A Partnership in Quality Reporting. Effectiveness of Care: Prevention and Screening

Transcription

1 A Partnership in Quality Reporting Effectiveness of Care: Prevention and Screening Codes to Identify Well-Child Visits Completed during First 15 Months of Life ICD-9-CM Diagnosis Codes 99381, 99382, 99391, 99392, 99432, V20.2, V20.3, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Codes to Identify Childhood Immunizations Completed by 2nd Birthday Immunization ICD-9-CM Diagnosis Codes DTaP 90698, 90700, 90721, IPV 90698, 90713, MMR 90707, Measles and rubella Measles Mumps Rubella HiB , 90698, 90721, Hepatitis B** 90723, 90740, 90744, 90747, 070.2, 070.3, V VZV 90710, , 053 Pneumococcal conjugate 90669, Hepatitis A , Rotavirus (two dose schedule) Rotavirus (three dose schedule) Influenza 90655, 90657, 90661, ICD-9-CM Procedure Codes * ICD-9-CM Diagnosis codes indicate evidence of disease ** The two-dose hepatitis B antigen Recombivax is recommended for children years of age only and is not included in this table. Codes to Identify Lead Screening One or more screenings by 2 years of age CPT Code Codes to Identify Well-Child Visits Completed in the Third, Fourth, Fifth, and Sixth Year of Life ICD-9-CM Diagnosis Codes 99382, 99383, 99392, V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Codes to Identify Adolescent Well-Care Visits Ages years ICD-9-CM Diagnosis Codes , V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

2 Codes to Identify BMI Percentile, Counseling for Nutrition and Counseling for Physical Activity Ages 3-17 years ICD-9 CM Diagnosis ICD-9 CM Procedure BMI Percentile V85.5 Counseling for nutrition V65.3 Counseling for physical V65.41 Codes to Identify Outpatient Visits , , , , , , , , , 99411, 99412, 99420, 99429, 99455, Codes to Identify BMI ICD-9 CM Diagnosis V85.0-V85.5 Codes to Identify Weight Assessment and Counseling for Nutritional and Physical Activity Ages 3-17 years , , , , , , , , , 99411, 99412, 99420, 99429, 99455, Codes to Identify Adult BMI Ages years V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Codes to Identify Breast Cancer Screening Ages years ICD-9 CM Diagnosis V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V , 87.37, V Codes: V76.11, V76.12 Codes to Identify Cervical Cancer Screening Ages years , 88147, 88148, 88150, , V Codes: V72.32, V , 88174, 88175

3 87110, 87270, 87320, A Partnership in Quality Reporting Codes to Identify Chlamydia Screening in Women Ages years LOINC 557-9, 560-3, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Effectiveness of Care: Respiratory Conditions Codes to Identify Appropriate Treatment for Children with Upper Respiratory Infection (URI) Ages 3 mos-18 yrs Acute nasopharyngitis 460 URI 465 ICD-9-Codes Appropriate Testing for Children With Pharyngitis Ages 2-18 years Acute pharyngitis 462 Acute tonsillitis 463 Streptococcal sore throat Codes to Identify Use of Appropriate Medications for People With Asthma ICD-9-CM Diagnosis Asthma 493 CPT UB Revenue Outpatient , , , 051x, , , 057x , , , 059x, 0982, , , , 99411, 99412, 99420, Antiasthmatic combinations Antibody inhibitor Inhaled steroid combinations Inhaled corticosteroids Preferred Asthma Therapy Medications* Prescriptions guaifenesintheophyllintheophylline potassium iodide- omalizumab budesonideformoterol mometasone/formoterol (Dulera) fluticasone-salmeterol (Advair) (Symbicort) beclomethasone (QVAR) budesonide flunisolide fluticasone CFC free (Flovent) mometasone

4 Leukotriene modifiers Mast cell stabilizers Methylxanthines montelukast (Singular) Cromolyn (Intal Inhaler or Intal Nebs) aminophylline dyphylline nedocromil Theophylline (Elixophyllin, Slobid and Uniphyl) Short-acting, inhaled beta-2 agonists Appropriate Asthma Therapy Medications* Prescriptions albuterol metaproterenol (Exclusive for Pro Air) *All medications listed are on the Molina Formulary. No Prior Authorization is required. When available, generic is preferred. Effectiveness of Care: Diabetes Codes to Identify Comprehensive Diabetes Care ICD-9-CM Diagnosis Diabetes 250, 357.2, 362.0, , Codes to Identify Visit Type CPT UB Revenue Outpatient 92002, 92004, 92012, 92014, , , , , , , , , , 99411, 99412, 99420, 99429, 99455, x, , , 057x-059x,, 082x-085x, 088x, 0982, 0983 Codes to Identify HbA1c Tests CPT CPT II LOINC 83036, F, 3045F, 3046F , , Codes to Identify HbA1c Levels > 9% Numerator compliant (HbA1c >9.0%) 3046F Not numerator compliant (HbA1c 9.0%) 3044F, 3045F Codes to Identify HbA1c Levels <8% Numerator compliant (HbA1c <8.0%) 3044F Not numerator compliant (HbA1c 8.0%) 3045F*, 3046F * 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, Molina Healthcare may use other sources (laboratory data, hybrid reporting method) to determine if the HbA1c result was <8%. Codes to Identify HbA1c Levels <7% Numerator compliant (HbA1c <7.0%) 3044F Not numerator compliant (HbA1c 7.0%) 3045F, 3046F

5 Codes to Identify Eye Exams by an Eye Care Professional* CPT CPT II** HCPCS ICD-9-CM ICD-9-CM Procedure Diagnosis 67028, 67030, 67031, 67036, , 2022F, S0620, V , 14.9, , 67105, 67107, 67108, 67110, 67112, 2024F, S0621, 95.04, 95.11, 95.12, 67113, 67121, 67141, 67145, 67208, 67210, 2026F, S0625** , 67220, 67221, 67227, 67228, 92002, 3072F***, S , 92012, 92014, 92018, 92019, 92225, 92226, 92230, 92235, 92240, 92250, 92260, , , * Eye exams provided by eye care professionals are a proxy for dilated eye examinations because there is no administrative way to determine that a dilated exam was performed. ** The organization does not need to limit codes or HCPCS S0625 to an optometrist or an ophthalmologist. These codes indicate an eye exam was performed by an eye care professional. *** code 3072F can only be used if the claim/encounter was during the measurement year because it indicates the member had no evidence of retinopathy in the prior year. Additionally, because the code definition itself indicates results were negative, an automated result is not required. Codes to Identify LDL-C Levels CPT CPT II LOINC 80061, 83700, 83701, 83704, F, 3049F, 3050F , , , , , , , , Codes to Identify Nephropathy Screening Tests CPT CPT II LOINC Nephropathy 82042, 3060F, 3061F , , , , , , screening 82043, 4, , , , , , , test 82044, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , CPT CPT II* HCPCS ICD-9-CM Diagnosis Urine macroalbumin test* Evidence of treatment for nephropathy ACE inhibitor/ ARB therapy ICD-9-CM Procedure LOINC , F , , , , , 36800, 36810, 36815, 36818, , , 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90920, 90921, 90924, 90925, 90935, 90937, 90940, 90945, 90947, , 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, F G0257, G0314- G0319, G0322, G0323, G0326, G0327, G0392, G0393, S F 250.4, 403, 404, , , , , 753.0, 753.1, 791.0, V42.0, V45.1, V , 39.27, 39.42, 39.43, 39.53, , 54.98,

6 Codes to Identify Systolic and Diastolic BP Levels <130/80 Systolic Diastolic Numerator compliant (BP <130/80 mm Hg) 3074F 3078F Not numerator compliant (BP 130/80 mm Hg) 3075F, 3077F 3079F, 3080F Codes to Identify Systolic and Diastolic BP Levels <140/90 Systolic Diastolic Numerator compliant (BP <140/90 mm Hg) 3074F, 3075F 3078F, 3079F Not numerator compliant (BP 140/90 mm Hg) 3077F 3080F