Fee for Service Pay for Performance Program Guidelines Program Year

Transcription

1 Fee for Service Pay for Performance Program Guidelines 2018 Program Year

2 2 General Program Guidelines Table of Contents General Program Guidelines... 4 Program Overview... 4 Provider Participation Eligibility... 4 Payment Schedule & Reports... 4 Adolescent (Teen) Well Visit... 5 Body Mass Index (BMI)... 6 Cervical Cancer Screening... 7 Depression Screening & Follow-up... 7 Diabetes Blood Pressure Control... 8 Diabetes Eye Exam... 8 Diabetes HbA1c... 9 Diabetes Medical Attention for Nephropathy (including screening)... 9 Initial Health Assessment (IHA) Mammogram for Breast Cancer Screening Postpartum Exam (OB/GYN) Prenatal Visit (OB/GYN) Substance Misuse (including alcohol) Screening, Brief Intervention, Referral & Treatment (SBIRT Screening) Well-child Visit 3-6 Years Old Women s Health Exam Member Detail Report Specifications P4P Fee for Service Track (2018 Program Year) Report Indicator Key (all measures) Measure Specifications I Initial Health Assessment (IHA) II Child Well Visit-3-6 year old (W34) III Adolescent (Teen) Well Visit IV Women s Health Exam V Cervical Cancer Screening (CCS) P4P VI CCS DOS VII Mammogram for Breast Cancer Screening (BCS) VIII BCS DOS IX Body Mass Index (BMI)... 17

3 Fee For Service Pay For Performance Program Guidelines 3 X Depression Screening $ XI Diabetes HbA1c Test 1 P4P XII Diabetes HbA1c Test 2 P4P XIII Diabetes HbA1c Test DOS XIV Diabetes HbA1c Test Result XV Diabetes Medical Attention for Nephropathy (including screening) XVI Diabetes Eye Exam XVII Diabetes Blood Pressure Control XVIII Substance use, Brief Intervention, Referral and Treatment (SBIRT) XIX Pre-natal Care XX Postpartum Care Appendix HEDIS Diabetes Diagnosis Specifications How Diabetic Patients Eligible for P4P are Identified Diabetes Diagnosis Codes Used for FFS P4P Free Health Education Materials that Support P4P Terms & Conditions Subject Index... 26

4 4 General Program Guidelines General Program Guidelines Program Overview Health Plan of San Mateo s (HPSM) fee for service Pay for Performance (FFS P4P) program offers performance bonus payments to in-network Medi-Cal providers for targeted quality measures to improve outcomes for HPSM members. The program is also designed to share data with HPSM providers on care information for their assigned HPSM patients. The targeted quality performance measure set focuses on member access and preventive care services. If you would like to participate in the program evaluation and update process in partnership with the Health Plan or if you have questions about the program, please contact our Provider Services Program Manager, Kati Phillips, at kati.phillips@hpsm.org. Provider Participation Eligibility Providers must have an active Medi-Cal contract with HPSM and must have a specialty type designation as a primary care or OB/GYN provider. The contract must be active as of the date of payment. After July 1, 2018 primary care providers need to be designated as Track 1 or 2 in the HPSM Primary Care Medi-Cal payment model. Payment Schedule & Reports Performance bonus payment by measure is contingent on meeting the measure specification criteria. Once the encounter information has been received and eligibility has been determined, payment will be made in the regular weekly Medi-Cal Remittance Advice (RA). Additional member detail and payment summary reports will be made available to providers through the HPSM ereports system. See page 15 for additional information on the monthly P4P Member Detail report. Website for ereports login: If you are unsure whether your organization has access, who in your organization has access, or would like to set up a log in to access the HPSM ereports system please contact the HPSM Provider Services Department Monday through Thursday, 8 a.m. to 5 p.m., or Friday 1 p.m. to 5 p.m. at (650) , or your Provider Service Representative.

5 Fee For Service Pay For Performance Program Guidelines 5 Adolescent (Teen) Well Visit Patient Eligibility: Patients years old Payment Rate: $90 up to once per eligible patient per calendar year Measure Definition: Annual well visit that includes: Full/interval history with evaluation of physical, behavioral, and emotional growth and development Complete physical exam Age-specific anticipatory guidance Completed Staying Healthy Assessment (SHA) tool; Found here: Instruction Guide for SHA: Billing Guidelines Procedure Code: for patients years old and ICD-10 diagnosis code Procedure Code: for patients years old and ICD-10 diagnosis code ICD-10 Diagnosis Codes (to be submitted with P4P FFS procedure code) Z Z Z00.00 Z00.01 Z00.8 Z02.0 Z02.1 Z02.2 Z02.3 Z02.4 Z02.5 Z02.6 Z02.71 Z02.79 Z02.82 Z02.89 Z02.9 Encounter for routine child health exam with abnormal findings Encounter for routine child health exam without abnormal findings Encounter for general adult health exam without abnormal findings Encounter for general adult health exam with abnormal findings Encounter for other general examination Encounter for examination for admission to educational institution Encounter for pre-employment examination Encounter for examination for admission to residential institution Encounter for examination for recruitment to armed forces Encounter for examination for driving license Encounter for examination for participation in sport Encounter for examination for insurance purposes Encounter for disability determination Encounter for issue of other medical certificate Encounter for adoption services Encounter for other administrative examinations Encounter for administrative examinations, unspecified

6 6 Body Mass Index (BMI) Body Mass Index (BMI) Patient Eligibility: All age ranges Payment Rate: $25 up to once per eligible patient per calendar year Measure Definition: Measure BMI for each patient annually and retain in patient s medical record Patients 0-2 years old: measure and record the weight-for-length percentile Patients 2-20 years old: measure and record BMI percentile Patients 21 years and older: measure and record height, weight, and BMI Billing Guidelines: Procedure Code with modifier WT; and BMI diagnosis code For patients 0-18 years old; include nutritional and physical activity counseling diagnosis codes ICD-10 Diagnosis Codes Patients 0-18 years old Z71.3 Nutrition Counseling Z71.89 Physical Activity Counseling Patients 2-20 years old: BMI percentile Z68.51 < 5th % for age Z % to < 85% for age Z68.53 Z % to < 95% for age 95% for age Patients 21 years and older: BMI Z68.1 < 20 Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z

7 Fee For Service Pay For Performance Program Guidelines 7 Cervical Cancer Screening Patient Eligibility: Women age years old who have not had a complete hysterectomy Payment Rate: $30 up to once per eligible patient per calendar year Measure Definition: Cervical cytology/pap smear screening Billing Guidelines: Procedure Code 3015F *Not available if Women s Health Exam P4P measure code G0101 has been submitted and paid in the current calendar year Depression Screening & Follow-up Patient Eligibility: Patients 12 years old and up Payment Rate: $30 up to once per eligible patient per calendar year Measure Definition: Annual depression screening using a standard depression screening tool (including HPSM Behavioral Health Screening tool available at: which includes PHQ-2 standard screening questions) Screening must be documented in patient s medical record If screening is positive, follow-up plan must be documented Billing Guidelines: Procedure Codes G8510 for negative screens (PHQ-2 score less than 3) G8431 for positive screens and documented follow-up plan *Submit HPSM P4P procedure codes in addition to covered benefit procedure codes for annual screenings. See HPSM Provider Announcements; or PCPreports@hpsm.org for a copy of the P4P and covered benefit billing guidelines if the HPSM Behavioral Health Screening tool is used.

8 8 Diabetes Blood Pressure Control Diabetes Blood Pressure Control Patient Eligibility: Patients 18 years old and up with a diagnosis of diabetes (definition on p. 19 of these guidelines) Payment Rate: up to once per eligible patient per calendar year (either poor control or not in poor control) Poor control 140/90 mm Hg: $30 Not in poor control <140/90 mm Hg: $70 Measure Definition: Annual diabetic blood pressure monitoring Billing Guidelines: *Must submit combination of one procedure code from systolic measurement, one from diastolic measurement, and an ICD-10 diabetes diagnosis code. Diabetes diagnosis code list provided in the appendix of these guidelines. Systolic Procedure Codes 3077F; Systolic (equal or greater than) >140 mmhg (poor control) 3075F; Systolic mmhg (not in poor control) 3074F; Systolic <130 mmhg (not in poor control) Diastolic Procedure Codes 3080F; Diastolic <80 mmhg (not in poor control) 3079F; Diastolic mmhg (not in poor control) 3078F; Diastolic (equal or greater than) >90 mmhg (poor control) ICD-10 Diabetes Diagnosis Code (full list in appendix) Diabetes Eye Exam Patient Eligibility: Patients 18 years old and up with a diagnosis of diabetes Payment Rate: $30 up to once per eligible patient per calendar year Measure Definition: Annual diabetic retinal eye exam Billing Guidelines: *Must submit combination of one procedure code and ICD-10 diabetes diagnosis code. Diabetes diagnosis code list provided in the appendix of these guidelines. Primary care provider should refer for the exam to an eye care specialist and submit the P4P code once the result has been sent back to the primary care provider and recorded in the patient s medical record. Submit for date of service when the test was ordered.

9 Fee For Service Pay For Performance Program Guidelines 9 Procedure Codes 3072F; Low risk for retinopathy (no evidence of retinopathy in the prior year as indicated by prior dilated eye exam) 2026F; Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed 2024F; 7 standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed 2022F; Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed ICD-10 Diabetes Diagnosis Code (full list in appendix) Diabetes HbA1c Patient Eligibility: Patients 18 years old and up with a diagnosis of diabetes *Payment Rate: up to *twice* per eligible patient per calendar year Poor control 9.0%: $15 Not in poor control <9.0%: $50 Measure Definition: Diabetic HbA1c blood glucose testing Billing Guidelines: *Must submit combination of one procedure code and ICD-10 diabetes diagnosis code. Diabetes diagnosis code list provided in the appendix of these guidelines. Primary care provider should order the test and submit the P4P code once the result has been recorded in the patient s medical record. Submit for date of service when the test was ordered. Procedure Codes 3044F; HbA1c level <7.0% 3045F; HbA1c level % 3046F; HbA1c level >9.0% (poor control) ICD-10 Diabetes Diagnosis Code (full list in appendix) Diabetes Medical Attention for Nephropathy (including screening) Patient Eligibility: Patients 18 years old and up with a diagnosis of diabetes Payment Rate: $30 up to once per eligible patient per calendar year Measure Definition: Annual nephropathy screening or medical attention for diabetic nephropathy

10 10 Initial Health Assessment (IHA) Billing Guidelines: *Must submit combination of one procedure code and ICD-10 diabetes diagnosis code. Diabetes diagnosis code list provided in the appendix of these guidelines. Primary care provider should order the test and submit the P4P code once the result has been recorded in the patient s medical record. Submit for date of service when the test was ordered. Procedure Codes 4010F; Angiotensin converting enzyme (ACE) inhibitor or Angiotensin Receptor Blocker (ARB) therapy prescribed or currently being taken 3066F; Documentation of treatment for nephropathy (e.g., patient receiving dialysis, patient being treated for ESRD, CRF, ARF, or renal insufficiency, any visit to a nephrologist) 3062F; Positive MACROalbuminuria test result documented and reviewed 3061F; Negative microalbuminuria test result documented and reviewed 3060F; Positive MICROalbuminuria test result documented and reviewed ICD-10 Diabetes Diagnosis Codes (full list in appendix) Initial Health Assessment (IHA) Patient Eligibility: Newly enrolled HPSM member (within 120 days of Health Plan enrollment) Payment Rate: $90 for each IHA; depending on patient Medi-Cal eligibility may be payable more than once per patient per year. Check HPSM enrollment date on Active Engagement report located in HPSM ereports system for assigned patients. Measure Definition: Initial health assessment of new patients (all ages) within 120 days of Health Plan enrollment that includes: Full history with evaluation of physical, behavioral, and emotional growth and development Complete physical exam Diagnosis(es) and care plan Age specific anticipatory guidance Completed Staying Healthy Assessment (SHA) tool: SHA Instruction Guide: Billing Guidelines: Procedure Codes 99381; Under 1 year old, initial comprehensive well baby preventive visit 99382; Age 1-4 years old, new patient early childhood well visit 99383; Age 5-11 years old, new patient late childhood well visit 99384; Age years old, new patient adolescent well visit 99385; Age years old, new patient adult well visit 99386; Age years old, new patient adult well visit 99387; Age 65+, new patient adult well visit

11 Fee For Service Pay For Performance Program Guidelines 11 ICD-10 IHA Diagnosis Code Z Health examination for newborn under 8 days old Z Health examination for newborn 8 to 28 days old Z Encounter for routine child health exam with abnormal findings Z Encounter for routine child health exam without abnormal findings Z00.00 Encounter for general adult health exam without abnormal findings Z00.01 Encounter for general adult health exam with abnormal findings Z00.8 Encounter for other general examination Z02.0 Encounter for examination for admission to educational institution Z02.1 Encounter for pre-employment examination Z02.2 Encounter for examination for admission to residential institution Z02.3 Encounter for examination for recruitment to armed forces Z02.4 Encounter for examination for driving license Z02.5 Encounter for examination for participation in sport Z02.6 Encounter for examination for insurance purposes Z02.71 Encounter for disability determination Z02.79 Encounter for issue of other medical certificate Z02.82 Encounter for adoption services Z02.89 Encounter for other administrative examinations Z02.9 Encounter for administrative examinations, unspecified Mammogram for Breast Cancer Screening Primary care providers can submit for this quality performance measure if they have a record that the patient had a mammogram during the current calendar year, regardless of whether they performed the mammogram themselves. Patient Eligibility: Women age years old who have not had a bilateral mastectomy Payment Rate: $10 up to once per eligible patient per calendar year Measure Definition: Mammogram for breast cancer screening; Primary care provider should order the test and submit the P4P code once the result has been recorded in the patient s medical record. Submit for date of service when the test was ordered. Billing Guidelines: Procedure Code 3014F *Not available if Women s Health Exam P4P measure code G0101 has been submitted and paid in the current calendar year

12 12 Postpartum Exam (OB/GYN) Postpartum Exam (OB/GYN) Patient Eligibility: Women who gave birth in the last 21 to 56 days Payment Rate: $50 up to once per patient per pregnancy Measure Definition: Postpartum exam performed within 21 to 56 days after delivery Billing Guidelines: Procedure Code with modifier PP Indicate date of delivery in the remarks section of the claim Prenatal Visit (OB/GYN) Patient Eligibility: Women in their first trimester of pregnancy Payment Rate: $100 up to once per patient per pregnancy Measure Definition: Prenatal visit with OB/GYN within first trimester of pregnancy Billing Guidelines: Fax the HPSM OB Referral Verification Form to HPSM at (650) A copy of the form can also be found online at Substance Misuse (including alcohol) Screening, Brief Intervention, Referral & Treatment (SBIRT Screening) Patient Eligibility: Patients 12 years old and up Payment Rate: $5 up to once per eligible patient per calendar year Measure Definition: Annual substance misuse screening using a standard screening tool (including HPSM Behavioral Health Screening tool available at: which includes AUDIT-C standard screening questions) Screening results must be documented in patient s medical record If screening is positive, follow-up plan must be documented and a brief intervention can be done in the primary care setting, which can be billed through patient s covered benefits (codes depend on type of insurance see covered benefit billing guidelines;

13 Fee For Service Pay For Performance Program Guidelines 13 Billing Guidelines: Procedure Code 3725F *Submit HPSM P4P procedure codes in addition to covered benefit procedure codes for annual screenings. See HPSM Provider Announcement referenced above or for a copy of the P4P and covered benefit billing guidelines if the HPSM Behavioral Health Screening tool is used. Well-child Visit 3-6 Years Old Patient Eligibility: Patients 3-6 years old Payment Rate: $90 up to once per eligible patient per calendar year Measure Definition: Annual well child visit for patients 3-6 years old that includes Full/interval history with evaluation of physical, behavioral, and emotional growth and development Complete physical exam Age specific anticipatory guidance Complete the SHA Tool Found here: SHA Instruction Guide: Billing Guidelines: Procedure Code 99392; Ages 3-4 years old 99393; Ages 5-6 years old ICD-10 Diagnosis Code for child well visit Z Encounter for routine child health exam with abnormal findings Z Encounter for routine child health exam without abnormal findings Z00.8 Encounter for other general examination Z02.0 Encounter for examination for admission to educational institution Z02.2 Encounter for examination for admission to residential institution Z02.5 Encounter for examination for participation in sport Z02.71 Encounter for disability determination Z02.6 Encounter for examination for insurance purposes Z02.79 Encounter for issue of other medical certificate Z02.82 Encounter for adoption services Z02.89 Encounter for other administrative examinations Z02.9 Encounter for administrative examinations, unspecified

14 14 Women s Health Exam Women s Health Exam Patient Eligibility: Women age years old who have not had a hysterectomy and/or bilateral mastectomy Payment Rate: $90 up to once per patient per calendar year Measure Definition: Women s health exam that includes; Cervical (pap smear) or vaginal cancer screening Full pelvic exam Clinical breast exam Billing Guidelines: Procedure Code G0101 *Not available if Cervical and/or Breast Cancer Screening P4P measure codes 3015F and/or 3014F have been submitted and paid in the current calendar year.

15 Fee For Service Pay For Performance Program Guidelines 15 Member Detail Report Specifications P4P Fee for Service Track (2018 Program Year) This report will outline member-level detail based on a primary care provider s assigned panel and member eligibility, as well as gaps/opportunities for performance program services and payments. Member age is calculated based on date the report run date (generally the 2 nd of each month). Report is run at the individual clinic level and lists all HPSM Medi-Cal and CareAdvantage patients currently assigned to that clinic. Measure data will reflect all claims submitted and paid up to the report run date for the current calendar (program) year. Report schedule = ~2 nd day of each month; accessible through HPSM ereports system Data reflected in the reports includes all claims received up to the report run date Report Indicator Key (all measures) Indicator Definition * Member is eligible for the P4P measure but some information is missing for the measure to have been met, i.e. service not provided (gap/opportunity); claim not submitted; lab result not received N/A Date of Service Date of Service** Member does not meet measure eligibility criteria Most recent date of service on file that meets measure criteria based on patient eligibility and measure definition; DOS does not have to have been with current assigned PCP; DOS should only be for during the measurement year (calendar year for most measures) Service provided by non-assigned PCP/clinic Measure Specifications I Initial Health Assessment (IHA) The IHA performance measure is available each time a member becomes newly enrolled with HPSM. Thus, the PCP may receive the incentive for the same member multiple times during the calendar year if the patient loses and then regains his/her Medi-Cal eligibility multiple times during the calendar year. Indicated date of service for paid claims with CPT code 99381, 99382, 99383, or AND claim message 8126 within 120 days of HPSM enrollment for members all ages Indicate members still within 120 day enrollment period with no IHA claim with * Indicate members outside of 120 day enrollment period (with or without IHA claim) as N/A

16 16 Measure Specifications II Child Well Visit-3-6 year old (W34) Indicate most recent date of service of paid claim with procedure (CPT) codes for members 3-4 years old and for members 5 to 6 years old Indicate members ages 3-6 with no paid child well visit claim in the reporting calendar year with * Indicate members outside of 3-6 years old as N/A III Adolescent (Teen) Well Visit Indicate date of service of paid claim with procedure (CPT) code for members years old Indicate date of service of paid claim with procedure (CPT) code for members years old Indicate members ages with no paid child well visit claim in the reporting calendar with * Indicate members outside of years old as N/A IV Women s Health Exam Indicate date of service of paid claim with procedure code G0101 for women 20 to 64 years old in current calendar year If no paid G0101 claim during current calendar year, AND no paid cervical cancer screening or breast cancer screening codes 3014F and/or 3015F indicate a * If 3014F and/or 3015F have been paid indicate N/A for Women s Health Exam If patient is male indicate N/A Indicate women outside of years of age as N/A V Cervical Cancer Screening (CCS) P4P Indicate date of service of paid claim with procedure code 3015F for women years old in current calendar year If no paid 3015F claim during current calendar year, AND no paid G0101 women s health exam claim indicate a * If paid G0101 claim during current calendar year indicate N/A for Cervical Cancer Screening If patient is male indicate N/A Indicate women outside of years of age as N/A Indicate women who meet HEDIS exclusion criteria for CCS as N/A VI CCS DOS List date of service for any paid claim (most recent date of service) for Cervical Cancer Screening for eligible members based on 2018 HEDIS specifications - (Cervical Cytology Value Set) in the prior 36 months up to the report run date Indicate members who do not meet HEDIS CCS criteria or meet exclusion criteria as N/A If eligible and no date of service in prior 36 months indicate as * This column is informational only for the provider and is not necessarily tied to P4P payment for the fee for service P4P program

17 Fee For Service Pay For Performance Program Guidelines 17 VII Mammogram for Breast Cancer Screening (BCS) Indicate date of service of paid claim with procedure code 3014F for women years old in current calendar year If no paid 3014F claim during current calendar year, AND no paid G0101 women s health exam claim indicate a * If paid G0101 claim during current calendar year indicate N/A for Breast Cancer Screening P4P If patient is male indicate N/A Indicate women outside of years of age as N/A Indicate women who meet HEDIS exclusion criteria for BCS as N/A VIII BCS DOS List date of service for any paid claim (most recent date of service) for Breast Cancer Screening for eligible members based on 2018 HEDIS specifications - (Mammography Value Set) in the prior 24 months up to the report run date Indicate members who do not meet HEDIS BCS criteria or meet exclusion criteria as N/A If eligible and no date of service in prior 24 months indicate as * This column is informational only for the provider and is not necessarily tied to P4P payment for the fee for service P4P program IX Body Mass Index (BMI) Indicate date of service of paid claim with procedure code with CPT code 99411, and modifier WT billed by the assigned PCP in current calendar year Indicate members with no paid BMI claim in the reporting calendar year with * X Depression Screening $30 Indicate date of service of paid claim with procedure code G8510 or G8431 for Medi-Cal and CMC members age 12 years old and up in current calendar year Indicate members <12 years old as N/A Indicate eligible members with no paid Depression Screening P4P claim as * XI Diabetes HbA1c Test 1 P4P Indicate first date of service of paid claim with procedure codes 3044F, 3045F, or 3046F, for Medi- Cal and CMC members age 18 years old and up in current calendar year Indicate members identified as having diabetes based on eligibility criteria with no paid claims with procedure codes 3044F, 3045F, or 3046F, in current calendar year as * Diabetes diagnosis criteria (eligibility) based on HEDIS specifications, listed at the end of this specification outline XII Diabetes HbA1c Test 2 P4P Indicate most recent date of service of paid claim with procedure codes 3044F, 3045F, or 3046F, for Medi-Cal and CMC members age 18 years old and up in current calendar year

18 18 Measure Specifications Indicate members identified as having diabetes based on eligibility criteria with no second paid claim with procedure codes 3044F, 3045F, or 3046F, AND valid diabetes diagnosis code in current calendar year as * Diabetes diagnosis criteria (eligibility) based on HEDIS specifications, listed at the end of this specification outline XIII Diabetes HbA1c Test DOS Indicate most recent date of service for eligible members (members who meet the HEDIS diabetes diagnosis criteria) within the program (calendar) year based on HEDIS specifications - (HbA1c Tests Value Set). If no date of service based on HEDIS specifications for eligible members list * If members do not meet diabetes diagnosis criteria list as N/A XIV Diabetes HbA1c Test Result For most recent date of service from column XIII list test result if available If test result is not available list * If no date of service or * (not eligible members) in column XIII list as N/A XV Diabetes Medical Attention for Nephropathy (including screening) Indicate most recent date of service of paid claim with procedure codes 3060F, 3061F, 3062F, 4010F, or 3066F, for Medi-Cal and CMC members age 18 years old and up in current calendar year Indicate members identified as having diabetes based on eligibility criteria with no paid claim with procedure codes 3060F, 3061F, 3062F, 4010F, or 3066F, AND valid diabetes diagnosis code in current calendar year as * Diabetes diagnosis criteria (eligibility) based on HEDIS specifications, listed at the end of this specification outline XVI Diabetes Eye Exam Indicate most recent date of service of paid claim with procedure codes 2022F, 2024F, 2026F, or 3072F, for Medi-Cal and CMC members age 18 years old and up in current calendar year Indicate members identified as having diabetes based on eligibility criteria with no paid claim with procedure codes 2022F, 2024F, 2026F, or 3072F, AND valid diabetes diagnosis code in current calendar year as * Diabetes diagnosis criteria (eligibility) based on HEDIS specifications, listed at the end of this specification outline XVII Diabetes Blood Pressure Control Indicate most recent date of service of paid claim with procedure codes 3074F, 3075F, or 3077F for Medi-Cal and CMC members age 18 years old and up in current calendar year

19 Fee For Service Pay For Performance Program Guidelines 19 Indicate members identified as having diabetes based on eligibility criteria with no paid claim with procedure codes 3074F, 3075F, or 3077F in current calendar year as * Diabetes diagnosis criteria (eligibility) based on HEDIS specifications, listed at the end of this specification outline XVIII Substance use, Brief Intervention, Referral and Treatment (SBIRT) Indicate most recent date of service of paid claim with procedure codes 3725F for all assigned MC and CMC members 12 years old and up in current calendar year Indicate members with no paid claim with procedure code 3725F in current calendar year as * XIX Pre-natal Care Indicate date of service of paid claim with CPT code 0500F and modifier K1 for prenatal OB visit XX Postpartum Care Indicate date of service of paid claim with CPT code & modifier PP for Postpartum Care XXI. PCP OB Referral Indicate date of service of paid claim with CPT code 0500F and modifier K2 for OB Referral Measures XIX, XX, and XXI will either have a date of service or will be blank

20 20 Appendix Appendix HEDIS Diabetes Diagnosis Specifications How Diabetic Patients Eligible for P4P are Identified There are two ways to identify members with diabetes: by claim/encounter data and by pharmacy data. The organization must use both methods to identify the eligible population, but a member only needs to be identified by one method to be included in the measure. Members may be identified as having diabetes during the measurement year or the year prior to the measurement year. Claim/Encounter Data: Members who met any of the following criteria during the measurement year or the year prior to the measurement year (count services that occur over both years): At least two outpatient visits, observation visits, ED visits or nonacute inpatient encounters on different dates of service, with a diagnosis of diabetes. Visit type need not be the same for the two visits. At least one acute inpatient encounter with a diagnosis of diabetes. Pharmacy Data: Members who were dispensed insulin or hypoglycemics/ antihyperglycemics on an ambulatory basis during the measurement year or the year prior to the measurement year. Diabetes Diagnosis Codes Used for FFS P4P Code Definition E10.10 Type 1 diabetes mellitus with ketoacidosis without coma E10.11 Type 1 diabetes mellitus with ketoacidosis with coma 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 E Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema

21 Fee For Service Pay For Performance Program Guidelines 21 Code Definition E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E10.36 Type 1 diabetes mellitus with diabetic cataract E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E10.49 Type 1 diabetes mellitus with other diabetic neurological complication E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E Type 1 diabetes mellitus with diabetic neuropathic arthropathy E Type 1 diabetes mellitus with other diabetic arthropathy E Type 1 diabetes mellitus with diabetic dermatitis E Type 1 diabetes mellitus with foot ulcer E Type 1 diabetes mellitus with other skin ulcer E Type 1 diabetes mellitus with other skin complications E Type 1 diabetes mellitus with periodontal disease E Type 1 diabetes mellitus with other oral complications E Type 1 diabetes mellitus with hypoglycemia with coma E Type 1 diabetes mellitus with hypoglycemia without coma E10.65 Type 1 diabetes mellitus with hyperglycemia E10.69 Type 1 diabetes mellitus with other specified complication E10.8 Type 1 diabetes mellitus with unspecified complications E10.9 Type 1 diabetes mellitus without complications E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma

22 22 Appendix Code Definition 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 E Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E Type 2 diabetes mellitus with diabetic neuropathic arthropathy E Type 2 diabetes mellitus with other diabetic arthropathy E Type 2 diabetes mellitus with diabetic dermatitis E Type 2 diabetes mellitus with foot ulcer E Type 2 diabetes mellitus with other skin ulcer

23 Fee For Service Pay For Performance Program Guidelines 23 Code Definition E Type 2 diabetes mellitus with other skin complications E Type 2 diabetes mellitus with periodontal disease E Type 2 diabetes mellitus with other oral complications E Type 2 diabetes mellitus with hypoglycemia with coma E Type 2 diabetes mellitus with hypoglycemia without coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 diabetes mellitus without complications E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E13.01 Other specified diabetes mellitus with hyperosmolarity with coma E13.10 Other specified diabetes mellitus with ketoacidosis without coma E13.11 Other specified diabetes mellitus with ketoacidosis with coma 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 E Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema E13.36 Other specified diabetes mellitus with diabetic cataract E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication

24 24 Appendix Code Definition E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified E13.41 Other specified diabetes mellitus with diabetic mononeuropathy E13.42 Other specified diabetes mellitus with diabetic polyneuropathy E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy E13.49 Other specified diabetes mellitus with other diabetic neurological complication E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other specified diabetes mellitus with other circulatory complications E Other specified diabetes mellitus with diabetic neuropathic arthropathy E Other specified diabetes mellitus with other diabetic arthropathy E Other specified diabetes mellitus with diabetic dermatitis E Other specified diabetes mellitus with foot ulcer E Other specified diabetes mellitus with other skin ulcer E Other specified diabetes mellitus with other skin complications E Other specified diabetes mellitus with periodontal disease E Other specified diabetes mellitus with other oral complications E Other specified diabetes mellitus with hypoglycemia with coma E Other specified diabetes mellitus with hypoglycemia without coma E13.65 Other specified diabetes mellitus with hyperglycemia E13.69 Other specified diabetes mellitus with other specified complication E13.8 Other specified diabetes mellitus with unspecified complications E13.9 Other specified diabetes mellitus without complications

25 Fee For Service Pay For Performance Program Guidelines 25 Free Health Education Materials that Support P4P We realize that, with more focus on obesity and weight management, diabetes and other health conditions, our members may turn to you and to HPSM for assistance on how to address these problems. To prepare for this need, HPSM has some generic health education materials in each of these areas. Many of these resources are available in English, Spanish, Chinese and Tagalog, If our members are interested in additional health education materials, have them call our Health Education line at (650) Some hospitals offer free educational classes on diabetes and other topics that are either available to the general community or require a physician referral. Check to see if your clinic offers these. We strongly encourage you to refer our members to these classes if they are free. If you need any other health education resources that you or your office staff think would be helpful for our members, please let us know. We appreciate working in partnership with you in caring for our members. Terms & Conditions Participation in HPSM s P4P program, as well as acceptance of performance bonus payments, does not in any way modify or supersede any terms or conditions of any agreement between HPSM and participating providers. There is no guarantee of future funding or payment under any HPSM P4P performance bonus program. HPSM s P4P program and/or its terms and conditions may be modified or terminated at any time, with or without notice, at HPSM s sole discretion. In consideration of HPSM s offering of its P4P program, provider agrees to fully and forever release and discharge HPSM from any and all claims, demands, causes of action, and suits, of any nature, pertaining to or arising from the offering by HPSM of the P4P Program. Any monies paid under the P4P program for services deemed inappropriately submitted will be recouped from future payment. All cases of suspected fraud or abuse will be investigated thoroughly and reported to the appropriate authorities. HPSM reserves the right to audit medical records to validate services have been completed as billed. If there is evidence of fraud, waste, or abuse, HPSM can recoup P4P payments found to be invalidly billed and the provider could lose privileges to participate in future HPSM P4P programs.

26 26 Subject Index Subject Index Body Mass Index... 6, 17 Cancer Screening Breast... 11, 14, 16, 17 Cervical... 7, 14, 16 CareAdvantage CMC... 15, 17, 18, 19 Depression Screening... 7, 17 Diabetes... 8, 9, 10, 17, 18, 19, 20, 25 Enrollment Period... 10, 15 ereports... 4, 10, 15 HEDIS... 16, 17, 18, 19, 20 Initial Health Assessment... 10, 11, 15 Medi-Cal... 4, 10, 15, 17, 18 Postpartum Exam Prenatal Care SBIRT Screening Staying Healthy Assessment... 5, 10, 13 Well Visit... 5, 13