-V85.54 Z68.51-Z , , , 0982, 0983 Nutrition Counseling G0270, G0271, G0447, S9449, S9452, S9470 V65.3 Z71.3 Physical Activity Counseling G0447, S9451 V65.41 Measure Exclusion Criteria: Any diagnosis of pregnancy during 2016 counts as an exclusion for this measure 15

16 WCC - Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Progress/Office Notes 2016 progress/office notes from PCP, Ob/Gyn or other provider who may have seen the child during an outpatient visit where the noted assessments were done (e.g., endocrinologist) May count services that occur over multiple visits, as long as all services occur in Medical Record Documentation Worksheets/Lists/Logs 2016 well-child check forms day care exams and state, sports or camp physicals HT/WT/BMI, BMI percentile charts and/or graphs HT/WT/BMI flow sheets 2016 referral forms to dieticians/physical therapy/obesity counseling Anticipatory guidance check forms/lists 16

17 ABA - Adult BMI Assessment The percentage of members years of age who had an outpatient visit and whose body mass index (BMI) was documented in 2015 or For members 21 years of age or older on the date of service, BMI in 2015 or 2016 For members younger than 21 years of age on the date of service, BMI percentile in 2015 or Common Chart Deficiencies and Tips: 1. Height and weight documented but no documentation of the BMI 2. ICD-9 codes V V85.5 can be used to make the member compliant without chart review 3. ICD-10 Z68 codes can be used to make a member compliant without chart review. HCPCS ICD-9-CM ICD-10 UB Revenue Office /Other Outpatient Service BMI, BMI Percentile G0402 G0438 G0439 G0463 T1015 V85.0 V85.1 V V85.25 V V85.39 V V85.45 V V85.54 Z68.1 Z Z68.39 Z Z68.45 Z Z x

18 ABA - Adult BMI Assessment Progress/Office Notes Documented BMI or BMI percentage with height and weight in 2015 or 2016 Medical Record Documentation Worksheets/Lists/Logs Height/weight sheets Vital signs sheets BMI age/growth charts Subjective, objective, assessment and plan (SOAP) note 18

19 CHL - Chlamydia Screening in Women The percentage of women years of age who were identified as sexually active and who had at least one test for chlamydia in LOINC Chlamydia Test Measure Exclusion Criteria: Pregnancy 81025, 84702, Exclusion Diagnostic Radiology Exclusion: Exclude female members who qualified for the denominator based on a pregnancy test alone and who meet either of the following: A pregnancy test in 2016 followed within seven days (inclusive) by a prescription for isotretinoin. A pregnancy test in 2016 followed within seven days (inclusive) by an x-ray. Exclusion Retinoid 87110, 87270, 87320, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 557-9, 560-3, , , , , UB Revenue 925 WITH UB Revenue OR Isotretinoin Prescription 19 LOINC , , , , , , , , , , , , , , , , , , , , , LOINC

20 CHL - Chlamydia Screening in Women Medical Record Documentation Progress/Office Notes Labs/Procedure Result Documentation in the progress notes of a chlamydia test with date and result of test in Chlamydia lab test with result in

21 BCS - Breast Cancer Screening The percentage of women years of age who had a mammogram to screen for breast cancer from October 2014 through December 31, Breast Cancer Screening HCPCS G0202, G0204, G0206 ICD-9 CM UB Revenue 87.36, , 0403 Measure Exclusion Criteria: Bilateral Mastectomy History of Bilateral Mastectomy Unilateral Mastectomy Bilateral Modifier A female who had the following: Bilateral mastectomy, unilateral mastectomy with bilateral modifier, two unilateral mastectomies, or unilateral mastectomy with right/left side modifier on or before December 31, Exclusion ICD-9 CM Unilateral Mastectomy Unilateral Mastectomy Exclusion Unilateral Mastectomy with Bilateral Modifier 19180, 19200, 85.41, 85.43, 85.45, 19220, 19240, WITH 50, 9950 Two Unilateral Mastectomy More Than 14 days Apart 19180, 19200, 19220, 19240, , 85.44, 85.46, , 85.43, 85.45, ICD-10 CM Z90.13 Unilateral Mastectomy with Right/Left Side Modifier 19180, 19200, 85.41, 85.43, 85.45, 19220, 19240, WITH Left Modifier LT OR Right Modifer Both of the following (on the same or a different dates of service) ICD-10 CM ICD-10 PCS 0HTV0ZZ Unilateral Mastectomy Left 0HTU0ZZ Right 0HTT0ZZ Absence of Breast Left Z90.12 Right Z RT

22 BCS - Breast Cancer Screening Medical Record Documentation Progress/Office Notes /Radiology Report Documented mammogram in last 3 months of 2014, 2015 or

23 CCS - Cervical Cancer Screening The percentage of women years of age who were screened for cervical cancer using either of the following criteria: Women age who had cervical cytology performed in 2014, 2015, or Women age who had cervical cytology/human papillomavirus (HPV) co-testing performed between 2012 and Common Chart Deficiencies and Tips: 1. Documentation of hysterectomy must include words such as 'complete', 'total', or 'radical' 2. Documentation of hysterectomy alone does not meet guidelines because it does not indicate the cervix was removed Cervical Cancer Screening HPV Tests , 88147, 88148, 88150, , , 88174, , 87621, HCSPCS G0123, G0124, G0141, G0143- G0145, G0147, G0148, P3000, P3001, Q0091 LOINC , , , , , , , , , , , , , , , , UB 0923 Measure Exclusion Criteria: Exclusion Hysterectomy A female who had a hysterectomy with no residual cervix on or before December 31, , 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, , 58548, 58550, , , 58951, 58953, 58954, 58956, ICD-9 PCS 68.41, 68.49, 68.51, 68.59, 68.61, 68.69, 68.71, 68.79, 68.8 ICD-9 CM 618.5, , V88.03, V88.01 ICD-10 PCS 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ ICD-10 CM Q51.5, Z90.710, Z

24 CCS - Cervical Cancer Screening Medical Record Documentation Progress/Office Notes Worksheets/lists/logs Labs/Procedure Result Documentation anytime in the woman s history of a total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH) or hysterectomy with no residual cervix. Problem list Medical/surgical history SOAP note Lab reports for cervical cytology and HPV between : Documentation must include the DOS and test results. 24

25 CBP - Controlling High Blood Pressure* The percentage of members years of age who had a diagnosis of hypertension (HTN) in the first six months of 2016 and whose BP was adequately controlled based on the following criteria: Members years of age whose BP was <140/90 mm Hg. Members years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg. Members years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg. *NOTE : This measure was selected for informational purposes only. The goal is to provide you with a list of members diagnosed with hypertension. Since blood pressure values can only be obtained from the medical record, your rate for this measure will always be zero. ICD-9 CM ICD-10 CM Hypertension 401, 401.1, I10 Measure Exclusion Criteria: Exclusion Evidence of ESRD Common Chart Deficiencies and Tips: 1. Retake the blood pressure if elevated - HEDIS accepts lowest BP 2. Ensure that the BP cuff is the correct size for patient's arm Exclude from the eligible population all members with evidence of end-stage renal disease (ESRD) or kidney transplant on or prior to December 31, 2016 or a diagnosis of pregnancy in , 36800, 36810, 36815, , , 90935, 90837, 90940, 90945, 90947, , 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, ICD-9 PCS 38.95, 39.27, 39.42, 39.43, 39.53, 39.93, 39.94, 39.95, ICD-9 CM 585.5, 585.6, V45.11, V45.12, ICD-10 PCS 3E1M39Z, 5A1D00Z, 5A1D60Z ICD-10 CM N18.5, N18.6, Z91.15, Z99.2 UB Revenue , 0809, , , , , 0859, , 0889 UB Type of Bill 072X HCPCS S9339, G0257 POS 65 25

26 CBP - Controlling High Blood Pressure Exclusion Kidney Transplant Pregnancy ICD-9 PCS ICD-10 PCS UB Revenue HCPCS 50300, 50320, 50340, 50360, 50365, 50370, TY00Z , TY00Z2, 0TY10Z0-367 S2065 0TY10Z2 ICD-9 CM V42.0 ICD-10 CM Z94.0 ICD-9 CM ICD-10 CM , V22, V23, V28 Medical Record Documentation Progress/Office Notes Worksheets/Lists/Logs Progress/office notes for diagnosis (Dx) of HTN on or before June 30, 2016, in members history AND Progress/office note for most recent BP reading taken in 2016 Problem lists Medication lists Vital sign flow sheet SOAP note O00.0-O9A53, Z03.71-Z36 26

27 CDC - Comprehensive Diabetes Care - HbA1c Testing Members 18 to 75 years of age with diabetes (type 1 and type 2) who had an HbA1c test in Common Chart Deficiencies and Tips: 1. Failure to order lab tests or lab results not documented in chart 2. Lab values show poor control Diabetes HbA1c Screening ICD-9 CM 250, 357.2, 362.0, , , ICD-10 CM E E13.9, O O24.33, O O24.83 LOINC , , HbA1c Result Lab Result <7% 7.0% - 9.0% II 3044F 3045F >9.0% 3046F Measure Exclusion Criteria: Identify members who do not have a diagnosis of diabetes, in any setting, during 2015 or 2016 and who meet either of the following criteria: A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during 2015 or Exclusion Diabetes Exclusions ICD-9 CM 249, 251.8, 962, 648.8, , 962 Progress/Office Notes Medical Record Documentation 2016 progress/office notes stating date of A1c test and result. ICD-10 CM E E09.9, O O24.439, O O24.93 Labs/Procedure Result Hemoglobin A1c, HgbA1c, A1c in 2016 Documentation must include the date of service and results of the tests. 27

28 CDC - Comprehensive Diabetes Care - Monitor for Nephropathy Diabetes Members 18 to 75 years of age with diabetes (type 1 and type 2) who received a nephropathy screening or monitoring test OR evidence of nephropathy in ICD-9 CM ICD-10 CM 250, 357.2, 362.0, , E10.10-E13.9, O O24.33, O O24.83 Monitoring for Nephropathy II LOINC Nephropathy Screening Urine Macroalbumin Test Common Chart Deficiencies and Tips: 1. Failure to order lab tests for Nephropathy screening 2. Failure to document monitoring for nephropathy 3. Incomplete or missing information from specialists who may be monitoring nephropathy , F, 3061F , F , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

29 CDC - Comprehensive Diabetes Care - Monitor for Nephropathy Treatment for Nephropathy ESRD Kidney Transplant 3066F, 4010-F ICD-9 CM 585.5, 585.6, V45.12, V , 36800, 36810, 36815, , , 90935, 90937, 90940, 90945, 90947, , 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, , 50320, 50340, 50360, 50365, 50370, ICD-9 CM 250.4, 403, 404, , , , , 753.0, , , 791 ICD-9 PCS 38.95, 39.27, 39.42, 39.43, 39.53, , POS 65 ICD-9 CM V42.0 HCPCS S9339, G0257 ICD-9 PCS 55.61, E08.21-E08.29, E09.21-E09.29, E E10.29, E11.21-E11.29, E13.21-E13.29, I12.0-I13.2, I15.0-I15.1, N00.0-N08, N14.0-N14.4, N17.0-N19, N25.0-N26.9, Q60.0-Q61.9, R80.0-R80.9 ICD-10 CM N18.5, N18.6, Z91.15, Z99.2 ICD-10 CM Z94.0 UB Rev ICD-10 CM , 809, , 829, , , , 859, , 889 ICD-10 PCS 0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY10Z2 ICD-9 CM ICD-10 CM Stage 4 Chronic Kidney Disease N18.4 ICD-10 PCS 3E1M39Z, 5A1D00Z, 5A1D60Z UB Type of Bill , 0727, 0728, 072A-072K, 072M, 072O, 072X-072Z UB Rev HCPCS 367 S

30 CDC - Comprehensive Diabetes Care - Monitor for Nephropathy Angiotensin converting enzyme inhibitors Angiotensin II inhibitors Anti- Hypertensive Combinations Exclusion Diabetes Exclusions Benazepril Captopril Enalapril Fosinopril Lisinopril Azilsartan Candesartan Eprosartan Irbesartan Aliskiren-valsartan Amlodipine-benazepril Amlodipine-hydrochlorothiazidevalsartan Amlodipine-hydrochlorothiazideolmesartan Amlodipine-olmesartan Amlodipine-telmisartan Amlodipine-valsartan Azilsartan-chlorthalidone Benazepril-hydrochlorothiazide Candesartan-hydrochlorothiazide Captopril-hydrochlorothiazide Enalapril-hydrochlorothiazide ACE Inhibitors/ARBs 249, 251.8, 962, 648.8, , 962 Moexipril Perindopril Quinapril Ramipril Trandolapril Losartan Olmesartan Telmisartan Valsartan Eprosartan-hydrochlorothiazide Fosinopril-hydrochlorothiazide Hydrochlorothiazide-lisinopril Hydrochlorothiazide-losartan Hydrochlorothiazide-moexipril Hydrochlorothiazide-olmesartan Hydrochlorothiazide-quinapril Hydrochlorothiazide-telmisartan Hydrochlorothiazide-valsartan Trandolapril-verapamil Measure Exclusion Criteria: Identify members who do not have a diagnosis of diabetes, in any setting, during 2015 or 2016 and who meet either of the following criteria: A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during 2015 or ICD-9 CM Hydrochlorothiazide-irbesartan ICD-10 CM E08.00-E09.9, O O24.439, O O24.93 Progress/Office Notes 2016 specialists consultations (Nephrologists) AND/OR 2016 progress/office notes Medical Record Documentation Worksheets/logs Problem List Medical/surgical history SOAP note Dialysis records 30 Labs/Procedure Result Urine test in 2016 for albumin or protein In 2016, microalbumin and macroalbumin, results Documentation must include the date of service and results of the tests.

31 CDC - Comprehensive Diabetes Care - Dilated Retinal Eye Exam Members 18 to 75 years of age with diabetes (type 1 and type 2) who had a dilated retinal eye exam in 2016 or a dilated retinal eye exam that was negative for retinopathy in Diabetes ICD-9 CM ICD-10 CM 250, 357.2, 362.0, , E10.10-E13.9, O O24.33, O O24.83 II Diabetic Retinal Screening 67028, 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, , 92230, 92235, 92240, 92250, 92260, , , F, 2022F, 2024F, 2026F HCPCS S3000, S0620, S0621, S0625 Measure Exclusion Criteria: Identify members who do not have a diagnosis of diabetes, in any setting, during 2015 or 2016 and who meet either of the following criteria: A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during 2015 or Exclusion ICD-9 CM Diabetes Exclusions 249, 251.8, 962, 648.8, , 962 Progress/Office Notes 2016 progress/office notes eye exams or name of eye care provider, if known Medical Record Documentation ICD-10 CM E08.00-E09.9, O O24.439, O O24.93 Worksheets/logs Problem List Medical/surgical history SOAP note Eye exam result form, letter from eye care provider to PCP with DOS and results 31

32 CDC - Comprehensive Diabetes Care - Blood Pressure Less Than 140/90 Diabetes Members 18 to 75 years of age with diabetes (type 1 and type 2) whose last blood pressure in 2016 was less than 140/90. ICD-9 CM ICD-10 CM Exclusion 250, 357.2, 362.0, , A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during 2015 or ICD-9 CM Diabetes Exclusions 249, 251.8, 962, 648.8, , 962 Medical Record Documentation Progress/Office Notes Progress/office notes showing last BP in 2016 E10.10-E13.9, O O24.33, O O24.83 II Codes to Identify Systolic and Diastolic BP Levels <140/90 II Systolic <140 Diastolic <90 Measure Exclusion Criteria: 3074F, 3075F 3078F, 3079F Identify members who do not have a diagnosis of diabetes, in any setting, during 2015 or 2016 and who meet either of the following criteria: ICD-10 CM E08.00-E09.9, O O24.439, O O

33 ADV - Annual Dental Visit The percentage of members 2 20 years of age who had at least one dental visit in This measure applies only if dental care is a covered benefit in the organization s Medicaid contract. Dental Visits 70300, 70310, 70320, 70350, HCPCS/CDT (Current Dental Terminology) D0120-D0999, D1110-D2999, D3110-D3999, D4210- D4999, D5110-D5899, D5994, D6010-D6205, D7111- D7999, D8010-D8999, D9110-D9999 Medical Record Documentation Progress/Office Notes Progress/office notes showing dental visit in

34 FPC - Frequency of Ongoing Prenatal Care The percentage of Medicaid deliveries between November 6, 2015 and November 5, 2016 that had the following number of expected prenatal visits: 21 percent of expected Visits 21 percent - 40 percent of expected visits 41 percent - 60 percent of expected visits 61 percent - 80 percent of expected visits 81 percent of expected visits Codes to Identify Prenatal Care Visits - Method 1 HCPCS Prenatal Bundled Services Stand Alone Prenatal Visits , , Prenatal Ultrasound 59400, 59425, 59426, 59510, 59610, , 76805, 76811, 76813, , H , 0500F, 0501F, 0502F H1000-H1004 Codes to Identify Prenatal Care Visits - Method 2 HCPCS UB Revenue T1015, G WITH One of the Following Diagnosis or Procedure Codes: ICD-9 PCS Obstetric Panel ICD-9 PCS ICD-10 PCS BY49ZZZ-BY4GZZZ OR HCPCS UB Revenue Provider Visit , , T1015, G WITH Toxoplasma Antibody, Rubella Antibody, Cytomegalovirus, and Herpes Simplex: 34

35 FPC - Frequency of Ongoing Prenatal Care LOINC Toxoplasma Antibody Herpes Simplex Antibody 86777, Rubella Antibody Cytomegalo- virus Antibody , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

36 FPC - Frequency of Ongoing Prenatal Care OR HCPCS UB Revenue Provider Visit , , WITH Rubella Antibody and ABO: LOINC T1015, G Rubella Antibody , , , , , , , , , , , , , , , , , , , , , , , , , , , AND ABO , OR HCPCS UB Revenue Provider Visit , , WITH Rubella Antibody and Rh: LOINC T1015, G Rubella Antibody , , , , , , , , , , , , , , , , , , , , , , , , , , , AND Rh , , , 972-0,

37 FPC - Frequency of Ongoing Prenatal Care OR HCPCS UB Revenue Provider Visit , , T1015, G WITH Rubella Antibody and ABO/Rh: LOINC Rubella Antibody , , , , , , , , , , , , , , , , , , , , , , , , , , , AND ABO/Rh 882-1, Medical Record Documentation Progress/Office Notes Worksheets/lists/logs Labs/Procedure Result 2014 and 2015 prenatal visit progress/office notes 2014 or 2015 hospital delivery records from November 6, 2014, and November 5, 2015) Prenatal flow sheet (ACOG, EMR, or other) Basic physical obstetric (OB) examination that includes: - Auscultation for fetal heart tone OR - Pelvic exam with OB observations OR - Measurement of fundus height LMP or ECC with: - Prenatal risk assessment with counseling/education - Complete OB history Gestational age may be found in hospital record. OB panel must include: - Hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen and Rh ABO blood typing - TORCH antibody panel alone - Rubella antibody test/titer with an Rh incompatibility (ABO/Rh) blood typing - Echography of pregnant uterus (ultrasound reports) 37

38 PPC - Prenatal and Postpartum Care The percentage of deliveries of live births between November 6, 2015 and November 5, For these women, the measure assesses the following facets of prenatal and postpartum care. Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization. Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. Common Chart Deficiencies and Tips 1. C-section suture/staple removal appointment prior to 21 days after delivery does not meet measure criteria 2. Schedule postpartum follow-up visit for C-section patients before they leave after suture/staple removal. Prenatal Bundled Services Stand Alone Prenatal Visits Prenatal Ultrasound Timeliness of Prenatal Care Codes to Identify First Visit - Method 1 HCPCS 59400, 59425, 59426, 59510, 59610, H , 0500F, 0501F, 0502F H1000-H1004 Codes to Identify Prenatal Care Visits - Method 2 HCPCS UB Revenue , , Obstetric Panel , 76805, 76811, 76813, , T1015, G WITH One of the Following Diagnosis or Procedure Codes: ICD-9 PCS ICD-9 PCS ICD-10 PCS BY49ZZZ-BY4GZZZ 38

39 PPC - Prenatal and Postpartum Care Provider Visit Toxoplasma Antibody 86777, Rubella Antibody Cytomegalo- virus Antibody Herpes Simplex Antibody , , OR HCPCS T1015, G0463 UB Revenue WITH Toxoplasma Antibody, Rubella Antibody, Cytomegalovirus, and Herpes Simplex: LOINC , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

40 PPC - Prenatal and Postpartum Care HCPCS UB Revenue , , Provider Visit T1015, G WITH Rubella Antibody and ABO: LOINC Rubella Antibody , , , , , , , , , , , , , , , , , , , , , , , , , , , AND ABO , OR HCPCS UB Revenue Provider Visit , , WITH Rubella Antibody and Rh: LOINC Rubella Antibody AND OR HCPCS UB Revenue AND T1015, G , , , , , , , , , , , , , , , , , , , , , , , , , , , Rh , , , 972-0, Provider Visit Rubella Antibody , , WITH Rubella Antibody and ABO/Rh: LOINC T1015, G , , , , , , , , , , , , , , , , , , , , , , , , , , , ABO/Rh 882-1,

41 PPC - Prenatal and Postpartum Care Postpartum Visit - Any of the following Meet Criteria ICD-9 ICD-9 CM ICD-10 CM PCS Postpartum Visit V24.1, V24.2, V25.11-V25.13, V72.31, V72.32, V76.2 HCPCS Z Z01.42, Z30.430, Z39.1, G0101 Z39.2 LOINC UB Rev HCPCS Cervical Cytology Postpartum Bundled Services 57170, 58300, 59430, 99501, 0503F , 88147, 88148, 88150, , , 88174, , , , , , , , , , , 59410, 59510, 59515, 59610, 59614, 59618, G0123, G0124, G0141, G0143- G0145, G0147, G0148, P3000, P3001, Q0091 Medical Record Documentation Progress/Office Notes Worksheets/lists/logs Labs/Procedure Result 2014 and 2015 prenatal and postpartum visit progress/office notes 2014 or 2015 hospital delivery records from November 6, 2014, and November 5, 2015) Prenatal flow sheet (ACOG, EMR, or other) Basic physical obstetric (OB) examination that includes: - Auscultation for fetal heart tone OR - Pelvic exam with OB observations OR - Measurement of fundus height LMP or ECC with: - Prenatal risk assessment with counseling/education - Complete OB history Postpartum checklist OB panel must include: - Hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen and Rh ABO blood typing - TORCH antibody panel alone - Rubella antibody test/titer with an Rh incompatibility (ABO/Rh) blood typing - Echography of pregnant uterus (ultrasound reports) 41

42 ADD - Follow-Up Care for Children Prescribed ADHD Medication The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication in 2016 who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported. Initiation Phase. The percentage of members 6 12 years of age with an ambulatory prescription dispensed for ADHD medication, who had one followup visit with practitioner with prescribing authority during the 30-day Initiation Phase. Continuation and Maintenance (C&M) Phase. The percentage of members 6 12 years of age with an ambulatory prescription dispensed for ADHD medication, whom remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended. Common Chart Deficiencies and Tips 1. No refills until the initial follow-up visit is complete 2. Conduct initial follow-up visit 2-3 weeks after member starts medication therapy 3. Schedule additional 2 visits within 9 months of medication at the time of the initial follow-up visit 4. If member cancels an appointment, reschedule ADHD Medications Prescriptions Amphetaminedextroamphetamine Lisdexamfetamine CNS stimulants Dexmethylphenidate Methamphetamine Dextroamphetamine Methylphenidate Alpha-2 receptor agonists Clonidine Guanfacine Miscellaneous ADHD medications Atomoxetine 42

43 Codes to Identify Follow-Up Visits - Initiation Phase HCPCS UB Revenue , , , 99078, , , , , , , , , , 99411, 99412, G0155, G0176, G0177, G0409-G411, G0463, H0002, H0004, H0031, H0034- H0037, H0039, H0040, H2000, H2001, H2010- H2020, M0064, S0201, S9480, S9484, S9485, T , 90792, 90801, 90802, , , , , , 90845, 90847, 90849, 90853, 90857, 90862, 90875, , 513, , , , 900, , 907, , 919, 982, 983 WITH 3, 5 7, 9, 11-15, 20, 22, 33, 49, 50, 52, 53, 71, , , 99238, 99239, WITH 52, 53 Codes to Identify Follow-Up Visits - C&M Phase All the codes listed above for the Initiation Phase PLUS Telephone Visits , POS Measure Exclusion Criteria: Exclusion ICD-9 CM ICD-10 CM Diagnosis of Narcolepsy , , , G47.411, G47.419, G47.421, G

44 FUH - Follow-Up After Hospitalization for Mental Illness The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses in 2016 and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: The percentage of discharges for which the member received follow-up within 30 days of discharge. The percentage of discharges for which the member received follow-up within 7 days of discharge. ICD-10 CM Mental Health Diagnosis F03.90, F03.91, F20.0-F25.9, F28- F34.9, F39, F40.00-F45.9, F48.1-F48.9, F50-F53, F59-F60.9, F63-F66, F68.10-F68-13, F68.8, F69, F80-F82, F84- F84.9, F88, F89 F90.0-F99 Codes to Identify Follow-Up Visits With a Mental Health Practitioner HCPCS , 99078, , , , , , , , , , 99211, 99412, ICD-9-CM Mental Health Diagnosis , 290.2, , , , 293, 293.1, , , , 295, , 295.1, , 295.2, , 295.3, ,35, 295.4, , 295.5, , 295.6, , 295.7, , 295.8, , 295.9, , 296, , 296.1, , 296.2, , 296.3, , 296.4, , 296.5, , 296.6, , 296.7, 296.8, , , , 296.9, , 297, , 297.8, 297.9, 298, , 298.8, 298.9, 299, , 299.1, , , 299.9, , 300.3, 300.4, 301, 301.1, , 301.2, , , , , , 301.6, 301.7, , , 301.9, 308, , 308.9, 309, 309.1, , , , 309.3, 309.4, , , 309.9, 311, 312, , 312.1, , 312.2, , 312.3, , , 312.4, , , , 312.9, 313, 313.1, , 313.3, , , 313.9, 314, , 314.1, 314.2, 314.8, G0155, G0176, G0177, G0409-G411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T