HbA1c Medical Attention for Nephropathy BP control Eye Exam

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2 Table of Contents Measure abbreviation Measure Description Page AAB Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 3 ABA Adult BMI Assessment 4 ADD Follow Up Care for Children Prescribed ADHD Medication 5 AMM2 Antidepressant Medication Management 6 AMR Asthma Medication Ratio 7 ART Disease Modifying Anti-Rh eumatic Drug Therapy for Rheumatoid Arthritis 7 AWC Adolescent Well -Ca re Visits 8 BCS Breast Cancer Screening 8 CBP Controlling High Blood Pressure 9 CAP Children and Adolescents Access to Primary Care Practitioner 10 CCS Cervical Cancer Screening 10 CDC Comprehensive Diabetes Care - HbA1c 11 CDC Comprehensive Diabetes Care - Medical Attention for Nephropathy 11 CDC Comprehensive Diabetes Care BP control 12 CDC Comprehensive Diabetes Care Eye Exam 12 CHL Chlamydia Screening in Women (16-24 years of age) 13 CWP Appropriate Testing for Children with Pharyngitis 13 CIS Childhood Immunization Status 14 COL Colorectal Cancer Screening 15 FUH Follow up after Hospitalization for Mental Illness 16 HPV Human Papillomavirus Vaccine for Female Adolescents 17 IMA Immunizations for Adolescents 17 IET Initiation and Engagement of Alcohol and Other Drug Dependence 18 LBP Use of Imaging Studies for Low Back Pain 19 MPM Annual Monitoring for Patients on Persistent Medications 19 MMA Medication Management for People with Asthma 20 NCS Non-recommended Cervical Cancer Screening in Adolescent Females 21 PBH Persistence of Beta Blocker Treatment after a Heart Attack 21 PCE 1 Pharmacotherapy Management of COPD Exacerbation (Bronchodilator ) 22 1

3 Table of Contents PCE 2 Pharmacotherapy Management of COPD Exacerbation (Systemic Corticosteroid) 22 PPC 1 Prenatal Care 23 PPC 2 Postpartum Care 23 SPR Use of Spirometry Testing for Assessment and Diagnosis of COPD 23 URI Appropriate Treatment for Children with Upper Respiratory Infec tions 24 W15 Well -Ch il rst 15 months of Life 24 W34 Well Child Visits in the 3 rd, 4 th, 5 th, and 6 th Years of Life 25 WWC 1 Weight Assessment and Counseling for Nutrition and Physical Activity 25 for Children/Adolescents Total Childhood BMI WWC 2 Weight Assessment and Counseling for Nutrition and Physical Activity 26 for Children/Adolescents Total - Nutrition WWC 3 Weig ht Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Total Physical Activity Appendix 1 Index of measures by HEDIS Domains Appendix 2 BMI Code Chart 30 Appendix 3 BMI Percentile Chart 31 Appendix 4 Asthma Medication Table 32 Appendix 5 D-MA RD Table 33 Appendix 6 Corticosteroid and Bronchodilators for COPD Exacerbation 34 2

4 Definitions Administrative Measures- Measure compliance is accessed by claims only Hybrid Measures- Medical Records may be required for assessment of measure compliance HEDIS Quality Measure Clinical Goal Criteria to meet the Goal AAB Administrative measure Adult Acute Bronchitis The % of adults years of age with a diagnosis of acute bronchitis who were NOT dispensed an antibiotic prescription. to 12/24 each year. Members treated for acute bronchitis (J20.9) should NOT be prescribed antibiotics unless there are co-morbid conditions (see table) or competing diagnoses that require antibiotic therapy. Asthma (J45) Tobacco use (F17 or Z72.0) wheezing (R06.2), fever (R50.9) and Diabetes (E08 E13) are not co-morbid or competing diagnosis exclusions to this measure Submit a claim with all appropriate diagnosis codes including any competing conditions (i.e. cellulitis) and any co-morbid condition diagnoses. Exclusions/ co-morbid ICD -10 CM conditions HIV B20, Z21 Malignant Neoplasms C00.0 C96.9; Z85.0 Z Emphysema J43.0 J43.9 COPD J44.0 J44.9 Cystic Fibrosis E84.0 E84.9 TB A15 A 19.9; O O98.03 Aspergillosis B44.81 Sickle Cell Disease with Acute D57.01, D57.211, D57.411, D Chest Chronic Bronchitis J41.0 J42 Other respiratory diagnoses J22; J47.0,J47.1,J47.9, J60 J96.92; J99 M30.1, M32.13, M33.01, M33.11, M33.21, M33.91, M34.81, M

5 ABA aka BMI Hybrid measure Adult Body Mass Index The % of members years of age who had an outpatient visit and whose body mass index (BMI) or BMI percentile, was documented during the measurement year or the year prior to the measurement year. For members years a BMI percentile is required. to 12/31 each year. For patients years of age document BMI, at least every 2 years. For patients years of age document BMI percentile at least every 2 years. Height, weight and BMI or BMI percentiles are required. If BMI or BMI percentile is not documented the record does not meet the measure. During the measurement year or the prior year the member has had their BMI or BMI percentile measured as evidenced by: For patients 21 and older submit a claim with the appropriate ICD10 CM code for BMI Z68.1 Z68.45 * For patients 18 to 20 submit a claim with the appropriate ICD10 CM code for BMI percentile Z68.51 to Z68.54 * OR Medical Record documentation of BMI or BMI percentile within the measurement year or the prior year. Exclusion: Members who have a diagnosis of pregnancy during the measurement year and the prior year are excluded from the measurement. See Appendix 2 and 3 for ICD10 codes for BMI and BMI percentiles (Page 30 and 31) *These codes are not currently eligible for reimbursement; correct coding guidelines still apply. 4

6 ADD Administrative measure Appropriate follow up for Children Prescribed ADHD medication The % of children newly prescribed, or restarting a medication commonly used for ADHD following a lapse of 120 days, who had at least three follow-up care visits within a 10- month period, one of which was with a prescribing provider within 30 days of when the medication was dispensed. If the member remains on the medication for 210 days then, in addition to the visit in the Initiation Phase, the member will have at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase. The measurement period is 3/1 of the prior year to 2/28 of the current year. Initiation Phase: The member must have an appointment with a provider with prescribing authority for a follow up visit within 30 days of starting or restarting a medication commonly used to treat ADHD. Continuation and Maintenance Phase: Then the member must have at least 2 additional follow up visits (these may be with a behavioral health practitioner) after the Initiation visit. If the member is noncompliant with the Initiation Phase then the member is noncompliant for both Initiation Phase and Continuation and Maintenance Phase. Submit a claim for a follow up visit with a prescribing provider and the appropriate CPT and ICD10 ADHD codes within 30 days of staring the medication and then at least 2 additional visits with a provider in the 9 months following the 30 day visit. The measure does not look at medication adherence, only member follow up care with a prescribing provider within 30 days of starting the medication and then 2 additional visits for ADHD with any provider. Utilize the Patient Care Summary to track prescription history of primary fill and refill dates to assess possible 120 day lapse in medication availability. Exclusions Narcolepsy or members who had an acute inpatient admission for mental health or chemical dependency during the 30 days after the date of medication fill. Submit a claim with the appropriate CPT and appropriate ICD10 ADHD code for each visit. Commonly used codes for provider with prescribing Stand Alone Visits ADD ICD10 Value Set ICD 10 ADD Dx. CPT value set codes 96150, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99383, 99384, 99393, POS Value Set N/A F90.0 ADHD, predominantly inattentive type F90.1 ADHD, predominantly hyperactive type F90.2 ADHD, combined type F90.8 ADHD, other type F90.9 ADHD, unspecified type 5

7 AMM Administrative measure Antidepressant Medication Management The % of members 18 years of age and older who were treated with antidepressant medication, with a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported: Effective Acute Phase Treatment. The percentage of member s who remained on an antidepressant medication for at least 84 days (12 weeks). Continuation Phase. The percentage of members who remained on an antidepressant medication for at least 180 days (6 months). The measurement period is 5/1 of the prior year to 4/30 of the current year. Members with a diagnosis of Major Depressive disorder will remain on medication therapy for a minimum of 12 weeks (Acute Phase) to 6 months (Continuation Phase) Educate the member regarding expected timeframe for medication to be effective and the importance of compliance. Assess member s response to medication within 30 days of Rx date. Consider a 90 day supply of medication after the initial dose has been well tolerated and proven effective. Once medication effectiveness has been established consider providing a prescription with refills x 6 Submit a claim for the appropriate member diagnosis. Receipt of pharmacy claims for 6 months of medication fill. ICD-10-CM codes Major Depressive Disorder F32.0, F32.1, F32.2, F32.3, F32.4, F32.9 F33.0, F33.1, F33.2, F33.3, F33.41, F33.9 Members placed on antidepressant therapy for other disorders such as episodic mood disorders, anxiety disorders, acute reaction to stress, or adjustment disorder are not included in this measure Disorders, not included in the measure. that may be treated antidepressant medication Anxiety Disorders F41.8 Acute Reaction to Stress F43.0 Adjustment Disorders F43.2, F43.8, F43.9 Dysthymic Disorders F34.1 6

8 AMR Administrative measure Asthma Medication Ratio The percentage of members 5 85 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year. to 12/31 each year. Patients with persistent asthma will receive Asthma controller prescriptions that account for at least 50% of their total asthma medications. (Controller meds versus rescue medications) Asthma Controller Meds = 50% Total All Asthma Meds = 100% Receipt of claims for asthma controller medications that account for at least 50% of all asthma medication prescriptions filled. Submit a claim for any exclusions that apply Exclusions Emphysema J43.0 J43.9 COPD J44.0 J44.9 Chronic Obstructive bronchitis J41 J42 Chronic conditions due to inhaled J68.4 fumes/vapors Cystic Fibrosis E84.0-E84.9 Acute Respiratory Failure J96.0; J96.2 See Appendix 4 (Pg. 32) for list of asthma medications per HEDIS specifications ART Administrative measure Disease-Modifying Anti- Rheumatic Drug Therapy for Rheumatoid Arthritis The % of members who were diagnosed with rheumatoid arthritis & who were dispensed at least one prescription for a disease-modifying antirheumatic drug. to 12/31 of the current year. Member will receive at least one ambulatory prescription for Disease-Modifying Anti- Rheumatic Drug (DMARD) Therapy. All patients not currently treated with a DMARD should be referred for a rheumatology consult to confirm diagnosis & assess for DMARD therapy. Receipt of a claim for at least one ambulatory prescription medication to treat Rheumatoid Arthritis. Submit a claim for exclusions that apply. Exclusions HIV anytime during the member s history to 12/31 of the measurement year Pregnancy anytime during the measurement year See Appendix 5 (Pg. 34) for list of DMARD Drugs per HEDIS specifications. 7

9 AWC Hybrid measure 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 measurement year. to 12/31 of the current year. Documentation in the medical record must include a note indicating a visit to a PCP or OB/GYN practitioner with: Health history Physical & mental development history Physical exam Health education/ anticipatory guidance Submit a claim for new or established patients for comprehensive preventative medicine services, BMI percentile, and all other services rendered. BCS Administrative measure Breast Cancer Screening The % of women years of age who had a mammogram to screen for breast cancer. 12/31 of the current year. There is a 27 month look back period from 10/1 two years prior to 12/31 of the current year. Members between the age of 52 and 74 years will have one or more mammograms at least every 2 years. (age 52 due to 2 year look back period) Educate your members on the importance of having a mammogram. This measure is for primary screening. Biopsies, ultrasounds or MRIs are not counted because they are not appropriate screening methods for primary breast cancer screening. Receipt of a mammogram claim from the radiology facility where the mammogram was performed anytime between October 1 st two years prior to the measurement year and December 31 of the measurement year. Exclusion: Documentation of a bilateral mastectomy or two unilateral mastectomies at least 14 days apart. Submit a claim using ICD10 code Z90.13 for history of bilateral mastectomy or Z90.11 Absence of right breast and Z90.12 Absence of left breast.* *These codes may be eligible for reimbursement; correct coding guidelines still apply. 8

10 CBP Hybrid measure Controlling High Blood Pressure The % of members years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year years of age whose BP was <140/90 mm Hg years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg 12/31 of the current year Control of high BP <140/90 is extremely important to prevent additional cardiovascular conditions. Educate patients on risk factors associated with poor control of BP. Medication compliance is essential to good control Tell patients what their goal BP should be Encourage patient to obtain a BP cuff and log BP at least 3 x week. Allow a short rest period after entering the exam room before the BP is checked. Recheck before leaving the office if >140/90 Submit a claim when appropriate with diagnosis of HTN. This measure requires collection of medical records for documentation of: 1 st diagnosis of HTN during the current year The last member BP in the record is used for the measure 9

11 CAP Administrative measure Children and Adolescents Access to Primary Care Practitioners (PCP) The percentage of members 12 months 19 years of age who had a visit with a PCP 12/31 of the current year Children 12 months to 6 years of age will have a visit with a PCP during the measurement year. Children and adolescents age 7 to 19 years of age will have a visit with a PCP during the measurement year or the year prior to the measurement year Submit a claim for all member visits CCS Hybrid measure Cervical Cancer Screening The % of women years of age who were screened for cervical cancer using either of the following criteria: Women age who had cervical cytology performed every 3 years OR Women age who had cervical cytology/human papillomavirus (HPV) cotesting performed every 5 years 12/31 of the current year. Women will have a cervical cytology (Pap smear) every 3 years OR Women age will have cervical cytology with HPV every 5 years Submit a claim for procedures completed with appropriate codes. OR Submit a claim using appropriate ICD10 code for history of exclusion *This code may be eligible for reimbursement; correct coding guidelines still apply. ICD-10-CM Codes for Exclusions Agenesis and Aplasia of Cervix Q51.5 Acquired Absence of cervix and uterus Z Acquired Absence of cervix with Z remaining uterus OR Submit medical record documentation of screening completed in the last 3 5 years as applicable or documentation of exclusion. 10

12 Comprehensive Diabetes Management - The % of members years of age with diabetes (type 1 and type 2) who had the following : *CPTII codes are not eligible for reimbursement. Exclusion: Members who do not have a diagnosis of diabetes, in any setting, during the measurement year, or the year prior to the measurement year, AND who had a diagnosis of gestational diabetes or steroid induced diabetes, in any setting, during the measurement year or the year prior. Hybrid measure: You will need to submit medical record documentation for this exclusion. CDC 1 and 2 Diabetes HbA1C Four rates are reported CDC 7 Medical Attention for Nephropathy Annual screening test Members will have a HbA1c test performed during the measurement year HbA1c poor control >9% HbA1c Control <8% HbA1c <7% Members will have an annual urine screen for albumin/protein done during the measurement year Submit a claim identifying the results of the HgbA1c utilizing one of the following three CPT II codes: 3046F HbA1c >9% 3045F HbA1c between % * 3044F-HbA1c less than 7.0% - Meets the measure with a claim * Medical record documentation of results of HbA1c test will be requested annually * The CPT Category II code (3045F) in this value set 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 must use other sources (laboratory data, hybrid reporting method) to identify the actual value and determine if the HbA1c result was <8%. Per HEDIS Specification Submit a claim identifying the results of the micro albumin screen utilizing one of the following two CPT II codes: 3060F or 3061F Screening tests for nephropathy 3062F- positive macroalbuminuria 3066F Exclusion in treatment for nephropathy OR Submit medical record documentation of results of nephropathy screen CDC 7 Nephropathy- ACE or ARB Evidence of treatment for nephropathy or ACE/ARB therapy There will be evidence of treatment for nephropathy with ACE/ARB therapy for members. Submit a claim identifying the patient was prescribed and is currently taking an ACE or ARB utilizing the following CPT II code: 4010F- patient prescribed or currently taking ACE or ARB 11

13 CDC BP Control <140/90 Members with diabetes will have blood pressure control of <140/90 Submit a claim with the 2 appropriate CPTII codes to report results of the BP monitoring. 3074F Systolic <130mm Hg. 3075F Systolic mm Hg. 3077F Systolic = 140mm Hg. 3078F Diastolic <80mm Hg. 3079F Diastolic 80-89mm Hg. 3080F Diastolic = 90mm Hg. OR Submit medical record documentation with results of most recent blood pressure CDC 4 Annual Eye Exam (Retina) Member will have retinal eye exam annually OR within two years if low risk of retinopathy in the prior year. If you have a report from the patient s ophthalmologist or optometrist Submit a claim with the appropriate CPTII code: 2022F Dilated eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed 2024F Seven (7) standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed. 2026F Eye Imaging validated to match diagnosis from seven (7) standard field stereoscopic photos results documented and reviewed. 3072F Low risk for retinopathy (no evidence of retinopathy in the prior year) Per NCQA HEDIS specifications Any code in the Diabetic Retinal Screening With Eye Care Professional, the Diabetic Retinal Screening With Eye Care Professional or the Diabetic Retinal Screening Negative Value Sets may be submitted by any provider type during the measurement year OR Submit medical record documentation of results of most recent eye exam. 12

14 CHL Administrative measure Chlamydia Screening in Women ages The % of women years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. The measurement year is 1/1 to 12/31 of the current year. Annual screening for Chlamydia is required for all sexually active females ages Obtain a urine sample or obtain a direct sample (i.e. cervix, urethra,vagina) for chlamydia culture yearly. Receipt of a Microbiology claim for chlamydia screening with appropriate CPT or LOINC codes Exclusion- members who have a pregnancy test and an x-ray on or within 6 days of the pregnancy test OR a pregnancy test and a prescription for isotretinoin on the date of or within 6 days of the pregnancy test. CWP Administrative measure Appropriate Testing for Children with Pharyngitis The percentage of children 3 18 years of age who were diagnosed with pharyngitis dispensed an antibiotic and received a group A streptococcus (strep) test. The measurement period is 7/1 of the prior year to 6/30 of the current year. Children 3-18 years of age diagnosed with pharyngitis/ tonsillitis must receive a strep test prior to receiving a prescription for antibiotics. Other family members with strep, parental refusal or clinical exam are not exclusions to this measure. ICD 9 codes = 034, 462 and 463 Submit a claim for a rapid strep test done in your office or send specimen for culture. Submit a claim for all additional competing diagnoses that would require antibiotic therapy. CWP Value Set ICD 10 CWP value set J02 all codes - Pharyngitis J03 all codes - Tonsillitis If you use one of the codes above the measure requires a strep test. CPT strep test codes 87070, 87071, 87081, 87430, 87650, 87651, 87652,

15 CIS Combo 10 Hybrid measure Childhood Immunization Status The percentage of children 2 years of age who had all the following immunizations: 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 (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. 12/31 of the current year. By the 2 nd birthday children will have the following vaccinations: 4 DTap 3 IPV 1 MMR 3 HiB 3 HepB 1 VZV 4 PCV 1 HepA 2 or 3 RV 2 flu vaccinations Immunizations must be done before the 2 nd birthday to meet the measure. DTa MM Hep PC Hep Influenz P IPV R HiB B VZV V A RV a Combo 2 Combo 3 Combo 4 Combo 5 Combo 6 Combo 7 Combo 8 Combo 9 Combo 10 Exclusions- Any particular vaccine- Anaphylactic reaction to the vaccine or its components. DTaP- Encephalopathy with a vaccine adverse-effect code MMR, VZV or influenza- Immunodeficiency, HIV, Lymphoreticular cancer, multiple myeloma or leukemia or anaphylactic reaction to neomycin IPV- Anaphylactic reaction to streptomycin, polymyxin B or neomycin. Hep B- Anaphylactic reaction to common baker s yeast OR Submit medical record documentation of all immunizations received. 14

16 COL Hybrid measure Colorectal Cancer Screening- The percentage of members years of age who had appropriate screening for colorectal cancer. to 12/31 of the current year. The member will have one of the following screening tests during the indicated period. Fecal occult blood test between 1/1 and 12/31 of the measurement year* Flexible sigmoidoscopy performed between 1/1 four (4) years prior to the measurement year and 12/31 of the measurement year. Colonoscopy performed between 1/1 nine (9) years prior to the measurement year and 12/31 *FOBT tests performed on a sample collected from a digital rectal exam do not meet the measure requirements Provide the patient with the appropriate equipment 1) Submit a claim to report 3 consecutive samples obtained and tested for Fecal Occult Blood (FOBT) screen using code with Z ) Receipt of a laboratory claim for FOBT screen Receipt of a claim for a sigmoidoscopy Receipt of a claim for a colonoscopy OR Medical Record documentation of a sigmoidoscopy or colonoscopy. Documentation must include a note indicating the date the colorectal cancer screening was performed. If the documentation is clearly part of the medical history no result is required. However, if it is not clear that the documentation is in the medical history a result must also be present. Exclusion: At any time during the member s history through December 31 st of the measurement year evidence is found of colorectal cancer or a total colectomy Submit a claim for Personal History of Other Malignant Neoplasm of the Large Intestines (ICD 9 = V10.05 and ICD 10 =Z85.038)* or Personal History of Other Malignant Neoplasm of the rectum, rectosigmoid junction and Anus (ICD 9 = V10.06 ICD 10 = Z85.048)* * These codes may be eligible for reimbursement; correct coding guidelines still apply. 15

17 FUH Administrative measure Follow-Up After Hospitalization for Mental Illness The % of discharges for members 6 years & older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: 1) Follow up within 7 days after discharge 2) Follow up within 30 days of discharge to 12/1 each year. The goal is: 1) Members that had an inpatient hospital- ization for a mental health diagnoses will be seen by a mental health practitioner within 7 days of discharge. 2) Members that had an inpatient hospital- ization for a mental health diagnoses will be seen by a mental health practitioner within 30 days of discharge. Follow up with a PCP does not meet the measure. The visit must be with a Behavioral Health Practitioner. Receipt of a claim for an outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner on or within 7 days after discharge. Applicable ICD 10 Dx Mental Illness codes Schizophrenia, Delusional disorders, Brief or F20.0 through F25.9 Shared psychotic disorders, Schizoaffective Psychotic disorders not due to substance or F28, F29 known physiologic condition Mood disorders F30.10 through 39 Obsessive-compulsive disorder, Reaction to F42 through F44.89 sever stress Puerpera psychosis F53 Disorders of adult personality & behavior F60 through F63.9, F68 Pervasive developmental disorders F 84 Behavioral & emotional disorders with onset in F90 through F94.9 childhood and adolescents ICD-9 CM codes , , , , , , , , , , , , , , , ,311,312, ,313, , 315, ,

18 HPV Hybrid measure Human Papillomavirus Vaccine for Female Adolescents The percentage of female adolescents 13 years of age who had three doses of the HPV vaccine by their 13 th birthday. to 12/31 each year. By the 13 th birthday Members 13 years of age will have at least three HPV vaccinations with different dates of service on or between the member s 9 th and 13 th birthdays. Submit a claim for all vaccinations members receive. Submit a claim for exclusion if appropriate. Exclude adolescents who had a contraindication for a specific vaccine. Anaphylactic reaction (ICD9= ICD10 = T80.52) to the vaccine or its components any time on or before the member s 13 th birthday (Anaphylactic reaction serum ICD9= ICD10 =T80.59) OR Submit medical record documentation with date of birth (DOB) and date of all immunizations received IMA Hybrid measure Immunizations for Adolescents The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) by their 13th birthday. The measure calculates a rate for each vaccine and one combination rate. to 12/31 each year By the 13 th birthday Before they turn 13 years of age members will have received: one dose of meningococcal vaccine AND one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) OR One tetanus, diphtheria toxoids vaccine (Td) by their 13th birthday. Submit a claim for all vaccinations members receive. Submit a claim for exclusions if appropriate Exclude adolescents who had a contraindication for a specific vaccine. Anaphylactic reaction (ICD9= ICD10 = T80.52) to the vaccine or its components any time on or before the member s 13 th birthday (Anaphylactic reaction serum ICD9= ICD10 =T80.59) to the vaccine or its components any time on or before the member s 13th birthday (Anaphylactic reaction serum value set) OR Submit medical record documentation that includes the date of birth (DOB) and date of all immunizations received 17

19 IET Administrative measure Initiation & Engagement of Drug or Alcohol The percentage of adolescent and adult members, 13 years and older with a new episode of alcohol or other drug (AOD) dependence who received the following: Initiation The % of members who initiate treatment through an outpatient visit, inpatient AOD admission, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis. Engagement -The % of members who initiated treatment and had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit. to 11/15 each year. Members who are diagnosed with alcohol or drug dependence will be referred immediately to an appropriate provider for treatment of alcohol or other drug dependence OR Schedule a follow up visit within 14 days at your practice, to initiate treatment of AOD dependence and then 2 additional follow up visits for AOD treatment in the 30 days following the Initiation visit. If member is noncompliant with Initiation within 14 days the member is then noncompliant for both Initiation and Engagement. Receipt of a claim for a visit to a behavioral health provider, or revisit with the provider who diagnosed the alcohol or drug dependence, within 14 days of the alcohol or other drug dependence diagnosis, utilizing an appropriate treatment code for AOD diagnosis. Followed by 2 additional visits for AOD treatment in the 30 days following the first treatment visit. Inform the behavioral health provider they are required to use an AOD dependence diagnosis code to meet the measure. (I.e. anxiety (300.00) does not meet the measure for AOD treatment. The provider needs to use anxiety due to alcohol (291.89) or anxiety drug abuse (292.89) Codes to Identify AOD Dependence F , F , F F , F , F F , F , F Not Included Remission and Other Codes F10.21, F10.9, F11.21, F11.9, F12.21, F12.9 F13.21, F13.9, F14.21, F14.9, F15.21, F15.9 F16.21, F16.9, F18.21, F18.9, F19.21, F19.9 Counseling and coordinating service with addiction specialists will be a large portion of maintenance - visits. Primary care clinicians can provide and bill for counseling without conducting a review of systems, and should use Counseling codes in place of E/M codes ( ). Documentation r for a counseling visit should include: Total visit time, time spent counseling or coordinating care (must be face-to-face) & the nature/content of the counseling. Please efer to the BCBSNC coding guide at: C_hcr_preventive_services_coding_guide.pdf 18

20 LBP Administrative measure Use of Imaging Studies for Low Back Pain The percentage of members with a primary diagnosis of low back pain who did NOT have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. to 12/3 each year. Members 18 to 50 years of will NOT receive imaging studies within 28 days of the initial diagnosis of low back pain. This includes a plain X-ray Consider referral for physical therapy evaluation before X- rays are ordered. Submit a claim with a code for low back pain with first symptom of low back pain. Submit a claim with code for exclusion if appropriate Exclusions- any member who had a diagnosis for which imaging is clinically appropriate. Any of the following meet criteria Per NCQA HEDIS specifications Malignant Neoplasms Other Neoplasms History of Malignant Neoplasm Recent Trauma IV drug Use Neurologic Impairment MPM Administrative measure Annual Monitoring for Patients on Persistent Medications The % of members 18 years of age who received at least 180 treatment days of medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event in the measurement year MPM 1- ACE and ARB MPM 2- digoxin MPM 3- diuretics to 12/31 of each year. Members 18 years old who remain on an ACE or ARB, digoxin, or a diuretic medication for 180 days will have lab tests done for the following: ACE and ARB at least one serum potassium and a serum creatinine Digoxin at least one serum potassium and a serum creatinine and serum digoxin level Diuretics at least one serum potassium and a serum creatinine Receipt of a claim for laboratory testing for required labs during the measurement year. 19

21 MMA Administrative measure Medication Management for People With Asthma The % of members 5 85 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported: The % of members who remained on an asthma controller medication for at least 75% of their treatment period. The % of members who remained on an asthma controller medication for at least 50% of their treatment period. to 12/31 of each year. Members with persistent asthma will be dispensed asthma control medications and will be compliant with use of the medication at least 75% of the treatment period.* Assess member compliance with use of medication as prescribed. Consider refill x 11 (1 per month) or 90 day supply. *Treatment period is defined as beginning on the earliest prescription dispensing date for any asthma controller medication during the measurement year (i.e. 2015) through the last day of the measurement year (i.e ) Claims will be received for asthma controller medication throughout the measurement year that will total 75% compliance. See Appendix 4 (Pg 33) for HEDIS common Asthma Controller Medications 20

22 NCS Administrative measure Non-Recommended Cervical Cancer Screen for Adolescent Females The % of females years of age who were screened unnecessarily for cervical cancer. 12/31 of the current year. Females will not be screened for cervical cancer unless there is a clinical reason for the screening. If a claim is received for cervical cancer screening in a female age the appropriate exclusion diagnosis history will be included in the claim. Exclusions Cervical Cancer History HIV disease Asymptomatic HIV state Disorders of the Immune System Z85.41; C53-D06 B20 Z21 D80; D81.0,81.1,81.2,81.4, 81.6,81.7,81.89,81.9; D82, D83, D84, D89.3, D D89.9 PBH Administrative measure Persistence of Beta Blocker Treatment After AMI The percentage of members 18 years of age who were hospitalized and discharged with a diagnosis of AMI and who remained on beta-blocker treatment for six months after discharge The measurement period is 7/1 of the prior year to 6/30 of the current year annually. Member s 18 years of age with new diagnosis of AMI will remain on beta-blocker treatment for six months after hospital discharge. Consider 90 day supply or refills x 6 if appropriate Receipt of pharmacy claims for 180 days supply of a beta blocker medication. Submit a claim if member has one of the following exclusion. Exclusions: ICD-10-CM Diagnosis Asthma J45.20-J45.52; J J Hypotension I ; I Heart block >1 degree I (excluding I44.3); I ; I45.6, I 49.5; I95.0 Sinus bradycardia R00.1 COPD J44.0 J44.9 Obstructive Chronic Bronchitis Chronic conditions due to inhaled fumes/vapors J41.0 J42 J

23 PCE 1 PCE 2 Administrative measure Pharmacotherapy Management of COPD Exacerbation The % of COPD exacerbations for members 40 years old who had an inpatient or ED visit and were dispensed appropriate medications. Two rates are reported: 1) Systemic Corticosteroid dispensed within 14 days of discharge date. 2) Bronchodilator dispensed within 30 days of discharge date. to 11/30 of the current year. Assess if patient was given appropriate medication Rx. at the time of discharge. AND has filled the Rx AND is taking medications as prescribed. Prescribe appropriate systemic corticosteroid within 14 days of the discharge date and bronchodilator within 30 days of discharge IF member was not given Rx at the time of discharge. Receipt of pharmacy claims for a systemic steroid within 14 days of date of discharge and a bronchodilator within 30 days from inpatient stay or ER visit OR an adequate supply of either medication for treatment after discharge from ER or Acute Inpatient stay. There are no exclusions to this measure. See Appendix 6 (Pg 34) for list of systemic corticosteroids and bronchodilators for this measure per HEDIS specifications. *NCQA will post a comprehensive list of medications and NDC codes to in November of the measurement year 22

24 PPC 1 PPC 2 Hybrid measure Prenatal Care The % of deliveries that received a prenatal visit in the first trimester (or within 42 days of enrollment in BCBSNC) Post Partum Care The % of deliveries, of live births, that had a postpartum visit on or between 21 and 56 days after delivery. The measurement period is 11/6 of the prior year to 11/5 of the current year. Members will receive a prenatal visit in the first trimester of pregnancy (or within 45 days of enrollment in BCBSNC) Members will receive a post partum visit with their provider between day 21 and day 56 post partum All providers must submit a claim for the prenatal visit on the date of service using the following codes: 0500F or 0501F and the appropriate ICD-10 diagnosis code All providers must submit a claim for the post partum visit on the date of service using the appropriate ICD-10 diagnosis code: Z39.2 and 0503F Post Partum Care Visit For Global Billing You must submit an additional claim with the dates of the prenatal and post partum visits. Refer to CRP SPR Administrative measure Use of Spirometry Testing in the Assessment and Diagnosis of COPD The % of members 40 years of age with a new Dx. of COPD or newly active COPD, who received appropriate spirometry testing to confirm the diagnosis. The measurement period is 7/1 of the prior year to 6/30 of the current year. Members 40 years old with a new or newly active diagnosis of COPD will have spirometry testing completed to confirm the diagnosis Submit a claim for spirometry testing on the date of service using appropriate CPT code. CPT codes 94010, 94014, 94015, 94016, 94060, 94070, 94375,

25 URI Administrative measure Appropriate Treatment for Children With Upper Respiratory Infection The % of children 3 months 18 years of age who were diagnosed with upper respiratory infection (URI) and were NOT dispensed an antibiotic prescription. The measurement period is 7/1 of the prior year to 6/30 of the current year. Antibiotics will NOT be prescribed to children who are diagnosed with URI only. If there is another diagnosis that requires antibiotic treatment you need to add that coding information to your claim. Submit a claim for all additional competing diagnoses requiring antibiotic therapy on or within 3 days after the date of claim for URI. W15 Administrative measure Well-Child Visits in the First 15 Months of Life (W15) The % of members who turned 15 months old during the measurement year and who had: none one, one, two, three, four, five, six or more well-child visits.(7 separate rates are calculated) 12/31 of the current year. The goal is to have 6 or more well child visits by the time the child is 15 months old. Submit a claim for all member visits with proper coding for the visit service. 24

26 W34 Administrative measure Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) The % of members 3 6 years of age who had one or more well-child visits with a PCP during the measurement year. 12/31 of the current year. Every child between 3 and 6 years of age will have a well child visit at least annually. Submit a claim for all member visits with proper coding for the visit service. WCC Hybrid measure Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents The % of members 3 17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of all the following during the measurement year: BMI percentile, Counseling for Nutrition and Counseling for Physical Activity WCC 1- BMI Percentile Members will be assessed for BMI percentile in the measurement year. Documentation must include height, weight & BMI percentile or BMI percentile plotted on age-growth chart during the measurement year. The height, weight & BMI must be from the same data source. Submit a claim including the appropriate code below ICD 9 code ICD 10 codes Percentile V85.51 Z68.51 Pediatric <5 th V85.52 Z68.52 Pediatric 5 th - <85 th V85.53 Z68.53 Pediatric 85 th 95 th V85.54 Z68.54 Pediatric 95 th Exclusion- Diagnosis of pregnancy This measure requires medical record collection. 25

27 WCC2 Counseling for Nutrition Documentation of counseling for nutrition or referral for nutrition education during the measurement (current) year as identified by administrative data or medical record review. Documentation of counseling for nutrition. Members will be counseled on nutrition in the measurement year. Documentation must include a note indicating the date of service and at least one of the following: Discussion of nutrition behavior (i.e. eating or diet behaviors) Checklist indicating nutrition was address Educational materials on nutrition given to the member during face to face visits Anticipatory guidance for nutrition Counseling or referral for nutrition education Weight or obesity counseling Submit a claim with the appropriate code. Z71.3 Dietary Counseling and surveillance G0447 Face to Face behavioral counseling for obesity- 15 minutes This measure requires medical record collection. WCC3 Counseling for Physical Activity Documentation of counseling for physical activity or referral for physical activity during the measurement year as identified by administrative data or medical record review Members will be counseled on physical activity in the measurement year. Documentation must include a note indicating the date of service and at least one of the following: Discussion of current physical activity behaviors (i.e. exercise routine, sports activities, exam for sports participation) Submit a claim including the appropriate code if applicable G0447 Face to face behavioral counseling for obesity - 15 minutes This measure requires medical record collection. 26

28 to 12/31 of the current year. Checklist indicating physical activity was addressed Counseling or referral for physical activity Member received educational materials on physical activity during a face-to-face visit Anticipatory guidance for physical activity 27

29 Appendix 1. Index of Measures Within Each Domain Effectiveness of Care Guidelines for Effectiveness of Care Measures Prevention and Screening ABA Adult BMI Assessment WCC Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents CIS Childhood Immunization Status IMA Immunizations for Adolescents HPV Human Papillomavirus Vaccine for Female Adolescents LSC Lead Screening in Children BCS Breast Cancer Screening CCS Cervical Cancer Screening COL Colorectal Cancer Screening CHL Chlamydia Screening in Women COA Care for Older Adults Respiratory Conditions CWP Appropriate Testing for Children With Pharyngitis SPR Use of Spirometry Testing in the Assessment and Diagnosis of COPD PCE Pharmacotherapy Management of COPD Exacerbation MMA Medication Management for People With Asthma AMR Asthma Medication Ratio Cardiovascular Conditions CBP Controlling High Blood Pressure PBH Persistence of Beta-Blocker Treatment After a Heart Attack SPC Statin Therapy for Patients With Cardiovascular Disease Diabetes CDC Comprehensive Diabetes Care SPD Statin Therapy for Patients With Diabetes 28

30 Musculoskeletal Conditions ART Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis OMW Osteoporosis Management in Women Who Had a Fracture Behavioral Health AMM Antidepressant Medication Management ADD Follow-Up Care for Children Prescribed ADHD Medication FUH Follow-Up After Hospitalization for Mental Illness SSD Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications SMD Diabetes Monitoring for People With Diabetes and Schizophrenia SMC Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia SAA Adherence to Antipsychotic Medications for Individuals With Schizophrenia APM Metabolic Monitoring for Children and Adolescents on Antipsychotics Medication Management MPM Annual Monitoring for Patients on Persistent Medications MRP Medication Reconciliation Post-Discharge Overuse/Appropriateness NCS Non-Recommended Cervical Cancer Screening in Adolescent Females PSA Non-Recommended PSA-Based Screening in Older Men URI Appropriate Treatment for Children With Upper Respiratory Infection AAB Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis LBP Use of Imaging Studies for Low Back Pain APC Use of Multiple Concurrent Antipsychotics in Children and Adolescents DDE Potentially Harmful Drug-Disease Interactions in the Elderly DAE Use of High-Risk Medications in the Elderly Access/Availability of Care CAP ADV IET PPC Children and Adolescents Access to Primary Care Practitioners Annual Dental Visit Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Prenatal and Postpartum Care 29

31 Appendix 2. ICD-10-CM BMI codes Z68.1 Body mass index (BMI) 19 or less, adult Z68.20 Body mass index (BMI) , adult Z68.21 Body mass index (BMI) , adult Z68.22 Body mass index (BMI) , adult Z68.23 Body mass index (BMI) , adult Z68.24 Body mass index (BMI) , adult Z68.25 Body mass index (BMI) , adult Z68.26 Body mass index (BMI) , adult Z68.27 Body mass index (BMI) , adult Z68.28 Body mass index (BMI) , adult Z68.29 Body mass index (BMI) , adult Z68.30 Body mass index (BMI) , adult Z68.31 Body mass index (BMI) , adult Z68.32 Body mass index (BMI) , adult Z68.33 Body mass index (BMI) , adult Z68.34 Body mass index (BMI) , adult Z68.35 Body mass index (BMI) , adult Z68.36 Body mass index (BMI) , adult Z68.37 Body mass index (BMI) , adult Z68.38 Body mass index (BMI) , adult Z68.39 Body mass index (BMI) , adult Z68.41 Body mass index (BMI) , adult Z68.42 Body mass index (BMI) , adult Z68.43 Body mass index (BMI) , adult Z68.44 Body mass index (BMI) , adult Z68.45 Body mass index (BMI) 70 or >, adult 30

32 Appendix 3. ICD-10-CM BMI percentile Z68.51 Body mass index (BMI) pediatric, less than 5th percentile for age Z68.52 Body mass index (BMI) pediatric, 5 th percentile to less than 85 th percentile for age Z68.53 Body mass index (BMI) pediatric, 85 th percentile to less than 95 th percentile for age Z68.54 Body mass index(bmi) pediatric, greater than or equal to 95th percentile for age 31

33 Appendix 4. Asthma Controller and Reliever Medications* Table AMR-A: Asthma Controller and Reliever Medications ASTHMA CONTROLLER MEDICATIONS Description Prescriptions Antiasthmatic combinations Dyphylline-guaifenesin Guaifenesin-theophylline Antibody inhibitors Omalizumab Inhaled steroid combinations Budesonide-formoterol Fluticasone-salmeterol Mometasone-formoterol Inhaled corticosteroids Beclomethasone Budesonide Ciclesonide Flunisolide Fluticasone CFC free Mometasone Leukotriene modifiers Montelukast Zafirlukast Zileuton Mast cell stabilizers Cromolyn Methylxanthines Aminophylline Dyphylline Theophylline ASTHMA RELIEVER MEDICATIONS Description Short-acting, inhaled beta-2 agonists Prescriptions Albuterol Levalbuterol Pirbuterol *Note: NCQA will post a comprehensive list of medications and NDC codes to in November of the measurement year 32

34 Appendix 5. Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis* Description 5-Aminosalicylates Alkylating agents Aminoquinolines Anti-rheumatics Immunomodulators Sulfasalazine Cyclophosphamide Hydroxychloroquine Auranofin Gold sodium thiomalate Abatacept Adalimumab Anakinra Certolizumab Prescription Leflunomide Methotrexate Certolizumab pegol Etanercept Golimumab Penicillamine Infliximab Rituximab Tocilizumab Immunosuppressive agents Azathioprine Cyclosporine Mycophenolate Janus kinase (JAK) inhibitor Tetracyclines Tofacitinib Minocycline * NCQA will post a comprehensive list of medications and NDC codes to in November of the measurement year 33

35 Appendix 6. Medications for Treatment of COPD Exacerbation* Systemic Corticosteroids* Description Glucocorticoids Betamethasone Dexamethasone Prescription Hydrocortisone Methylprednisolone Prednisolone Prednisone Triamcinolone Bronchodilators* Description Anticholinergic agents Beta 2-agonists Methylxanthines Albuterol-ipratropium Aclidinium-bromide Albuterol Arformoterol Budesonide-formoterol Fluticasone-salmeterol Fluticasone-vilanterol Aminophylline Dyphylline-guaifenesin Guaifenesintheophylline Prescription Ipratropium Tiotropium Formoterol Indacaterol Levalbuterol Mometasoneformoterol Metaproterenol Dyphylline Theophylline Umeclidinium Olodaterol hydrochloride Pirbuterol Salmeterol Umeclidinium-vilanterol * NCQA will post a comprehensive list of medications and NDC codes to in November of the measurement year 34