OPA 2017 NETWORK + INCENTIVE GUIDE

Transcription

1 PO Box 90 Buffalo, New York CONTACT MERI NOTARO opawny.com OPA 2017 NETWORK + INCENTIVE GUIDE Prepared For: A GUIDE FOR PRIMARY CARE PHYSICIANS Date Issued: Valid To: OPA PHYSICIAN PARTNERS

2 Table of Contents CONTENTS Take a look at what you'll find inside this guide. INTRODUCTION TIERING PROGRAM STANDARD INCENTIVE OPA Overview 2017 Network Standards OPA Resources OPA Primary Care Physician Tiering Overview 2017 PCP Tiering Structure Standard Incentive Overview Primary Care Metrics Pediatric Care Metrics Network Incentive and PCP Tiering Overview 9 Standard Incentive Metrics CENTERS OF EXCELLENCE PRACTICE OPTIMIZATION PROGRAM (POP) APPENDICES Centers of Excellence Overview 25 Practice Optimization Program (POP) Guidelines 31 Standard Incentive Lists 45 Activity Based Performance Measures 27 Sample POP Application 39 Utilization Based Performance Measures 28 Centers of Excellence Metrics

3 [ the platform that simplifies the practice of medicine ] Organization Overview OPA is an organization committed to excellence. Learn a little bit more about us. Optimum Physician Alliance (OPA), formed in 2012, is the platform that simplifies the practice of medicine. It consists of approximately 600 physicians in the areas of primary and specialty care, located mainly in Erie and Niagara counties. OPA is committed to promoting practice transformation, with a patient-centered approach, and understands the importance of leveraging healthcare data to support high quality outcomes for patients. This systematic approach to healthcare is anchored by the primary care physician and driven by collaboration between primary and specialty care physicians, hospitals, a health plan and most importantly, patients. This collaborative relationship sets OPA apart as a unique organization which facilitates meaningful engagement among healthcare partners. OPA provides key resources to reduce administrative burdens and offers incentive programs designed to promote the type of practice transformation necessary for success in this evolving industry. This handbook is for you, our physician partner, to navigate and explore the benefits of being an OPA physician, and provide you with an understanding of OPA's Network Standards, Resources, Incentive Programs and more! We accelerate smart, patient-centered and value based care. Take a look at the values that help us achieve our vision and define our culture. WHY CHOOSE US? PATIENT FOCUSED INTEGRITY COMMITMENT RESPECT FORWARD-THINKING 3 4

4 [ 2017 network standards ] As an Optimum Physician Alliance (OPA) provider you have agreed to actively participate in, and to adhere to, the Network Standards.* * The Network Standards are reviewed on an intermittent basis, and revised if warranted Standard No. 4 Each OPA practice must identify and commit a physician champion (solo physicians are champion by default), and an administrative champion. Standard No. 1 Standard No. 5 Physicians must be credentialed through BlueCross BlueShield of Western New York (BCBSWNY) in order to participate in OPA. Each OPA physician and administrative champion must have a unique functioning address. Standard No. 2 Participating OPA providers must have privileges at Kaleida Health or an agreement in place with a hospital group that has privileges at Kaleida. Standard No. 6 All champions (as stated in #5) must meet with their OPA Physician Advisor on a regular basis throughout the year. Standard No. 3 Standard No. 7 Participating OPA practice must have an operational EMR. Each OPA provider practice must be compliant with the HEALTHeLINK Consent Process AND have an effective workflow in place to obtain HEALTHeLINK consents from patients 5 6

5 [ resources that we provide ] The way you practice medicine has changed drastically in the last few years. On top of your clinical responsibilities there are greater administrative burdens placed on your practice. OPA understands the need to focus on healthcare, and not just administration. As a member of OPA, you can receive comprehensive support through the following services: EMR Support Specialist Variation Analysis Integrated Care for Kids (Inc/K) Review and analysis of care management platforms, predictive modeling tools, EMR systems and network connectivity to illustrate the value of care coordination and outcomes achieved in care management initiatives OPA physicians, within the same specialty type, are brought together to examine unwarranted variations in care and develop common standards that improve quality and access to care Behavioral Health (BH) support for children and their families, therapy and psychiatry services conveniently provided at the patient's PCP office, assistance with medication management, and help linking families to other BH support services Nutrition Education Health Coach Pharmacist PCMH/PCSP Consulting Patient Centered Medical Home Patient Centered Specialty Practice Outreach Associate One-on-one nutrition education for adults and children, nutrition education for those with chronic diseases, follow-ups by phone or in office, electronic medical record (EMR) documentation for each one-on-one visit with BlueCross BlueShield of Western New York (BCBSWNY) members Support for weight management, physical activity, stress management, smoking cessation, disease prevention and free wellness education classes Pharmacy support services include high level practice analysis to improve both the quality and efficiency of care as well as patient specific education with a focus on best practice and therapeutic efficacy Supports practices in achieving PCMH or PCSP recognition Communication assistance to keep patients up-to-date on appointments and necessary milestones, training for staff to improve efficiency and better meet the needs of patients, and assistance streamlining organizational workflows 7 8

6 [ 2017 PCP incentive program overview ] Standard Incentive NETWORK INCENTIVES AND OPA TIERING PROGRAM OVERVIEW The standard incentive is broken down into two (2) components - the Network Incentive and the At-Risk Incentive. These incentives will be evaluated based on the performance of the overall OPA network. It is a well-known fact that early detection is key to preventing and/or lessening the impact of chronic conditions and illnesses, however screening rates for common diseases have not changed much year after year. The Network Incentives were designed to engage our OPA partners in developing population management techniques, which will be critical to future success in healthcare. The At-Risk Incentive is designed to facilitate coordination and cooperation among physicians to improve the quality of care for patients and reduce unnecessary costs. Additional information will be available about this incentive in the coming weeks. OPA is excited to offer several incentive programs for 2017, giving practices the opportunity to earn additional revenue through quality focused initiatives, network engagement and improvements in the quality and coordination of patient care. The objectives, structure, and reimbursement methodologies vary across incentive programs, but are all tied to OPA s goal to be the platform that simplifies the practice of medicine. To qualify for each incentive, physicians must be active OPA providers and practice a minimum of twelve (12) clinical hours per week. Centers of Excellence This incentive focuses on engagement and encourages physicians to attend local events, network with peers in the community, and allows for the opportunity to share and receive information on both local and national healthcare trends. The specific benchmarks are described in more detail within the Centers of Excellence section of this guide. Payment of this incentive is distributed quarterly and will be based on practice performance. In addition, starting January 1, 2017, OPA will be launching a new PCP Tiering Program. The Tiering Program is an initiative aimed at improving the quality, efficiency, and overall engagement of the OPA primary care physician network and will impact eligibility for OPA s incentive program. For more information on the Tiering Program, please see the Tiering section of this guide. Practice Optimization Program The Practice Optimization Program (POP) is designed to provide the necessary support and resources to prepare physicians and their practices for the next decade of healthcare evolution. It is an incentive opportunity designed to empower OPA practices to determine how they would like their incentive dollars applied within their practice. In order to receive incentive dollars, practices must submit the POP application within the designated time-frames and identify a project that will help transform their practice. Payment of this incentive is distributed quarterly. 9 10

7 OPA Primary Care Physician Tiering Program TIERING [ 2017 PCP tiering program overview ] Effective, January 1, 2017, OPA will be implementing a Tiering Program designed to improve the quality, efficiency, and cooperation among OPA physicians. The Tiering Program will be applicable to primary care physicians and will impact eligibility for OPA s incentive program, which will ultimately shift incentive dollars to the practices dedicated to practice transformation, committed to providing high quality patient care and community integration. The program is also linked to OPA s Network Standards, which were developed to encourage engagement within OPA. The more OPA aligns as a cohesive network of healthcare providers, the more opportunities OPA has to build a seamless continuum of patient-centered care, improve collaboration and reduce duplication of services

8 [ 2017 tiering structure ] The Tiering Program is comprised of three (3) tiers the amount of incentive dollars practices can earn will be dependent upon which tier they belong. Tiering Criteria Tier 1 Tier 2 Tier 3 1 MEET AND APPLY OPA NETWORK STANDARDS 100% COMPLIANCE 100% COMPLIANCE 2 PATIENT CENTERED MEDICAL HOME (PCMH) RECOGNIZED 100% COMPLIANCE PURSUING RECOGNITION IN CORTEXT COMPLIANCE IN % COMPLIANCE ALL PHYSICIANS MET 3 OUT OF 4 QUARTERS FAILURE TO ACHIEVE TIER I OR II STATUS 4 WORKGROUP PARTICIPATION IN % COMPLIANCE ALL PHYSICIANS MET 3 OUT OF 4 QUARTERS TIER DETERMINATIONS TIERING CRITERIA 1-4 MUST BE MET TIERING CRITERIA 1-4 MUST BE MET INCENTIVE ELIGIBILITY ELIGIBLE $ + + ELIGIBLE $ + INELIGIBLE TIERING Determination & Timelines Tiering levels will be determined by December 31, 2016 and will be based on a practice s completion of the criteria above. Please be advised that in order to be eligible for Tier I or II, all criteria must be met for that Tier group Practices in Tier II or III will have an opportunity to move up a tier on a quarterly basis if they meet the Tiering criteria by the last day of the quarter. Practices will receive retroactive payment. Physicians who are no longer on a practice s roster as of January 1, will have no impact to the Tiering position for that coming year. Please note - no exceptions will be made after this time. To retain Tier status, practices must continue to meet the criteria for that Tier group throughout In order to be eligible, all physicians and all locations must be compliant. It s important to understand that an unengaged physician can jeopardize the incentive payout for the whole practice

9 [ tiering criteria ] Network Standards Patient Centered Medical Home Recognition Cortext PCP Workgroups Practices who have met the 2016 Network Standards by December 31, 2016 will be eligible for Tier I or II. Practices must continue to adhere to the Network Standards during 2017 to remain eligible for Tier I or II. Practices will be eligible for Tier I if they are fully PCMH recognized (all physicians and at all locations) or if they have submitted their applications to the National Committee for Quality Assurance (NCQA) by December 31, In order to be eligible for Tier I status, all physicians in a practice must have utilized Cortext a minimum of three (3) times per month throughout Practices who met this criterion for only three (3) quarters of 2016 will qualify for Tier II or III.* In order to be eligible for Tier 1, all physicians in a practice must have attended a PCP workgroup meeting, once per quarter, during Practices who met this criterion for only three (3) quarters of 2016 will qualify for Tier II or III.* Providers who are not recognized or who have not submitted their application by December 31, 2016, still have an opportunity to meet this criterion if they purchase the 2014 NCQA PCMH Tool by March 31, 2017 and submit their application to NCQA by September 30, Tiering placement will be retroactive to the date of PCMH submission, but will be contingent upon NCQA recognition. If the PCMH application is denied, the practice will be placed in the appropriate tier. Practices that acquire a new location, which is not PCMH recognized, will have a twelve (12) month grace period in which to submit their application to NCQA for the new location. During the first two (2) quarters of 2017, practices will have an opportunity to make up missed Cortext or Workgroup requirements that occurred during 1Q16 or 2Q16. Attending a workgroup in 1Q17 and 2Q17 will apply towards missed workgroups in 1Q16 and 2Q16 Utilizing Cortext 3x a month in 1Q17 and 2Q17 will apply to missed Cortext utilization in 1Q16 & 2Q

10 [ 2017 standard incentive ] Standard Incentive Overview The Standard Incentive was designed to support practices in developing population health management programs, with the goal of proactively keeping patients healthy and controlling healthcare costs. Primary care physicians must learn to identify patient risks and care opportunities, even in instances where patients aren t actively seeking care. This can be done by leveraging data from electronic medical records, claims data and other available resources, and then subsequently developing mechanisms for patient outreach and engagement. There are two main components to the Standard Incentive At-Risk and the Network Incentive. Both incentives are measured and assessed at the OPA network level and are paid out annually if established benchmarks are met. At-Risk The At-Risk Incentive is designed to facilitate coordination and cooperation among physicians to improve the quality of care for patients and reduce unnecessary costs. There will be more information about this incentive in the coming weeks. Network Incentive Summary It is a well-known fact that early detection is key to preventing and/or lessening the impact of chronic conditions and illnesses, however screening rates for common diseases have not changed much year over year. The Network Incentives were designed to engage our OPA partners in developing population management techniques which will be critical to future success in healthcare. The metrics identified for 2017 are built around Healthcare Effectiveness Data and Information Set (HEDIS) measurements and national engagement statistics. In this section you will find a description of each measure, national benchmarks and OPA network thresholds needed to receive payment for each measure. The baseline values represent where the OPA network stands today. In order to achieve the maximum reward for each metric, the entire network must exceed the target amount and hit the maximum amount

11 [ primary care metrics ] METRIC 1: Breast Cancer Screening METRIC 3: Colorectal Screening Background Breast cancer is an extremely common cancer which affects one (1) in eight (8) women in the United States today. It is a significant source of both morbidity and mortality, and has a substantial impact on both the patients and their families. If detected at an early stage, meaningful intervention is possible, but unfortunately due to the perceived inconvenience, discomfort and a lack of an organized system to encourage and monitor routine screenings, we have never been able to achieve optimal screening rates among this at-risk population. GOAL The goal of this metric is for OPA providers to refocus their efforts on breast cancer screenings and identify new mechanisms to engage patients and encourage them to receive the proper evaluations. This is a network wide metric and as such, it is an opportunity to engage with our partners in OPA and to share best practices. For a listing of applicable CPT and diagnosis codes, please see Appendix I. Background Colorectal cancer is a major source of morbidity and mortality in both the male and female populations. Despite the highly effective screening mechanisms available, a significant portion of the population fails to adhere to the screening recommendations. The intent of this metric is to put a new focus on identifying patients who are at-risk for colorectal cancer and to ensure that they are appropriately screened and treated. GOAL The goal of this metric is for practices to identify at-risk patients and to encourage them to have the recommended screening. Acceptable colorectal screening mechanisms include colonoscopies, fecal occult blood test (FOBT) and flexible sigmoidoscopy. For a listing of applicable CPT and diagnosis codes, please see Appendix III. METRIC 2: Adult Body Mass Index (BMI) Assessment METRIC 4: Osteoporosis Management Post Fracture Background The obesity epidemic is dramatically changing the care needs of both the adult and pediatric populations. With the logic that you can't manage what you don't measure, it is hoped that this metric will help practices develop a strategy to more appropriately identify and target patients who struggle with weight gain. Additionally, this data can be used to develop a better understanding of the impact of obesity in our community and how to more effectively address it. GOAL The goal of this metric is to encourage practices to develop a mechanism for actively identifying patient s BMI and entering that information on the claim for later analysis. It is recognized that most modern electronic medical record systems will automatically calculate body mass index (BMI), however this information is contained within the body of the electronic record, and not easily shared. The ultimate goal is to better assess this population so that OPA can better focus our resources moving forward. For a listing of applicable CPT and diagnosis codes, please see Appendix II. Background While osteoporosis affects both genders, it predominantly affects the postmenopausal female population. It is not uncommon for these patients to present with a fracture as an initial sign of bone loss. This is an opportunity for practices to appropriately identify, screen, and if necessary, treat these at-risk patients. GOAL The goal of this metric is to implement a practice-wide population screening device, which is capable of monitoring the practice on an ongoing basis. The intent is to identify patients who were recently diagnosed with a fracture and have them appropriately screened and treated for osteoporosis. For a listing of applicable CPT and diagnosis codes, please see Appendix IV

12 [ primary care metrics ] [ pediatric care metrics ] METRIC 5: Diabetes Care Eye Exam Background Diabetes is an increasingly common public health concern and is steadily approaching epidemic proportions. Over the long-term, inadequate control of blood sugars can result in a cascade of medical complications, including but not limited to vision loss. METRIC 6: Diabetes Care Monitoring for Kidney Disease Background Diabetes mellitus with hypertension is the number one (1) cause of renal failure in the United States and is a major cost driver in the American Health. The literature supports that if we are able to identify patients with mild renal involvement at its early stages, it will allow for intervention, which can delay and/or prevent ultimate kidney failure. GOAL The goal of this metric is to implement a practice-wide population management and outreach program, which will identify patients with diabetes in need of screening for diabetic retinopathy and to successfully engage them in a retinopathy screening and treatment program. Depending on a practice s needs and capabilities, this can either be done internally or through a referral to an eye care specialist. For a listing of applicable CPT and diagnosis codes, please see Appendix V. GOAL The goal of this metric is to implement a practice-wide population management and outreach program, which will aid practices in identifying patients who are at-risk for diabetic renal failure and to target them for appropriate screenings. For a listing of applicable CPT and diagnosis codes, please see Appendix VI. METRIC 1: BMI Assessment ages 3-11 and METRIC 2: BMI Assessment ages Background The obesity epidemic is dramatically changing the care needs of both the adult and pediatric populations. With the logic that you can't manage what you don't measure, it is hoped that this metric will help practices develop a strategy to more appropriately identify and target patients who struggle with weight gain. Additionally, this data can be used to develop a better understanding of the impact of obesity in our community and how to more effectively address it. GOAL The goal of this metric is to encourage practices to develop a mechanism for actively identifying patient s BMI and entering that information on the claim for later analysis. It is recognized that most modern electronic medical record systems will automatically calculate body mass index (BMI), however this information is contained within the body of the electronic record, and not easily shared. With this data, we hope to better assess this population so that OPA can better focus resources moving forward. For a listing of applicable CPT and diagnosis codes, please see Appendix VII. METRIC 7: Diabetes Care HbA1c>9 METRIC 3: Counseling for Nutrition ages METRIC 4: Counseling for Nutrition ages Background The correlation between improved control of blood sugars and decreased diabetes related complications, has long been established in literature. This incentive is designed to help identify and target those patients who are not effectively controlling their blood sugars. GOAL The goal of this metric is to have practices develop a process for identifying patients with poorly controlled diabetes and to deploy strategies to help bring blood sugars under better control. Background With obesity rates on the rise, nutrition counseling, particularly at a young age, is becoming increasingly important. While counseling for nutrition is a standard part of a pediatric visit, it s often not clearly documented and rarely included on the claim, making it difficult to realize the impact and value of counseling. GOAL The goal of this metric is to develop a practice pattern where nutritional coding is routinely submitted, with other evaluation and management codes. For a listing of applicable CPT and diagnosis codes, please see Appendix VIII

13 [ standard incentive metrics ] PCP & PEDS PCP INCENTIVE MEASURE NATIONAL BENCHMARK OPA 2015 OPA 2016 BREAST CANCER SCREENING ADULT BMI ASSESSMENT COLORECTAL SCREENING OSTEOPOROSIS MANAGEMENT POST FRACTURE DIABETES CARE- EYE EXAM DIABETES CARE- MONITORING FOR KIDNEY DISEASE DIABETES CARE- HBAIC >9 (INVERSE MEASURE, LOWER IS BETTER) Nat Av: 67.52% NYS Av: 69.05% Nat Av: 77.35% NYS Av: 82.39% NAT AV: 61.80% NYS AV: 62.46% NAT AV: 26.45% NYS AV: 23.07% NAT AV: 60.02% NYS AV: 64.35% NAT AV: 85.35% NYS AV: 85.39% NAT AV: 38.81% NYS AV: 37.61% 74.24% n= 13, % n=50, % n=28, % n= % n=6, % n=6, % n=6,319 PEDS INCENTIVE MEASURE NATIONAL BENCHMARK OPA 2015 OPA 2016 BMI ASSESSMENT AGE 3-11 BMI ASSESSMENT AGE COUNSELING FOR NUTRITION 3 TO 11 YEARS COUNSELING FOR NUTRITION YEARS NAT AV: 51.53% NYS AV: 72.06% NAT AV: 55.53% NYS AV: 72.06% NAT AV: 52.92% NYS AV: 72.94% NAT AV: 52.92% NYS AV: 72.94% 24.99% n=5, % n=4, % n=5, % n=4,009 THRESHOLD (95% Payout) TARGET (100% Payout) TBD 74.24% 76.47% 78.69% TBD 72.71% 75.03% 77.35% TBD 63.30% 65.20% 67.10% TBD 26.45% 27.24% 28.04% TBD 64.35% 66.28% 68.21% TBD 86.28% 88.87% 91.46% TBD 38.81% 37.65% 36.48% THRESHOLD (95% Payout) TARGET (100% Payout) TBD 48.44% 49.98% 51.53% TBD 52.20% 53.86% 55.53% TBD 49.74% 51.33% 52.92% TBD 49.74% 51.33% 52.92% MAX (105% Payout) MAX (105% Payout) **PMPM will be based on membership as of December 2017 TIER I practices will earn $3 PMPM for BCBSWNY members TIER II practices will earn $2 PMPM for BCBSWNY members TIER III practices are ineligible 23 24

14 [ this is an overview of our centers of excellence ] Centers of Excellence The Centers of Excellence incentive focuses on physician engagement and encourages physicians to attend local events, network with peers in the community, and allows for the opportunity to share and receive information on both local and national healthcare trends. These incentives are paid quarterly and are based on performance at the group level. They are divided into two (2) main components: Activity Based Performance Utilization Based Performance ACTIVITY BASED PERFORMANCE MEASURES The Activity Based Performance Measures (ABPM) were created to strengthen interactions across the OPA network. They also provide a forum for open and transparent dialogue with members of the OPA team. To receive the maximum incentive payout, every physician in a practice must meet each metric. Below is a brief description of each metric. ALL PHYSICIANS IN A PRACTICE MUST ATTEND FOUR (4) QUARTERLY PRIMARY CARE WORKGROUPS To achieve this incentive, physicians are required to attend one (1) Primary Care Workgroup, per quarter, per year. PCP Workgroups are offered eighteen (18) times per quarter or six (6) workgroups monthly, at a variety of convenient locations throughout Western New York. The workgroups provide physicians with opportunities to gain more information about the goals and initiatives of OPA, healthcare trends, and how we can best prepare for the changes to come. The workgroups are kept small so that attendees can have productive discussions with peers, voice concerns and offer feedback. A schedule of workgroups and locations can be found by visiting opawny.com/events/pcp-workgroups/. Please note that you must register for these workgroups as seating is limited. INCREASE IN-NETWORK REFERRALS BY 5% A physician network works bests when the members of the network work together and support one another. The more OPA aligns as a cohesive network of healthcare providers, the more opportunities OPA has to build a seamless continuum of patient-centered care, improve collaboration and reduce duplication in services

15 [ activity based performance measures continued ] [ utilization based performance measures ] UTILIZE GREAT LAKES ACCESS CENTER TWICE A YEAR The Great Lakes Access Center (GLAC) was established as a one-stop-shop for a variety of adult and pediatric resources. GLAC can assist with referrals to specialist and PCPs, access to care, and can help coordinate care. They also provide private-pay quotes for patients who choose to pay out-of-pocket and can assist patients seeking affordable health insurance. Great Lakes Access Center 726 Exchange Street Buffalo, NY General #: CARE (2273) Pediatric #: KIDS (5437) AccessCenter@kaleidahealth.org Website: GROUP REPRESENTATION AT TWO (2) CARE INTEGRATION CONFERENCES These interdisciplinary conferences are designed to improve working partnerships across OPA s network, and between the health system and health plan. They will provide opportunities to network with peers, collaborate, share best practices, and discuss clinical and/or administrative challenges. While speakers may present on topics of relevance, these events are designed to promote valuable interaction among the stakeholders. It is our hope that participants take away actionable ideas to help transform their practices and play a part in effecting real change in the WNY community. INCREASE ADVANCE CARE PLANNING CONVERSATION ENCOUNTERS BY 5% Conversations around end of life planning are not easy and are time sensitive. This metric focuses on the importance of these conversations for both patients and the physicians caring for them. The more we understand a patient s needs and preferences, the better positioned we are to provide them with the most appropriate care and/or resources. The CPT codes and description for Advance Care Planning are as follows: CPT CODE Advance Care Planning includes the explanation and discussion of advance care directives, as well as the completion of standard forms by the physician or other qualified health care professionals. This code should be billed for the first thirty (30) minutes, face-to-face, with the patient, family member(s), and/or surrogate. CPT CODE This code should be billed for each additional 30 minutes (list separately in addition to code for primary procedure). THE GOAL of this incentive is to reduce overall Emergency Room/Urgent Care (ER/UC) utilization in an effort to ensure patients receive the appropriate care, in the appropriate setting. This measure applies to PCPs treating patients eighteen (18) years or older and physicians treating patients eighteen (18) years or younger, and is paid out based on group performance. The incentive targets for each population can be found on the next page

16 [ centers of excellence metrics ] PCP/PEDS $6/PMPM INCENTIVE MEASURES DESCRIPTION *QUARTERLY PAYMENT FOR MEETING THE METRIC ALL PHYSICIANS ATTEND 4 QUARTERLY PRIMARY CARE WORKGROUPS CONTINUE TO BUILD A COHESIVE NETWORK $1/PMPM INCREASE IN NETWORK REFERRALS BY 5% INCREASE INTEGRATION WITHIN OPA NETWORK $1/PMPM ACTIVITY PCP UTILIZE GREAT LAKES ACCESS CENTER TWICE A YEAR INCREASE USE OF THE GREAT LAKES ACCESS CENTER $1/PMPM GROUP BASED ADVANCED CARE PLANNING CONVERSATION ENCOUNTERS - INCREASE 5% GROUP REPRESENTATION AT 2 CARE INTEGRATION CONFERENCES (CIC) INCREASE QUALITY OF CARE FOR PATIENT KALEIDA SPONSORED - 12 EVENTS PER YEAR $1/PMPM $1/PMPM INCENTIVE MEASURES PEER 2015 OPA/ OPA/1000 TARGET QUARTERLY PAYMENT FOR MEETING THE METRIC UTILIZATION OPA PCP ER/UC UTILIZATION (COMMERCIAL >18 YO) TBD $1/PMPM OPA PEDS ER/UC UTILIZATION (COMMERCIAL <18 YO) TBD **PMPM will be based on membership as of December

17 [ this is an overview of the practice optimization program (POP) ] Practice Optimization Program Guidelines OVERVIEW OPA understands that different practices have different needs based on size, location, and area of focus. To that end, the Practice Optimization Program (POP) helps physicians obtain the necessary resources to deliver highquality, high-value, efficient care. Consider your application an opportunity to define for yourself, and how you envision your practice transforming in the years to come. Practices will be responsible and accountable for ensuring the awarded funds are allocated and applied to achieving the objectives stated in their POP application and that they are aligned with the goals of OPA. In addition, the responsibility is on the practice to monitor and produce reports, upon request, highlighting the progress made, the effectiveness of the program, and/or barriers encountered. GENERAL INSTRUCTIONS FOR APPLICATION SUBMISSION This guide includes the program outline, necessary instructions and the applicable requirements for submission, unless otherwise noted. Submissions must be aligned with OPA s mission and goals, with a focus on promoting practice transformation There are four (4) POP application submission cycles per year. OPA encourages early submissions. It is up to the practice to determine if more than one application is required for the calendar year. SUBMISSION DATE AND TIMES SUBMISSION OPEN SUBMISSION CLOSES PROGRAM EFFECTIVE DATES NOVEMBER 14 DECEMBER 9 JANUARY 1 FEBRUARY 1 MARCH 10 APRIL 1 MAY 1 JUNE 9 JULY 1 AUGUST 1 SEPTEMBER 8 OCTOBER

18 [ POP guidelines ] Program Criteria and Eligibility The practice must be in Tier I or Tier II. The applicant must be a participating OPA Primary Care practice. Application Due Date Applications must be received by 11:59 pm on the close date. Applications received after the deadline will be held until the next quarterly submission. Applications will not be accepted after September 8, Submission Methodology Applications must be submitted electronically. Electronic copies of the application can be found at and can be ed to fitzgerald.rachel@opawny.com Withdrawing an Application An applicant may withdraw an application from consideration at any time. Withdrawal notifications should be sent via to fitzgerald.rachel@opawny.com. All eligible primary care physicians within the group must be participating in OPA. Eligible primary care physicians are defined as participating OPA physicians who conduct patient care a minimum of twelve (12) hours per week at sites directly associated with the applicant s group. OPA practices must have eleven (11) or more BCBSWNY patients. Practices with ten (10) or less BCBSWNY patients are not eligible. POP applications must support OPA s goal to support physicians in their effort to transform their practices. Eligibility is determined at the group level, not per location. Funding and Allowable Expenses Funds may be used for the following types of expenses provided they are directly attributable to the program and support practice transformation: Staffing-salaries for employees dedicated to the success of the program Consultant fees Office Equipment Technology in support of the practice 33 34

19 [ POP guidelines continued ] Incentive Distribution Time Frame Funding Restrictions Exclusions include, but are not limited to, the following: Construction or renovation of facilities Political campaigns Endowments Indirect costs and other standard expenses Debt reduction Fundraising Event sponsorship Projects completed prior to the initiation of this program Capital campaigns Employee gifts Scholarships Land acquisition Investments Allowable Amounts Eligible groups may request up to the maximum annual value, which is determined by using the methodology below. The POP payment will be based on the reconciled number of eligible PCPs at the time of submission. (# of eligible primary care physicians at the time of submission) x ($2,500) x (# of months) Calendar Year Example with a Program Timeline of 01/01/16 12/31/16: (10 eligible PCP s) x ($2,500) x (12 months) = $300,000 Number of months is based on the program effective date and end date listed in the application. Funds will be distributed on a quarterly basis. Payment will be determined by the dollars approved for your program and the allowable amount as defined at the bottom of page 35. Application Review Process Each application will be reviewed for the following: Thoroughness and completeness Supporting documentation Alignment to OPA s mission and goals Clearly defined time frame If clarification is needed, additional information may be requested. The requested information must be submitted within three (3) days of the request. Applications deemed incomplete, ineligible or non-compliant will not be accepted and the group will be notified. Clinical Review Team The Clinical Review Team is comprised of OPA physicians who have the ultimate decision making authority to approve or deny an application. Award Notification The final determination and the awarded amount will be communicated in writing to applicant within fifteen (15) days of submission (unless additional information is needed)

20 [ POP guidelines continued ] Practice Optimization Program Examples The Practice Optimization Program was designed to help physicians transform their practices to prepare for the evolution of healthcare over the next decade. Included for your reference is a list of possible program topics for you to consider when completing your application. Appeal Process If an application is denied, the applicant may appeal the decision within three (3) business days. Appeals must be made in writing and should be accompanied by the denial letter. All documentation can be ed to fitzgerald.rachel@opawny.com. Denied applications may be resubmitted and will be reviewed by a separate reviewer. Each applicant is allowed one (1) cycle of revisions. If more than one (1) cycle is needed, the application may be rejected, but can be resubmitted at the next submission cycle. Audit Requirements CLINICAL CARE COORDINATION STAFF A practice may employ personnel to help with patient outreach and care coordination. Alternately, a practice may use the resources for hiring diabetic educators, nutritionists, pharmacists, trainers or other general support services, which will improve integration of patient care. If a practice does not need a full-time associate in one (1) given field or cannot afford a full-time associate in a particular field, it is permissible to use part-time resources. It is also possible to combine resources in order to bring on multiple skill sets. For example, a practice may choose to hire a part-time dietitian and a part-time pharmacist to help in the practice. AFTER HOURS CARE A practice may wish to use the funds to pay for care outside of their current patient hours. For example, if they do not currently offer Saturday office hours, they may use the money to fund staffing to cover the additional cost of being open during that time. TECHNOLOGY A practice may wish to use the money to invest in technology to optimize practice transformation. Items that might be covered under this consideration would include, but are not limited to telehealth, remote monitoring systems, additional EMR licenses, technological enhancements. Items which would not be covered in this category include - acquisition and agreed to fees for maintenance of electronic medical record or routine subscriptions. These are part of the day-to-day cost of doing business. A random sampling of approved applicants will occur on a quarterly basis. Groups may be asked to provide a transaction report identifying cash expenditures year-to-date, process workflows, program descriptions and/or to complete a self-audit form. OTHER A practice may identify a need unique to their own considerations. This may be approved at the discretion of the application review team

21 2017 [ practice optimization program (POP) application 2017 ] THANK YOU for your interest in participating in the 2017 Optimum Physician Alliance (OPA) Practice Optimization Program (POP). For additional information on this program, including application instructions, program rules, reimbursement methodology and the review process, please see the POP Guidelines. It is important to remember while completing this application that submissions must be aligned with OPA s goal to support physicians in their effort to transform their practices. APPLICATIONS MUST BE SUBMITTED ELECTRONICALLY. Electronic copies of the application can be found at and can be ed to fitzgerald.rachel@opawny.com Application Submission Date Complete Group Name APPLICATION FORM practice optimization program Tax Identification Number Address(Primary Address Only) Assigned Project Administrator & Title Administrator Telephone Administrator Fax Administrator Address Name of Physician Advisor PO Box 90. Buffalo, New York CONTACT Rachel Fitzgerald fitzgerald.rachel@opawny.com Number of Eligible Primary Care Physicians Amount of this Request ($) Maximum Annual Value Per Eligible Group = (number of eligible primary care physicians) x ($2,500) x (twelve months). Example for a full year is as follows: (10 eligible PCPS) x ($2,500) x (12) = $300,000 Time Frame in Which Funds Will Be Used From To 39 40

22 Projected Project Budget Please be sure to include only eligible expenses. For a listing of ineligible expenses, please see the POP Guidelines. ITEM PRACTICE CONTRIBUTION OPA CONTRIBUTION TOTAL 02. Program Information A. Goals: What goals do you hope to achieve by implementing this program? Goals are overarching principles that guide decision making. They reflect the big picture and clearly serve the interests of the program. TOTAL Budget Rationale Explain each line item above. B. Milestones: Describe the milestones you plan to achieve as a result of the goal set above. Milestones act as landmarks along the path to achieving your goal. They should describe the anticipated outcomes and can be either qualitative or quantitative. Baseline data should be presented as a point of reference. C. Activities: What activities are necessary to achieve your goal and address the need(s) identified in the need statement? If applicable, cite research verifying that the activities you want to adopt will be effective in addressing the need. PLEASE COMPLETE EACH QUESTION BELOW. IF ADDITIONAL SPACE IS NEEDED, PLEASE BE SURE TO LIMIT THE LENGTH OF YOUR ANSWERS TO NO MORE THAN 6 PAGES TOTAL (FOR THE ENTIRE APPLICATION). 01. Statement of Need: Why is this program important and how will it support practice transformation? It s very important to present a clear, compelling case about why this program is needed. D. Key Personnel: The key personnel section should include anyone who is going to work on the project and their role in your organization

23 F. Evaluation Plan: In the grid below, please include the objective(s) you ve developed and the corresponding activities needed to meet each objective. Include the method of measurement (how data will be measured) and the source of that data. Don t forget to include your projected start and completion date and the individual(s) ultimately responsible for each action item. RESPONSIBLE INDIVIDUAL COMPLETION DATE START DATE SOURCE OF DATA OBJECTIVE ACTIVITY METHOD OF MEASURE PATIENT SURVEY PATIENT S 1/1/2017 3/1/2017 JANE DOE IMPLEMENT NEW WORK FLOWS EX: IMPROVE CUSTOMER SATISFACTION 03. Additional Information: Please include any additional information about your organization or project that you think is relevant to this submission. Also, please list any supporting documentation that is being submitted with this application

24 [ appendix I - breast cancer screening ] [ appendix I - breast cancer screening ] Value Set Name Definition Value Set Name Definition Absence of Left Breast Z90.12 [Z90.12] Acquired absence of left breast and nipple Absence of Right Breast Z90.11 [Z90.11] Acquired absence of right breast and nipple Bilateral Mastectomy 0HTV0ZZ [0HTV0ZZ] Resection of Bilateral Breast, Open Approach ICD10PCS Bilateral Mastectomy Bilat simple mastectomy ICD9PCS Bilateral Mastectomy Bilat extend simp mastec ICD9PCS Bilateral Mastectomy Bilat radical mastectomy ICD9PCS Bilateral Mastectomy Bil exten rad mastectomy ICD9PCS Bilateral Modifier 50 CPT Bilateral Modifier CPT History of Bilateral Mastectomy Z90.13 [Z90.13] Acquired absence of bilateral breasts and nipples Left Modifier LT CPT Mammography CPT Mammography CPT Mammography CPT Mammography G0202 Screening mammography, producing direct digital image, bilateral, all views (G0202) Mammography Breast xerography ICD9PCS Mammography Mammography NEC ICD9PCS Mammography 0403 UBREV Right Modifier RT CPT Unilateral Mastectomy CPT Unilateral Mastectomy CPT Unilateral Mastectomy CPT Unilateral Mastectomy CPT Unilateral Mastectomy CPT Unilateral Mastectomy CPT Unilateral Mastectomy CPT Unilateral Mastectomy CPT Unilateral Mastectomy CPT Unilateral Mastectomy Unilat simple mastectomy ICD9PCS Unilateral Mastectomy Unilat exten simp mastec ICD9PCS Unilateral Mastectomy Unilat radical mastectom ICD9PCS Unilateral Mastectomy Unil ext rad mastectomy ICD9PCS Unilateral Mastectomy Left 0HTU0ZZ [0HTU0ZZ] Resection of Left Breast, Open Approach ICD10PCS Unilateral Mastectomy Right 0HTT0ZZ [0HTT0ZZ] Resection of Right Breast, Open Approach ICD10PCS 45 46

25 [ appendix II - adult BMI codes ] [ appendix III - colorectal screening codes ] Value Set Name Definition Value Set Name Definition BMI Z68.1 Body mass index (BMI) 19 or less, adult ICD-10-CM BMI Z68.20 Body mass index (BMI) , adult ICD-10-CM BMI Z68.21 Body mass index (BMI) , adult ICD-10-CM BMI Z68.22 Body mass index (BMI) , adult ICD-10-CM BMI Z68.23 Body mass index (BMI) , adult ICD-10-CM BMI Z68.24 Body mass index (BMI) , adult ICD-10-CM BMI Z68.25 Body mass index (BMI) , adult ICD-10-CM BMI Z68.26 Body mass index (BMI) , adult ICD-10-CM BMI Z68.27 Body mass index (BMI) , adult ICD-10-CM BMI Z68.28 Body mass index (BMI) , adult ICD-10-CM BMI Z68.29 Body mass index (BMI) , adult ICD-10-CM BMI Z68.30 Body mass index (BMI) , adult ICD-10-CM BMI Z68.31 Body mass index (BMI) , adult ICD-10-CM BMI Z68.32 Body mass index (BMI) , adult ICD-10-CM BMI Z68.33 Body mass index (BMI) , adult ICD-10-CM BMI Z68.34 Body mass index (BMI) , adult ICD-10-CM BMI Z68.35 Body mass index (BMI) , adult ICD-10-CM BMI Z68.36 Body mass index (BMI) , adult ICD-10-CM BMI Z68.37 Body mass index (BMI) , adult ICD-10-CM BMI Z68.38 Body mass index (BMI) , adult ICD-10-CM BMI Z68.39 Body mass index (BMI) , adult ICD-10-CM BMI Z68.41 Body mass index (BMI) , adult ICD-10-CM BMI Z68.42 Body mass index (BMI) , adult ICD-10-CM BMI Z68.43 Body mass index (BMI) , adult ICD-10-CM BMI Z68.44 Body mass index (BMI) , adult ICD-10-CM BMI Z68.45 Body mass index (BMI) 70 or greater, adult ICD-10-CM Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT 47 48

26 [ appendix III - colorectal screening codes ] [ appendix III - colorectal screening codes ] Value Set Name Definition Value Set Name Definition Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy CPT Colonoscopy Colonoscopy G0105 G0121 Colorectal cancer screening; colonoscopy on individual at high risk (G0105) Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk (G0121) Colonoscopy Endosc lg bowel thru st ICD9PCS Colonoscopy Colonoscopy ICD9PCS Colonoscopy Clos large bowel biopsy ICD9PCS Colonoscopy Endo polpectomy lrge int ICD9PCS Colonoscopy Endosc destru lg int les ICD9PCS Colorectal Cancer G0213 Pet imaging whole body; diagnosis; colorectal [G0213] Colorectal Cancer G0214 Pet imaging whole body; initial staging; colorectal [G0214] Colorectal Cancer Colorectal Cancer G0215 G0231 Pet imaging whole body; restaging; colorectal cancer [G0215] Pet, whole body, for recurrence of colorectal or colorectal metastatic cancer; gamma cameras only [G0231] Colorectal Cancer C18.0 [C18.0] Malignant neoplasm of cecum Colorectal Cancer C18.1 [C18.1] Malignant neoplasm of appendix Colorectal Cancer C18.2 [C18.2] Malignant neoplasm of ascending colon Colorectal Cancer C18.3 [C18.3] Malignant neoplasm of hepatic flexure Colorectal Cancer C18.4 [C18.4] Malignant neoplasm of transverse colon Colorectal Cancer C18.5 [C18.5] Malignant neoplasm of splenic flexure Colorectal Cancer C18.6 [C18.6] Malignant neoplasm of descending colon Colorectal Cancer C18.7 [C18.7] Malignant neoplasm of sigmoid colon Colorectal Cancer C18.8 [C18.8] Malignant neoplasm of overlapping sites of colon Colorectal Cancer C18.9 [C18.9] Malignant neoplasm of colon, unspecified Colorectal Cancer C19 [C19] Malignant neoplasm of rectosigmoid junction Colorectal Cancer C20 [C20] Malignant neoplasm of rectum Colorectal Cancer C21.2 [C21.2] Malignant neoplasm of cloacogenic zone Colorectal Cancer C21.8 [C21.8] Malignant neoplasm of overlapping sites of rectum, anus and anal canal 49 50

27 [ appendix III - colorectal screening codes ] [ appendix III - colorectal screening codes ] Value Set Name Definition Value Set Name Definition Colorectal Cancer C78.5 Colorectal Cancer Z Colorectal Cancer Z [C78.5] Secondary malignant neoplasm of large intestine and rectum [Z85.038] Personal history of other malignant neoplasm of large intestine [Z85.048] Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus Colorectal Cancer Mal neo hepatic flexure ICD9CM Colorectal Cancer Mal neo transverse colon ICD9CM Colorectal Cancer Mal neo descend colon ICD9CM Colorectal Cancer Mal neo sigmoid colon ICD9CM Colorectal Cancer Malignant neoplasm cecum ICD9CM Colorectal Cancer Malignant neo appendix ICD9CM Colorectal Cancer Malig neo ascend colon ICD9CM Colorectal Cancer Mal neo splenic flexure ICD9CM Colorectal Cancer Malignant neo colon NEC ICD9CM Colorectal Cancer Malignant neo colon NOS ICD9CM Colorectal Cancer Mal neo rectosigmoid jct ICD9CM Colorectal Cancer Malignant neopl rectum ICD9CM Colorectal Cancer Sec malig neo lg bowel ICD9CM Colorectal Cancer V10.05 Hx of colonic malignancy ICD9CM Colorectal Cancer V10.06 Hx-rectal & anal malign ICD9CM Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy CPT Flexible Sigmoidoscopy G0104 Colorectal cancer screening; flexible sigmoidoscopy (G0104) Flexible Sigmoidoscopy Flexible sigmoidoscopy ICD9PCS FOBT CPT FOBT CPT FOBT G0328 FOBT FOBT FOBT FOBT FOBT Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous (G0328) Hemoglobin.gastrointestinal [Presence] in Stool --4th specimen Hemoglobin.gastrointestinal [Presence] in Stool --5th specimen Hemoglobin.gastrointestinal [Presence] in Stool --1st specimen Hemoglobin.gastrointestinal [Presence] in Stool --2nd specimen Hemoglobin.gastrointestinal [Presence] in Stool --3rd specimen FOBT Hemoglobin.gastrointestinal [Presence] in Stool FOBT Hemoglobin.gastrointestinal [Mass/mass] in Stool FOBT FOBT FOBT FOBT FOBT FOBT Hemoglobin.gastrointestinal [Presence] in Stool --6th specimen Hemoglobin.gastrointestinal [Presence] in Stool --7th specimen Hemoglobin.gastrointestinal [Presence] in Stool --8th specimen Hemoglobin.gastrointestinal [Presence] in Stool by Immunologic method Hemoglobin.gastrointestinal [Presence] in Stool by Immunologic method --2nd specimen Hemoglobin.gastrointestinal [Presence] in Stool by Immunologic method --3rd specimen 51 52

28 [ appendix III - colorectal screening codes ] [ appendix IV - osteoporosis management post fracture ] Value Set Name Definition Value Set Name Definition FOBT FOBT FOBT Hemoglobin.gastrointestinal [Presence] in Stool by Immunologic method --1st specimen Hemoglobin.gastrointestinal [Mass/volume] in Stool by Immunologic method Hemoglobin.gastrointestinal [Presence] in Stool by Rapid immunoassay Total Colectomy CPT Total Colectomy CPT Total Colectomy CPT Total Colectomy CPT Total Colectomy CPT Total Colectomy CPT Total Colectomy CPT Total Colectomy CPT Total Colectomy CPT Total Colectomy CPT Total Colectomy CPT Total Colectomy 0DTE0ZZ [0DTE0ZZ] Resection of Large Intestine, Open Approach ICD10PCS Total Colectomy Total Colectomy Total Colectomy 0DTE4ZZ 0DTE7ZZ 0DTE8ZZ [0DTE4ZZ] Resection of Large Intestine, Percutaneous Endoscopic Approach [0DTE7ZZ] Resection of Large Intestine, Via Natural or Artificial Opening [0DTE8ZZ] Resection of Large Intestine, Via Natural or Artificial Opening Endoscopic ICD10PCS ICD10PCS ICD10PCS Total Colectomy Lap tot intr-ab colectmy ICD9PCS Total Colectomy Op tot intr-abd colectmy ICD9PCS Total Colectomy Tot abd colectmy NEC/NOS ICD9PCS Bone Mineral Density Tests CPT Bone Mineral Density Tests CPT Bone Mineral Density Tests CPT Bone Mineral Density Tests CPT Bone Mineral Density Tests CPT Bone Mineral Density Tests CPT Bone Mineral Density Tests CPT Bone Mineral Density Tests G0130 Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) (G0130) Bone Mineral Density Tests BP48ZZ1 [BP48ZZ1] Ultrasonography of Right Shoulder, Densitometry ICD10PCS Bone Mineral Density Tests BP49ZZ1 [BP49ZZ1] Ultrasonography of Left Shoulder, Densitometry ICD10PCS Bone Mineral Density Tests BP4GZZ1 [BP4GZZ1] Ultrasonography of Right Elbow, Densitometry ICD10PCS Bone Mineral Density Tests BP4HZZ1 [BP4HZZ1] Ultrasonography of Left Elbow, Densitometry ICD10PCS Bone Mineral Density Tests BP4LZZ1 [BP4LZZ1] Ultrasonography of Right Wrist, Densitometry ICD10PCS Bone Mineral Density Tests BP4MZZ1 [BP4MZZ1] Ultrasonography of Left Wrist, Densitometry ICD10PCS Bone Mineral Density Tests BP4NZZ1 [BP4NZZ1] Ultrasonography of Right Hand, Densitometry ICD10PCS Bone Mineral Density Tests BP4PZZ1 [BP4PZZ1] Ultrasonography of Left Hand, Densitometry ICD10PCS Bone Mineral Density Tests BQ00ZZ1 [BQ00ZZ1] Plain Radiography of Right Hip, Densitometry ICD10PCS Bone Mineral Density Tests BQ01ZZ1 [BQ01ZZ1] Plain Radiography of Left Hip, Densitometry ICD10PCS Bone Mineral Density Tests BQ03ZZ1 [BQ03ZZ1] Plain Radiography of Right Femur, Densitometry ICD10PCS Bone Mineral Density Tests BQ04ZZ1 [BQ04ZZ1] Plain Radiography of Left Femur, Densitometry ICD10PCS Bone Mineral Density Tests Bone Mineral Density Tests Bone Mineral Density Tests BR00ZZ1 BR07ZZ1 BR09ZZ1 [BR00ZZ1] Plain Radiography of Cervical Spine, Densitometry [BR07ZZ1] Plain Radiography of Thoracic Spine, Densitometry [BR09ZZ1] Plain Radiography of Lumbar Spine, Densitometry ICD10PCS ICD10PCS ICD10PCS Bone Mineral Density Tests BR0GZZ1 [BR0GZZ1] Plain Radiography of Whole Spine, Densitometry ICD10PCS Long-Acting Osteoporosis Medications J3487 Injection, zoledronic acid (zometa), 1 mg (J3487) Long-Acting Osteoporosis Medications J3488 Injection, zoledronic acid (reclast), 1 mg (J3488) 53 54

29 [ appendix IV - osteoporosis management post fracture ] [ appendix V - diabetes care - eye exam ] Value Set Name Definition Value Set Name Definition Long-Acting Osteoporosis Medications Long-Acting Osteoporosis Medications J3489 Injection, zoledronic acid, 1 mg (J3489) Q2051 Injection, zoledronic acid, not otherwise specified, 1mg (Q2051) Osteoporosis Medications J0630 Injection, calcitonin salmon, up to 400 units (J0630) Osteoporosis Medications J0897 Injection, denosumab, 1 mg (J0897) Osteoporosis Medications J1740 Injection, ibandronate sodium, 1 mg (J1740) Osteoporosis Medications J3110 Injection, teriparatide, 10 mcg (J3110) Osteoporosis Medications J3487 Injection, zoledronic acid (zometa), 1 mg (J3487) Osteoporosis Medications J3488 Injection, zoledronic acid (reclast), 1 mg (J3488) Osteoporosis Medications J3489 Injection, zoledronic acid, 1 mg (J3489) Osteoporosis Medications Q2051 Injection, zoledronic acid, not otherwise specified, 1mg (Q2051) Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT 55 56

30 [ appendix V - diabetes care - eye exam ] [ appendix VI - diabetes care - monitoring for kidney disease ] Value Set Name Definition Value Set Name Definition Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening CPT Diabetic Retinal Screening Diabetic Retinal Screening Diabetic Retinal Screening S0620 S0621 S3000 Routine ophthalmological examination including refraction; new patient (S0620) Routine ophthalmological examination including refraction; established patient (S0621) Diabetic indicator; retinal eye exam, dilated, bilateral (S3000) Diabetic Retinal Screening Negative 3072F CPT Diabetic Retinal Screening With Eye Care Professional 2022F CPT Diabetic Retinal Screening With Eye Care Professional 2024F CPT Diabetic Retinal Screening With Eye Care Professional 2026F CPT CKD Stage 4 N18.4 [N18.4] Chronic kidney disease, stage 4 (severe) CKD Stage Chr kidney dis stage IV ICD9CM ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT ESRD CPT 57 58

31 [ appendix VI - diabetes care - monitoring for kidney disease ] [ appendix VI - diabetes care - monitoring for kidney disease ] Value Set Name Definition Value Set Name Definition ESRD CPT ESRD CPT ESRD ESRD G0257 S9339 Unscheduled or emergency dialysis treatment for an esrd patient in a hospital outpatient department that is not certified as an esrd facility (G0257) Home therapy; peritoneal dialysis, administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (S9339) ESRD N18.5 [N18.5] Chronic kidney disease, stage 5 ESRD N18.6 [N18.6] End stage renal disease ESRD Z91.15 [Z91.15] Patient's noncompliance with renal dialysis ESRD Z99.2 [Z99.2] Dependence on renal dialysis ESRD 3E1M39Z [3E1M39Z] Irrigation of Peritoneal Cavity using Dialysate, Percutaneous Approach ICD10PCS ESRD 5A1D00Z [5A1D00Z] Performance of Urinary Filtration, Single ICD10PCS ESRD 5A1D60Z [5A1D60Z] Performance of Urinary Filtration, Multiple ICD10PCS ESRD Chron kidney dis stage V ICD9CM ESRD End stage renal disease ICD9CM ESRD V45.11 Renal dialysis status ICD9CM ESRD V45.12 Noncmplnt w renal dialys ICD9CM ESRD Ven cath renal dialysis ICD9PCS ESRD Dialysis arteriovenostom ICD9PCS ESRD Revis ren dialysis shunt ICD9PCS ESRD Remov ren dialysis shunt ICD9PCS ESRD Arterioven fistula rep ICD9PCS ESRD Insert ves-to-ves cannul ICD9PCS ESRD Replac ves-to-ves cannul ICD9PCS ESRD Hemodialysis ICD9PCS ESRD Peritoneal dialysis ICD9PCS ESRD 65 End-Stage Renal Disease Treatment Facility POS ESRD 0800 UBREV ESRD 0801 UBREV ESRD 0802 UBREV ESRD 0803 UBREV ESRD 0804 UBREV ESRD 0809 UBREV ESRD 0820 UBREV ESRD 0821 UBREV ESRD 0822 UBREV ESRD 0823 UBREV ESRD 0824 UBREV ESRD 0825 UBREV ESRD 0829 UBREV ESRD 0830 UBREV ESRD 0831 UBREV ESRD 0832 UBREV ESRD 0833 UBREV ESRD 0834 UBREV ESRD 0835 UBREV ESRD 0839 UBREV ESRD 0840 UBREV ESRD 0841 UBREV ESRD 0842 UBREV ESRD 0843 UBREV ESRD 0844 UBREV ESRD 0845 UBREV ESRD 0849 UBREV ESRD 0850 UBREV ESRD 0851 UBREV ESRD 0852 UBREV ESRD 0853 UBREV ESRD 0854 UBREV ESRD 0855 UBREV 59 60

32 [ appendix VI - diabetes care - monitoring for kidney disease ] [ appendix VI - diabetes care - monitoring for kidney disease ] Value Set Name Definition Value Set Name Definition ESRD 0859 UBREV ESRD 0880 UBREV ESRD 0881 UBREV ESRD 0882 UBREV ESRD 0889 UBREV ESRD 0720 UBTOB ESRD 0721 UBTOB ESRD 0722 UBTOB ESRD 0723 UBTOB ESRD 0724 UBTOB ESRD 0725 UBTOB ESRD 0727 UBTOB ESRD 0728 UBTOB ESRD 072A UBTOB ESRD 072B UBTOB ESRD 072C UBTOB ESRD 072D UBTOB ESRD 072E UBTOB ESRD 072F UBTOB ESRD 072G UBTOB ESRD 072H UBTOB ESRD 072I UBTOB ESRD 072J UBTOB ESRD 072K UBTOB ESRD 072M UBTOB ESRD 072O UBTOB ESRD 072X UBTOB ESRD 072Y UBTOB ESRD 072Z UBTOB ESRD Obsolete CPT ESRD Obsolete CPT ESRD Obsolete CPT ESRD Obsolete CPT ESRD Obsolete CPT ESRD Obsolete CPT ESRD Obsolete CPT ESRD Obsolete ESRD Obsolete ESRD Obsolete ESRD Obsolete ESRD Obsolete ESRD Obsolete G0308 G0309 G0310 G0311 G0312 G0313 End stage renal disease (esrd) related services during the course of treatment, for patients under 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month [G0308] End stage renal disease (esrd) related services during the course of treatment for patients under 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2 or 3 face-to-face physician visits per month [G0309] End stage renal disease (esrd) related services during the course of treatment, for patients under 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month [G0310] End stage renal disease (esrd) related services during the course of treatment, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month [G0311] End stage renal disease (esrd) related services during the course of treatment, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2 or 3 face-to-face physician visits per month [G0312] End stage renal disease (esrd) related services during the course of treatment, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month [G0313] 61 62

33 [ appendix VI - diabetes care - monitoring for kidney disease ] [ appendix VI - diabetes care - monitoring for kidney disease ] Value Set Name Definition Value Set Name Definition ESRD Obsolete G0314 End stage renal disease (esrd) related services, during the course of treatment, for patients between 12 and 19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month [G0314] ESRD Obsolete ESRD Obsolete G0326 G0327 End stage renal disease (esrd) related services less than full month, per day; for patients between twelve and nineteen years of age [G0326] End stage renal disease (esrd) related services less than full month, per day; for patients twenty years of age and over [G0327] ESRD Obsolete G0315 End stage renal disease (esrd) related services during the course of treatment, for patients between 12 and 19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2 or 3 face-to-face physician visits per month [G0315] ESRD Obsolete ESRD Obsolete G0392 G0393 Transluminal balloon angioplasty, percutaneous; for maintenance of hemodialysis access, arteriovenous fistula or graft; arterial [G0392] Transluminal balloon angioplasty, percutaneous; for maintenance of hemodialysis access, arteriovenous fistula or graft; venous [G0393] ESRD Obsolete ESRD Obsolete ESRD Obsolete ESRD Obsolete ESRD Obsolete ESRD Obsolete ESRD Obsolete G0316 G0317 G0318 G0319 G0321 G0322 G0323 End stage renal disease (esrd) related services during the course of treatment, for patients between 12 and 19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month [G0316] End stage renal disease (esrd) related services during the course of treatment, for patients 20 years of age and over; with 4 or more face-to-face physician visits per month [G0317] End stage renal disease (esrd) related services during the course of treatment, for patients 20 years of age and over; with 2 or 3 face-to-face physician visits per month [G0318] End stage renal disease (esrd) related services during the course of treatment, for patients 20 years of age and over; with 1 face-to-face physician visit per month [G0319] ESRD related services for home dialysis patients per full month; for patients 2 to 11 years of age to include monitoring for adequacy of nutrition, assessment of growth and development, and counseling of parents [G0321] End stage renal disease (esrd) related services for home dialysis patients per full month; for patients twelve to nineteen years of age to include monitoring for adequacy of nutrition, assessment of growth and development, and counseling of parents [G0322] End stage renal disease (esrd) related services for home dialysis patients per full month; for patients twenty years of age and older [G0323] Kidney Transplant CPT Kidney Transplant CPT Kidney Transplant CPT Kidney Transplant CPT Kidney Transplant CPT Kidney Transplant CPT Kidney Transplant CPT Kidney Transplant S2065 Simultaneous pancreas kidney transplantation (S2065) Kidney Transplant Z94.0 [Z94.0] Kidney transplant status Kidney Transplant Kidney Transplant Kidney Transplant Kidney Transplant Kidney Transplant Kidney Transplant 0TY00Z0 0TY00Z1 0TY00Z2 0TY10Z0 0TY10Z1 0TY10Z2 [0TY00Z0] Transplantation of Right Kidney, Allogeneic, Open Approach [0TY00Z1] Transplantation of Right Kidney, Syngeneic, Open Approach [0TY00Z2] Transplantation of Right Kidney, Zooplastic, Open Approach [0TY10Z0] Transplantation of Left Kidney, Allogeneic, Open Approach [0TY10Z1] Transplantation of Left Kidney, Syngeneic, Open Approach [0TY10Z2] Transplantation of Left Kidney, Zooplastic, Open Approach ICD10PCS ICD10PCS ICD10PCS ICD10PCS ICD10PCS ICD10PCS Kidney Transplant V42.0 Kidney transplant status ICD9CM ESRD Obsolete G0325 ESRD related services for home dialysis (less than full month), per day; for patients between 2 and 11 years of age [G0325] Kidney Transplant Renal autotransplant ICD9PCS Kidney Transplant Kidney transplant NEC ICD9PCS 63 64

34 [ appendix VI - diabetes care - monitoring for kidney disease ] [ appendix VI - diabetes care - monitoring for kidney disease ] Value Set Name Definition Value Set Name Definition Kidney Transplant 0367 UBREV Nephropathy Treatment 3066F CPT Nephropathy Treatment 4010F CPT Nephropathy Treatment E08.21 Nephropathy Treatment E08.22 Nephropathy Treatment E08.29 Nephropathy Treatment E09.21 Nephropathy Treatment E09.22 Nephropathy Treatment E09.29 Nephropathy Treatment E10.21 Nephropathy Treatment E10.22 Nephropathy Treatment E10.29 Nephropathy Treatment E11.21 Nephropathy Treatment E11.22 Nephropathy Treatment E11.29 Nephropathy Treatment E13.21 Nephropathy Treatment E13.22 Nephropathy Treatment E13.29 Nephropathy Treatment I12.0 Nephropathy Treatment I12.9 [E08.21] Diabetes mellitus due to underlying condition with diabetic nephropathy [E08.22] Diabetes mellitus due to underlying condition with diabetic chronic kidney disease [E08.29] Diabetes mellitus due to underlying condition with other diabetic kidney complication [E09.21] Drug or chemical induced diabetes mellitus with diabetic nephropathy [E09.22] Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease [E09.29] Drug or chemical induced diabetes mellitus with other diabetic kidney complication [E10.21] Type 1 diabetes mellitus with diabetic nephropathy [E10.22] Type 1 diabetes mellitus with diabetic chronic kidney disease [E10.29] Type 1 diabetes mellitus with other diabetic kidney complication [E11.21] Type 2 diabetes mellitus with diabetic nephropathy [E11.22] Type 2 diabetes mellitus with diabetic chronic kidney disease [E11.29] Type 2 diabetes mellitus with other diabetic kidney complication [E13.21] Other specified diabetes mellitus with diabetic nephropathy [E13.22] Other specified diabetes mellitus with diabetic chronic kidney disease [E13.29] Other specified diabetes mellitus with other diabetic kidney complication [I12.0] Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease [I12.9] Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease Nephropathy Treatment I13.0 Nephropathy Treatment I13.10 Nephropathy Treatment I13.11 Nephropathy Treatment I13.2 [I13.0] Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease [I13.10] Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease [I13.11] Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease [I13.2] Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease Nephropathy Treatment I15.0 [I15.0] Renovascular hypertension Nephropathy Treatment I15.1 [I15.1] Hypertension secondary to other renal disorders Nephropathy Treatment N00.0 Nephropathy Treatment N00.1 Nephropathy Treatment N00.2 Nephropathy Treatment N00.3 Nephropathy Treatment N00.4 Nephropathy Treatment N00.5 Nephropathy Treatment N00.6 Nephropathy Treatment N00.7 Nephropathy Treatment N00.8 Nephropathy Treatment N00.9 Nephropathy Treatment N01.0 [N00.0] Acute nephritic syndrome with minor glomerular abnormality [N00.1] Acute nephritic syndrome with focal and segmental glomerular lesions [N00.2] Acute nephritic syndrome with diffuse membranous glomerulonephritis [N00.3] Acute nephritic syndrome with diffuse mesangial proliferative glomerulonephritis [N00.4] Acute nephritic syndrome with diffuse endocapillary proliferative glomerulonephritis [N00.5] Acute nephritic syndrome with diffuse mesangiocapillary glomerulonephritis [N00.6] Acute nephritic syndrome with dense deposit disease [N00.7] Acute nephritic syndrome with diffuse crescentic glomerulonephritis [N00.8] Acute nephritic syndrome with other morphologic changes [N00.9] Acute nephritic syndrome with unspecified morphologic changes [N01.0] Rapidly progressive nephritic syndrome with minor glomerular abnormality 65 66

35 [ appendix VI - diabetes care - monitoring for kidney disease ] [ appendix VI - diabetes care - monitoring for kidney disease ] Value Set Name Definition Value Set Name Definition Nephropathy Treatment N01.1 Nephropathy Treatment N01.2 Nephropathy Treatment N01.3 Nephropathy Treatment N01.4 [N01.1] Rapidly progressive nephritic syndrome with focal and segmental glomerular lesions [N01.2] Rapidly progressive nephritic syndrome with diffuse membranous glomerulonephritis [N01.3] Rapidly progressive nephritic syndrome with diffuse mesangial proliferative glomerulonephritis [N01.4] Rapidly progressive nephritic syndrome with diffuse endocapillary proliferative glomerulonephritis Nephropathy Treatment N02.4 Nephropathy Treatment N02.5 Nephropathy Treatment N02.6 [N02.4] Recurrent and persistent hematuria with diffuse endocapillary proliferative glomerulonephritis [N02.5] Recurrent and persistent hematuria with diffuse mesangiocapillary glomerulonephritis [N02.6] Recurrent and persistent hematuria with dense deposit disease Nephropathy Treatment N01.5 Nephropathy Treatment N01.6 Nephropathy Treatment N01.7 Nephropathy Treatment N01.8 [N01.5] Rapidly progressive nephritic syndrome with diffuse mesangiocapillary glomerulonephritis [N01.6] Rapidly progressive nephritic syndrome with dense deposit disease [N01.7] Rapidly progressive nephritic syndrome with diffuse crescentic glomerulonephritis [N01.8] Rapidly progressive nephritic syndrome with other morphologic changes Nephropathy Treatment N02.7 Nephropathy Treatment N02.8 Nephropathy Treatment N02.9 [N02.7] Recurrent and persistent hematuria with diffuse crescentic glomerulonephritis [N02.8] Recurrent and persistent hematuria with other morphologic changes [N02.9] Recurrent and persistent hematuria with unspecified morphologic changes Nephropathy Treatment N01.9 [N01.9] Rapidly progressive nephritic syndrome with unspecified morphologic changes Nephropathy Treatment N03.0 [N03.0] Chronic nephritic syndrome with minor glomerular abnormality Nephropathy Treatment N02.0 [N02.0] Recurrent and persistent hematuria with minor glomerular abnormality Nephropathy Treatment N03.1 [N03.1] Chronic nephritic syndrome with focal and segmental glomerular lesions Nephropathy Treatment N02.1 [N02.1] Recurrent and persistent hematuria with focal and segmental glomerular lesions Nephropathy Treatment N03.2 [N03.2] Chronic nephritic syndrome with diffuse membranous glomerulonephritis Nephropathy Treatment N02.2 [N02.2] Recurrent and persistent hematuria with diffuse membranous glomerulonephritis Nephropathy Treatment N03.3 [N03.3] Chronic nephritic syndrome with diffuse mesangial proliferative glomerulonephritis Nephropathy Treatment N02.3 Nephropathy Treatment N03.4 Nephropathy Treatment N03.5 [N02.3] Recurrent and persistent hematuria with diffuse mesangial proliferative glomerulonephritis [N03.4] Chronic nephritic syndrome with diffuse endocapillary proliferative glomerulonephritis [N03.5] Chronic nephritic syndrome with diffuse mesangiocapillary glomerulonephritis Nephropathy Treatment N03.7 Nephropathy Treatment N03.8 Nephropathy Treatment N03.9 [N03.7] Chronic nephritic syndrome with diffuse crescentic glomerulonephritis [N03.8] Chronic nephritic syndrome with other morphologic changes [N03.9] Chronic nephritic syndrome with unspecified morphologic changes Nephropathy Treatment N03.6 [N03.6] Chronic nephritic syndrome with dense deposit disease Nephropathy Treatment N04.0 [N04.0] Nephrotic syndrome with minor glomerular abnormality 67 68

36 [ appendix VI - diabetes care - monitoring for kidney disease ] [ appendix VI - diabetes care - monitoring for kidney disease ] Value Set Name Definition Value Set Name Definition Nephropathy Treatment N04.1 Nephropathy Treatment N04.2 Nephropathy Treatment N04.3 Nephropathy Treatment N04.4 Nephropathy Treatment N04.5 [N04.1] Nephrotic syndrome with focal and segmental glomerular lesions [N04.2] Nephrotic syndrome with diffuse membranous glomerulonephritis [N04.3] Nephrotic syndrome with diffuse mesangial proliferative glomerulonephritis [N04.4] Nephrotic syndrome with diffuse endocapillary proliferative glomerulonephritis [N04.5] Nephrotic syndrome with diffuse mesangiocapillary glomerulonephritis Nephropathy Treatment N04.6 [N04.6] Nephrotic syndrome with dense deposit disease Nephropathy Treatment N04.7 Nephropathy Treatment N04.8 Nephropathy Treatment N04.9 Nephropathy Treatment N05.0 Nephropathy Treatment N05.1 Nephropathy Treatment N05.2 Nephropathy Treatment N05.3 Nephropathy Treatment N05.4 Nephropathy Treatment N05.5 [N04.7] Nephrotic syndrome with diffuse crescentic glomerulonephritis [N04.8] Nephrotic syndrome with other morphologic changes [N04.9] Nephrotic syndrome with unspecified morphologic changes [N05.0] Unspecified nephritic syndrome with minor glomerular abnormality [N05.1] Unspecified nephritic syndrome with focal and segmental glomerular lesions [N05.2] Unspecified nephritic syndrome with diffuse membranous glomerulonephritis [N05.3] Unspecified nephritic syndrome with diffuse mesangial proliferative glomerulonephritis [N05.4] Unspecified nephritic syndrome with diffuse endocapillary proliferative glomerulonephritis [N05.5] Unspecified nephritic syndrome with diffuse mesangiocapillary glomerulonephritis Nephropathy Treatment N05.7 Nephropathy Treatment N05.8 Nephropathy Treatment N05.9 Nephropathy Treatment N06.0 Nephropathy Treatment N06.1 Nephropathy Treatment N06.2 Nephropathy Treatment N06.3 Nephropathy Treatment N06.4 Nephropathy Treatment N06.5 [N05.7] Unspecified nephritic syndrome with diffuse crescentic glomerulonephritis [N05.8] Unspecified nephritic syndrome with other morphologic changes [N05.9] Unspecified nephritic syndrome with unspecified morphologic changes [N06.0] Isolated proteinuria with minor glomerular abnormality [N06.1] Isolated proteinuria with focal and segmental glomerular lesions [N06.2] Isolated proteinuria with diffuse membranous glomerulonephritis [N06.3] Isolated proteinuria with diffuse mesangial proliferative glomerulonephritis [N06.4] Isolated proteinuria with diffuse endocapillary proliferative glomerulonephritis [N06.5] Isolated proteinuria with diffuse mesangiocapillary glomerulonephritis Nephropathy Treatment N06.6 [N06.6] Isolated proteinuria with dense deposit disease Nephropathy Treatment N06.7 [N06.7] Isolated proteinuria with diffuse crescentic glomerulonephritis Nephropathy Treatment N06.8 [N06.8] Isolated proteinuria with other morphologic lesion Nephropathy Treatment N06.9 Nephropathy Treatment N07.0 Nephropathy Treatment N07.1 Nephropathy Treatment N07.2 Nephropathy Treatment N07.3 Nephropathy Treatment N07.4 Nephropathy Treatment N07.5 [N06.9] Isolated proteinuria with unspecified morphologic lesion [N07.0] Hereditary nephropathy, not elsewhere classified with minor glomerular abnormality [N07.1] Hereditary nephropathy, not elsewhere classified with focal and segmental glomerular lesions [N07.2] Hereditary nephropathy, not elsewhere classified with diffuse membranous glomerulonephritis [N07.3] Hereditary nephropathy, not elsewhere classified with diffuse mesangial proliferative glomerulonephritis [N07.4] Hereditary nephropathy, not elsewhere classified with diffuse endocapillary proliferative glomerulonephritis [N07.5] Hereditary nephropathy, not elsewhere classified with diffuse mesangiocapillary glomerulonephritis Nephropathy Treatment N05.6 [N05.6] Unspecified nephritic syndrome with dense deposit disease Nephropathy Treatment N07.6 [N07.6] Hereditary nephropathy, not elsewhere classified with dense deposit disease 69 70

37 [ appendix VI - diabetes care - monitoring for kidney disease ] [ appendix VI - diabetes care - monitoring for kidney disease ] Value Set Name Definition Value Set Name Definition Nephropathy Treatment N07.7 Nephropathy Treatment N07.8 Nephropathy Treatment N07.9 [N07.7] Hereditary nephropathy, not elsewhere classified with diffuse crescentic glomerulonephritis [N07.8] Hereditary nephropathy, not elsewhere classified with other morphologic lesions [N07.9] Hereditary nephropathy, not elsewhere classified with unspecified morphologic lesions Nephropathy Treatment N08 [N08] Glomerular disorders in diseases classified elsewhere Nephropathy Treatment N14.0 [N14.0] Analgesic nephropathy Nephropathy Treatment N14.1 Nephropathy Treatment N14.2 [N14.1] Nephropathy induced by other drugs, medicaments and biological substances [N14.2] Nephropathy induced by unspecified drug, medicament or biological substance Nephropathy Treatment N14.3 [N14.3] Nephropathy induced by heavy metals Nephropathy Treatment N14.4 [N14.4] Toxic nephropathy, not elsewhere classified Nephropathy Treatment N17.0 [N17.0] Acute kidney failure with tubular necrosis Nephropathy Treatment N17.1 [N17.1] Acute kidney failure with acute cortical necrosis Nephropathy Treatment N17.2 [N17.2] Acute kidney failure with medullary necrosis Nephropathy Treatment N17.8 [N17.8] Other acute kidney failure Nephropathy Treatment N17.9 [N17.9] Acute kidney failure, unspecified Nephropathy Treatment N18.1 [N18.1] Chronic kidney disease, stage 1 Nephropathy Treatment N18.2 [N18.2] Chronic kidney disease, stage 2 (mild) Nephropathy Treatment N18.3 [N18.3] Chronic kidney disease, stage 3 (moderate) Nephropathy Treatment N18.4 [N18.4] Chronic kidney disease, stage 4 (severe) Nephropathy Treatment N18.5 [N18.5] Chronic kidney disease, stage 5 Nephropathy Treatment N18.6 [N18.6] End stage renal disease Nephropathy Treatment N18.9 [N18.9] Chronic kidney disease, unspecified Nephropathy Treatment N19 [N19] Unspecified kidney failure Nephropathy Treatment N25.0 [N25.0] Renal osteodystrophy Nephropathy Treatment N25.1 [N25.1] Nephrogenic diabetes insipidus Nephropathy Treatment N25.81 [N25.81] Secondary hyperparathyroidism of renal origin Nephropathy Treatment N25.89 Nephropathy Treatment N25.9 [N25.89] Other disorders resulting from impaired renal tubular function [N25.9] Disorder resulting from impaired renal tubular function, unspecified Nephropathy Treatment N26.1 [N26.1] Atrophy of kidney (terminal) Nephropathy Treatment N26.2 [N26.2] Page kidney Nephropathy Treatment N26.9 [N26.9] Renal sclerosis, unspecified Nephropathy Treatment Q60.0 [Q60.0] Renal agenesis, unilateral Nephropathy Treatment Q60.1 [Q60.1] Renal agenesis, bilateral Nephropathy Treatment Q60.2 [Q60.2] Renal agenesis, unspecified Nephropathy Treatment Q60.3 [Q60.3] Renal hypoplasia, unilateral Nephropathy Treatment Q60.4 [Q60.4] Renal hypoplasia, bilateral Nephropathy Treatment Q60.5 [Q60.5] Renal hypoplasia, unspecified Nephropathy Treatment Q60.6 [Q60.6] Potter's syndrome Nephropathy Treatment Q61.00 [Q61.00] Congenital renal cyst, unspecified Nephropathy Treatment Q61.01 [Q61.01] Congenital single renal cyst Nephropathy Treatment Q61.02 [Q61.02] Congenital multiple renal cysts Nephropathy Treatment Q61.11 [Q61.11] Cystic dilatation of collecting ducts Nephropathy Treatment Q61.19 [Q61.19] Other polycystic kidney, infantile type Nephropathy Treatment Q61.2 [Q61.2] Polycystic kidney, adult type Nephropathy Treatment Q61.3 [Q61.3] Polycystic kidney, unspecified Nephropathy Treatment Q61.4 [Q61.4] Renal dysplasia Nephropathy Treatment Q61.5 [Q61.5] Medullary cystic kidney Nephropathy Treatment Q61.8 [Q61.8] Other cystic kidney diseases Nephropathy Treatment Q61.9 [Q61.9] Cystic kidney disease, unspecified Nephropathy Treatment R80.0 [R80.0] Isolated proteinuria Nephropathy Treatment R80.1 [R80.1] Persistent proteinuria, unspecified Nephropathy Treatment R80.2 [R80.2] Orthostatic proteinuria, unspecified Nephropathy Treatment R80.3 [R80.3] Bence Jones proteinuria Nephropathy Treatment R80.8 [R80.8] Other proteinuria Nephropathy Treatment R80.9 [R80.9] Proteinuria, unspecified Nephropathy Treatment DMII renl nt st uncntrld ICD9CM Nephropathy Treatment DMI renl nt st uncntrld ICD9CM Nephropathy Treatment DMII renal uncntrld ICD9CM Nephropathy Treatment DMI renal uncntrld ICD9CM Nephropathy Treatment Mal hy kid w cr kid I-IV ICD9CM 71 72

38 [ appendix VI - diabetes care - monitoring for kidney disease ] [ appendix VI - diabetes care - monitoring for kidney disease ] Value Set Name Definition Value Set Name Definition Nephropathy Treatment Mal hyp kid w cr kid V ICD9CM Nephropathy Treatment Ben hy kid w cr kid I-IV ICD9CM Nephropathy Treatment Ben hyp kid w cr kid V ICD9CM Nephropathy Treatment Hy kid NOS w cr kid I-IV ICD9CM Nephropathy Treatment Hyp kid NOS w cr kid V ICD9CM Nephropathy Treatment Mal hy ht/kd I-IV w/o hf ICD9CM Nephropathy Treatment Mal hyp ht/kd I-IV w hf ICD9CM Nephropathy Treatment Mal hy ht/kd st V w/o hf ICD9CM Nephropathy Treatment Mal hyp ht/kd stg V w hf ICD9CM Nephropathy Treatment Ben hy ht/kd I-IV w/o hf ICD9CM Nephropathy Treatment Ben hyp ht/kd I-IV w hf ICD9CM Nephropathy Treatment Ben hy ht/kd st V w/o hf ICD9CM Nephropathy Treatment Ben hyp ht/kd stg V w hf ICD9CM Nephropathy Treatment Hy ht/kd NOS I-IV w/o hf ICD9CM Nephropathy Treatment Hyp ht/kd NOS I-IV w hf ICD9CM Nephropathy Treatment Hy ht/kd NOS st V w/o hf ICD9CM Nephropathy Treatment Hyp ht/kd NOS st V w hf ICD9CM Nephropathy Treatment Mal renovasc hypertens ICD9CM Nephropathy Treatment Benign renovasc hyperten ICD9CM Nephropathy Treatment Renovasc hypertension ICD9CM Nephropathy Treatment Ac proliferat nephritis ICD9CM Nephropathy Treatment Ac rapidly progr nephrit ICD9CM Nephropathy Treatment Ac nephritis in oth dis ICD9CM Nephropathy Treatment Acute nephritis NEC ICD9CM Nephropathy Treatment Acute nephritis NOS ICD9CM Nephropathy Treatment Nephrotic syn, prolifer ICD9CM Nephropathy Treatment Epimembranous nephritis ICD9CM Nephropathy Treatment Membranoprolif nephrosis ICD9CM Nephropathy Treatment Minimal change nephrosis ICD9CM Nephropathy Treatment Nephrotic syn in oth dis ICD9CM Nephropathy Treatment Nephrotic syndrome NEC ICD9CM Nephropathy Treatment Nephrotic syndrome NOS ICD9CM Nephropathy Treatment Chr proliferat nephritis ICD9CM Nephropathy Treatment Chr membranous nephritis ICD9CM Nephropathy Treatment Chr membranoprolif nephr ICD9CM Nephropathy Treatment Chr rapid progr nephrit ICD9CM Nephropathy Treatment Chr nephritis in oth dis ICD9CM Nephropathy Treatment Chronic nephritis NEC ICD9CM Nephropathy Treatment Chronic nephritis NOS ICD9CM Nephropathy Treatment Proliferat nephritis NOS ICD9CM Nephropathy Treatment Membranous nephritis NOS ICD9CM Nephropathy Treatment Membranoprolif nephr NOS ICD9CM Nephropathy Treatment Rapidly prog nephrit NOS ICD9CM Nephropathy Treatment Renal cort necrosis NOS ICD9CM Nephropathy Treatment Nephr NOS/medull necros ICD9CM Nephropathy Treatment Nephritis NOS in oth dis ICD9CM Nephropathy Treatment Nephritis NEC ICD9CM Nephropathy Treatment Nephritis NOS ICD9CM Nephropathy Treatment Ac kidny fail, tubr necr ICD9CM Nephropathy Treatment Ac kidny fail, cort necr ICD9CM Nephropathy Treatment Ac kidny fail, medu necr ICD9CM Nephropathy Treatment Acute kidney failure NEC ICD9CM Nephropathy Treatment Acute kidney failure NOS ICD9CM Nephropathy Treatment Chro kidney dis stage I ICD9CM Nephropathy Treatment Chro kidney dis stage II ICD9CM Nephropathy Treatment Chr kidney dis stage III ICD9CM Nephropathy Treatment Chronic kidney dis NOS ICD9CM Nephropathy Treatment 586 Renal failure NOS ICD9CM Nephropathy Treatment 587 Renal sclerosis NOS ICD9CM Nephropathy Treatment Renal osteodystrophy ICD9CM Nephropathy Treatment Nephrogen diabetes insip ICD9CM Nephropathy Treatment Sec hyperparathyrd-renal ICD9CM Nephropathy Treatment Impair ren funct dis NEC ICD9CM Nephropathy Treatment Impaired renal funct NOS ICD9CM 73 74

39 [ appendix VI - diabetes care - monitoring for kidney disease ] [ appendix VI - diabetes care - monitoring for kidney disease ] Value Set Name Definition Value Set Name Definition Nephropathy Treatment Renal agenesis ICD9CM Nephropathy Treatment Cystic kidney diseas NOS ICD9CM Nephropathy Treatment Congenital renal cyst ICD9CM Nephropathy Treatment Polycystic kidney NOS ICD9CM Nephropathy Treatment Polycyst kid-autosom dom ICD9CM Nephropathy Treatment Polycyst kid-autosom rec ICD9CM Nephropathy Treatment Renal dysplasia ICD9CM Nephropathy Treatment Medullary cystic kidney ICD9CM Nephropathy Treatment Medullary sponge kidney ICD9CM Nephropathy Treatment Cystic kidney diseas NEC ICD9CM Nephropathy Treatment Proteinuria ICD9CM Stage I-IV Kidney Disease I12.9 Stage I-IV Kidney Disease I13.10 [I12.9] Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease [I13.10] Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease Stage I-IV Kidney Disease Mal hy kid w cr kid I-IV ICD9CM Stage I-IV Kidney Disease Ben hy kid w cr kid I-IV ICD9CM Stage I-IV Kidney Disease Hy kid NOS w cr kid I-IV ICD9CM Stage I-IV Kidney Disease Mal hy ht/kd I-IV w/o hf ICD9CM Stage I-IV Kidney Disease Ben hy ht/kd I-IV w/o hf ICD9CM Stage I-IV Kidney Disease Hy ht/kd NOS I-IV w/o hf ICD9CM Stage I-IV Kidney Disease Pneu mycplsm pneumoniae ICD9CM Urine Protein Tests CPT Urine Protein Tests CPT Urine Protein Tests CPT Urine Protein Tests CPT Urine Protein Tests CPT Urine Protein Tests CPT Urine Protein Tests CPT Urine Protein Tests CPT Urine Protein Tests CPT Urine Protein Tests 3060F CPT Urine Protein Tests 3061F CPT Urine Protein Tests 3062F CPT Urine Protein Tests Microalbumin [Mass/volume] in Urine by Test strip Urine Protein Tests Protein [Mass/volume] in 12 hour Urine Urine Protein Tests Albumin/Creatinine [Mass Ratio] in 24 hour Urine Urine Protein Tests Protein/Creatinine [Mass Ratio] in 24 hour Urine Urine Protein Tests Albumin/Creatinine [Molar ratio] in Urine Urine Protein Tests Microalbumin [Mass/time] in 24 hour Urine Urine Protein Tests Microalbumin [Mass/volume] in Urine Urine Protein Tests Microalbumin/Creatinine [Mass Ratio] in 24 hour Urine Urine Protein Tests Microalbumin/Creatinine [Mass Ratio] in Urine Urine Protein Tests Albumin [Presence] in Urine Urine Protein Tests Albumin [Mass/volume] in Urine Urine Protein Tests Albumin [Mass/time] in 24 hour Urine Urine Protein Tests Albumin renal clearance in 24 hour Urine Protein Tests Protein [Mass/time] in 6 hour Urine Urine Protein Tests Protein [Presence] in Urine by Test strip Urine Protein Tests Albumin/Creatinine [Presence] in Urine by Test strip Urine Protein Tests Albumin [Mass/volume] in 24 hour Urine Urine Protein Tests Protein [Mass/volume] in 24 hour Urine Urine Protein Tests Protein [Mass/time] in 12 hour Urine Urine Protein Tests Protein [Units/volume] in Urine Urine Protein Tests Protein [Presence] in Urine Urine Protein Tests Protein [Mass/volume] in Urine Urine Protein Tests Protein [Mass/time] in 24 hour Urine Urine Protein Tests Protein/Creatinine [Mass Ratio] in Urine Urine Protein Tests Microalbumin/Creatinine [Ratio] in Urine Urine Protein Tests Microalbumin/Creatinine [Ratio] in Urine by Test strip Urine Protein Tests Microalbumin [Mass/volume] in 24 hour Urine Urine Protein Tests Protein [Presence] in 24 hour Urine by Test strip Urine Protein Tests Albumin/Creatinine [Ratio] in Urine Urine Protein Tests Protein [Mass] in Urine collected for unspecified duration 75 76

40 [ appendix VI - diabetes care - monitoring for kidney disease ] [ appendix VI - diabetes care - monitoring for kidney disease ] Value Set Name Definition Value Set Name Definition Urine Protein Tests Protein/Creatinine [Ratio] in Urine Urine Protein Tests Protein [Mass/volume] in Urine collected for unspecified duration Urine Protein Tests Protein/Creatinine [Ratio] in 24 hour Urine Urine Protein Tests Protein [Mass/time] in 12 hour Urine --resting Urine Protein Tests Protein [Mass/time] in 12 hour Urine --upright Urine Protein Tests Microalbumin [Mass/volume] in 4 hour Urine Urine Protein Tests Microalbumin [Mass/time] in 4 hour Urine Urine Protein Tests Microalbumin [Mass/time] in 12 hour Urine Urine Protein Tests Microalbumin/Creatinine [Mass Ratio] in 12 hour Urine Urine Protein Tests Microalbumin/Protein.total in 24 hour Urine Urine Protein Tests Microalbumin [Mass/time] in Urine collected for unspecified duration Urine Protein Tests Protein [Mass/volume] in Urine by Automated test strip Urine Protein Tests Albumin [Presence] in Urine by Test strip Urine Protein Tests Protein [Mass/time] in 1 hour Urine Urine Protein Tests Protein [Presence] in Urine by SSA method Urine Protein Tests Urine Protein Tests Urine Protein Tests Microalbumin [Mass/volume] in 24 hour Urine by Detection limit <= 1.0 mg/l Microalbumin [Mass/volume] in Urine by Detection limit <= 1.0 mg/l Microalbumin [Mass/time] in 24 hour Urine by Detection limit <= 1.0 mg/l Urine Protein Tests Microalbumin [Mass/time] in 8 hour Urine Urine Protein Tests Microalbumin [Mass/volume] in 12 hour Urine Urine Protein Tests Protein [Presence] in Urine by Automated test strip Urine Protein Tests Protein [Mass/volume] in Urine by Test strip Urine Protein Tests Microalbumin ug/min [Mass/time] in 24 hour Urine Urine Protein Tests Protein [Mass/time] in 18 hour Urine Urine Protein Tests Microalbumin/Creatinine [Ratio] in 24 hour Urine Urine Protein Tests Protein/Creatinine [Mass Ratio] in 12 hour Urine Urine Protein Tests Microalbumin [Mass/time] in 18 hour Urine Urine Protein Tests Urine Protein Tests Urine Protein Tests Albumin [Moles/volume] in Urine by Detection limit <= 3.0 mg/l Microalbumin/Creatinine [Ratio] in Urine by Detection limit <= 1.0 mg/l Microalbumin/Creatinine [Ratio] in 24 hour Urine by Detection limit <= 1.0 mg/l Urine Protein Tests Albumin/Creatinine [Mass Ratio] in Urine Urine Protein Tests Albumin/Creatinine [Ratio] in 24 hour Urine 77 78

41 [ appendix VII - pediatric BMI codes ] [ appendix VIII - pediatric nutrition counseling ] Value Set Name Definition Value Set Name Definition BMI Z68.52 th percentile to less than 85th percentile for age ICD-10-CM BMI Z th percentile to less than 95th percentile for age ICD-10-CM BMI Z68.54 greater than or equal to 95th percentile for age ICD-10-CM Nutrition Counseling CPT Nutrition Counseling CPT Nutrition Counseling CPT Nutrition Counseling Nutrition Counseling Nutrition Counseling Nutrition Counseling Nutrition Counseling G0270 G0271 G0447 S9449 S9452 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes (G0270) Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes (G0271) Face-to-face behavioral counseling for obesity, 15 minutes (G0447) Weight management classes, non-physician provider, per session (S9449) Nutrition classes, non-physician provider, per session (S9452) Nutrition Counseling S9470 Nutritional counseling, dietitian visit (S9470) Nutrition Counseling Z71.3 [Z71.3] Dietary counseling and surveillance Nutrition Counseling V65.3 Dietary surveil/counsel ICD9CM 79 80

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