Healthcare Effectiveness Data and Information Set Quality Assurance Reporting Requirements

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1 HEDIS/QARR Healthcare Effectiveness Data and Information Set Quality Assurance Reporting Requirements 2015 Quick Reference Guide ADULTS Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) Antibiotics should not be prescribed for adults years of age with a diagnosis of acute bronchitis Adults Access to Preventive/Ambulatory Health Services (AAP) Adults ages 20 years and older should have at least one ambulatory or preventive care visit Office and other outpatient services CPT-4: , , Home services CPT-4: , Nursing facility care CPT-4: , 99315, 99316, Domiciliary, rest home, or custodial care services CPT-4: , Preventive medicine CPT-4: , , , 99411, 99412, 99420, Ophthalmology and optometry CPT-4: 92002, 92004, 92012, General medical examination ICD-9 Diagnosis: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Adult BMI Assessment (ABA) Adults years old should have a BMI documented at least once per year ICD-9 Diagnosis: V85.0, V85.1, V85.21 V85.25, V85.30 V85.39, V85.41 V85.45, V85.51 V

2 Antidepressant Medication Management (AMM) Adults 18 years and older diagnosed with a new episode of depression should remain on medication for a minimum of 84 days (12 weeks) and optimally 180 days (six months) Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) Adults 18 years and older diagnosed with Rheumatoid Arthritis should be dispensed at least one prescription for a disease-modifying anti-rheumatic drug (DMARD). DO NOT use Rheumatoid Arthritis diagnosis codes when ruling out the disease Use of Appropriate Asthma Medications for People with Asthma (ASM) Children and adults ages 5 64 diagnosed with persistent asthma should be dispensed at least one prescription for an asthma controller medication Breast Cancer Screening (BCS) Women years old should have a mammogram every 1 2 years CPT-4: ICD-9 Procedure: 87.36, Care for Older Adults (COA) Adults 66 years and older should have the following documented at least annually: Advanced Care Planning CPT Category II: 1157F, 1158F Medication List/Review CPT Category II: 1159F, 1160F CPT-4: 90863, 99605, Functional Status Assessment CPT Category II: 1170F Pain Assessment CPT Category II: 1125F, 1126F 2

3 Cervical Cancer Screening (CCS) Women years old should be screened for cervical cancer using either of the following: years old Cervical cytology every 1 3 years years old Cervical cytology with HPV co-testing every 1 5 years Cervical Cytology CPT-4: , 88147, 88148, 88150, , , 88174, HPV Test CPT-4: Chlamydia Screening in Women (CHL) Women years old identified as sexually active should be screened annually for Chlamydia CPT-4: 87110, 87270, 87320, 87490, 87491, 87492, Colorectal Cancer Screening (COL) Adults aged should be screened for colorectal cancer by one of the following: Fecal occult blood test (FOBT, gfobt, ifobt) every year CPT-4: 82270, Flexible sigmoidoscopy during the measurement year or four years prior CPT-4: , , ICD-9 Procedure: Colonoscopy during the measurement year or nine years prior CPT-4: , 44397, 45355, , 45391, ICD-9 Procedure: 45.22, 45.23, 45.25, 45.42,

4 Comprehensive Diabetes Care (CDC) Adults years old diagnosed with diabetes (type 1 and 2) should have each of the following at least annually: HbA1c testing Goal: <7.0% (most recent in measurement year) CPT-4: 83036, CPT Category II: 3044F, 3045F, 3046F Blood Pressure Goal: <140/90mm HG (most recent in measurement year) CPT Category II: Systolic 3074F, 3075F; Diastolic 3078F, 3079F Medical Attention for Nephropathy Microalbumin urine test CPT-4: 82042, 82043, 82044, Positive Macroalbumin test* CPT-4: , ACE/ARB prescription CPT Category II: 4010F Evidence of treatment for nephropathy CPT-4: 36147, 36800, 36810, 36815, , , 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947, , 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, CPT Category II: 3066F CPT Category II: 3060F, 3061F CPT Category II: 3062F ICD-9 Diagnosis: , , , , , , , , , , 580.0, 580.4, , , 580.9, , , , 581.9, , 582.4, , , 582.9, , 583.4, , , , 583.9, , , 585.9, 586, 587, , , , 588.9, 753.0, , , 791.0, V42.0, V45.11, V45.12 ICD-9 Procedure: 38.95, 39.27, 39.42, 39.43, 39.53, , 54.98, 55.61, Dilated retinal eye exam by an eye care professional (annually) or negative for retinopathy in the year prior to the measurement year CPT-4: 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, , , CPT Category II: 2022F, 2024F, 2026F, 3072F** * A CPT Category II code indicates a positive result for urine macroalbumin; laboratory data to confirm a positive result for tests identified by CPT or LOINC codes are needed. ** CPT Category II 3072F code indicates no evidence of retinopathy in the prior year; negative result for eye exam in prior year is needed. 4

5 Controlling High Blood Pressure (CBP) Adults years old should have their Blood Pressure documented at least once per year Members Goal: <140/90mm Hg (most recent reading) Members with a diagnosis of diabetes Goal: <140/90mm Hg (most recent reading) Members without a diagnosis of diabetes Goal: <150/90mm Hg (most recent reading) Follow-up After Hospitalization for Mental Illness (FUH) Children six years and older, and adults, should have an outpatient follow-up visit with a mental-health practitioner within seven days after discharge CPT-4: , 99078, , , , , , , , , , 99411, 99412, CPT-4: 90791, 90792, , , 90845, 90847, 90849, 90853, , 90875, with POS: 03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 24, 33, 49, 50, 52, 53, 71, 72 CPT-4: , , 99238, 99239, with POS: 52, 53 HIV/AIDS Comprehensive Care (HCC) Children and adults diagnosed with HIV/AIDS should receive each of the following: Two outpatient visits for primary care or HIV-related care one in the first six months of the year; one in the second six months of the year (ages two years and older) CPT-4: , , , , , , , , 99411, 99412, 99420, ICD-9 Diagnosis: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Two viral load tests one in the first six months of the year; one in the second six months of the year (ages two years and older) CPT-4: , One syphilis test (age 19 and older only) CPT-4: ,

6 Use of Imaging Studies for Lower Back Pain (LBP) Adults years with a primary diagnosis of lower back pain who did not have an imaging study (plain x-ray, MRI, CT scan) within 28 days of diagnosis unless clinically indicated Medication Management for People with Asthma (MMA) Children and adults ages 5 64 who were identified as having persistent asthma and were dispensed appropriate medications must remain on an asthma controller for at least 75% of the treatment period Annual Monitoring for Patients on Persistent Medications (MPM) Adults 18 years and older who received at least 180 days of ambulatory medication therapy for select therapeutic agents should receive at least one therapeutic monitoring event: ACE/ARB and/or Diuretics-lab panel; or one serum potassium and a serum creatinine Digoxin-lab panel and a serum digoxin; or one serum potassium and a serum creatinine and a serum digoxin Lab Panel CPT-4: 80047, 80048, 80050, 80053, Serum Potassium (K+) CPT-4: 80051, Serum creatinine (SCr) CPT-4: 82565, Digoxin Level CPT-4: Medication Reconciliation Post-Discharge (MRP) Adults 66 years and older should have medications reconciled by outpatient provider within 30 days of discharge CPT Category II: 1111F CPT-4: 99495, Osteoporosis Management in Women Who Had a Fracture (OMW) Women years of age who suffered a fracture should have a bone mineral density test or be dispensed a drug to treat or prevent osteoporosis within six months after the fracture Bone Mineral Density Test CPT-4: 76977, 77078, ICD-9 Procedure:

7 Pharmacotherapy Management of COPD Exacerbation (PCE) Adults 40 years and older who had an acute inpatient discharge or ED encounter for COPD exacerbation should be dispensed the following medications: A systemic corticosteroid within 14 days of discharge A bronchodilator within 30 days of discharge Prenatal Visits Timeliness of First Visit (PPC) and Frequency of Visits (FPC) Prenatal Care: initial prenatal visit must be within first trimester or within 42 days (6 weeks) of enrollment with health plan ICD-9 Diagnosis: V22 V23, V28 AND CPT-4: , , OR CPT Category II: 0500F, 0501F, 0502F Postpartum Care (PPC) Postpartum Care: postpartum visit must occur 3 8 weeks (21 56 days) after delivery ICD-9 Diagnosis: V24.1, V24.2, V25.11 V25.13, V72.3, V72.31, V72.32, V76.2; ICD-9 Procedure Code OR CPT-4: 57170, 58300, 59430, , 88147, 88148, 88150, , , 88174, 88175, OR CPT Category II: 0503F Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) Adults 40 years and older with a new diagnosis of COPD or newly active COPD should receive appropriate spirometry testing that must occur two years prior to six months after diagnosis CPT-4: 94010, , 94060, 94070, 94375,