HEDIS Resource Guide Pediatric

Transcription

1 HEDIS Resource Guide Pediatric NA8PROGDE04235E_0000

2 2018 HEDIS Pediatric Resource Guide 2

3 What s Inside 1 What is HEDIS? 3 HEDIS Reference Guide for Pediatrics 17 Bright Futures/AAP Recommendations for Preventive Pediatric Health Care 27 Pediatric HEDIS Measures 34 Pregnancy HEDIS Measures

4 What is HEDIS? The Healthcare Effectiveness Data and Information Set (HEDIS) of performance measures is utilized by more than 90 percent of America s health plans. The performance measure rates generated using the HEDIS measures specifications allow health plans to compare how well they perform to other health plans in the following areas: Quality of care Access to care Member satisfaction with the health plan and doctors Why HEDIS Is Important HEDIS is a tool used by health plans to measure performance of health plans by consumers and employers. Value of HEDIS to You, Our Providers HEDIS can help save you time while also potentially reducing health care costs. By proactively managing patients care, you are able to effectively monitor their health, prevent further complications and identify issues that may arise with their care. HEDIS can also help you: Identify noncompliant members to ensure they receive preventive screenings. Understand how you compare with other WellCare providers as well as with the national average. Value of HEDIS to Your Patients, Our Members HEDIS gives members the ability to review and compare plans scores, helping them to make informed health care choices. What You Can Do Encourage your patients to schedule preventive exams. Remind your patients to follow up with ordered tests. Complete outreach calls to noncompliant members. If you have questions about HEDIS or need more information, please contact your local Provider Relations representative or Quality Practice Advisor (QPA) HEDIS Pediatric Resource Guide 1

5 Consumer Assessment of Healthcare Providers and Systems (CAHPS ) The CAHPS survey asks members and consumers to report on and evaluate their experiences with health care. The survey covers topics that are important to consumers and focus on aspects of quality that consumers are best qualified to assess. Topics include provider communication skills and ease of access to health care services. Your patients will be asked to evaluate you, the child s doctor or other health care provider, on the following topics: How often did your doctor listen carefully to you? How often did your doctor show respect for what you had to say? How often did your doctor spend enough time with you? Care coordination between PCP and specialists Getting appointments and care quickly Ease of getting needed care/seeing specialists Advising smokers to quit Flu vaccinations All CAHPS surveys are in the public domain, which means anyone can download and use these surveys to assess experience with care. CAHPS survey users include patients and consumers, quality monitors and regulators, provider organizations, health plans, community collaboratives, and public and private purchasers of health care. These individuals use the survey results to make informed decisions and to improve the quality of health care services. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Source: HEDIS Pediatric Resource Guide 2

6 HEDIS Reference Guide for Pediatrics The following diagnosis and/or procedure codes in the HEDIS Quick Reference Guide are in compliance with the HEDIS 2018 Volume 2 Technical Specifications. Reimbursement for these services will be in accordance with the terms and conditions of your provider agreement. ICD-10 codes must be used effective October 1, ICD-9 codes are included for certain measures because they remain in effect for 2018 HEDIS. Prevention and Screening Lead Screening in Children (LSC): Percentage of children 2 years of age who had one or more capillary or venous lead blood tests for lead poisoning by their second birthday. CPT Codes Childhood Immunizations by their 2 nd Birthday (CIS): Percentage of children two years of age who had four diphtheria, tetanus and acellular pertussis (DTaP), three polio (IPV), one measles, mumps and rubella (MMR), three H influenza type B (HiB), three hepatitis B (HepB), one chicken pox vaccine (VZV), four pneumococcal conjugate (PCV), one hepatitis A (HepA), two or three rotavirus (RV), and two influenza vaccines (flu) on or before their second birthday. Hx of Mumps: 072.0, 072.1, 072.2, , , , 072.8, Hx of Measles: 055.0, 055.1, 055.2, , , 055.8, Hx of Rubella: , , , , , 056.8, ICD-9-CM Diagnosis Hx of Hep B: , , V02.61 Hx of VZV: 052.0, 052.1, 052.2, 052.7, 052.8, 052.9, 053.0, , , , , , , 053.8, Hx of Hep A: 070.0, ICD-9-CM Procedure Newborn Hep B Vaccine: Hx of Mumps: B26.0, B26.1, B26.2. B26.3, B26.81-B26.85, B26.89, B26.9 Hx of Measles: B05.0, B05.1, B05.2, B05.3, B05.4, B05.81, B05.89, B05.9 Hx of Rubella: B06.00, B06.01, B06.02, B06.09, B06.81, B06.82, B06.89, B06.9 ICD-10-CM-Diagnosis Hx of Hep B: B16.0, B16.1, B16.2, B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, Z22.51 Hx of VZV: B01.0, B01.11, B01.12, B01.2, B01.81, B01.89, B01.9, B02.0, B02.1, B02.21, B02.22, B02.23, B02.24, B02.29, B02.30, B02.31, B02.32, B02.33, B02.34, B02.39, B02.7, B02.8, B02.9 Hx of Hep A: B15.0, B15.9 ICD-10-CM Procedure Newborn Hep B Vaccine: 3E0234Z DTap (4): 90698, 90700, 90721, IPV (3): 90698, 90713, HIB (3): , 90698, 90721, Hep B (3): 90723, 90740, 90744, 90747, VZV (1): 90710, MMR (1): 90707, Measles: CPT Codes Measles/Rubella: Rubella: Mumps: Hep A (1): Pneumococcal conjugate (4): (7 valent), (13 valent) Influenza (2): 90655, 90657, 90661, 90662, 90673, 90685, Rotavirus: (2 doses) (3 doses) 2018 HEDIS Pediatric Resource Guide 3

7 CVX Codes HCPCS Codes DTap (4): 20, 50, 106, 107, 110, 120 IPV (3): 10, 89, 110, 120 HIB (3): 17, 46-51, 120, 148 Hep B (3): 08, 44, 45, 51, 110 VZV (1): 21, 94 MMR (1): 03, 94 Measles: 05 Measles/Rubella: 04 Rubella: 06 Mumps: 07 Hep A (1): 31, 83, 85 Pneumococcal conjugate (4): 100 (7 valent), 133 (13 valent), 152 Influenza (2): 88, 135, 140, 141, 150, 153, 155, 161, 166 Rotavirus: 119 (2 doses), 116 (3 doses), 122 Hep B (3): G0010 Pneumococcal conjugate (4): G0009 Influenza (2): G0008 Immunizations for Adolescents (IMA): The percentage of adolescents 13 years of age who had one dose of meningococcal conjugate vaccine, one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine and have completed the human papillomavirus (HPV) vaccine series by their 13 th birthday. Meningococcal (1 dose): CPT Codes Tdap (1): Human Papillomavirus Vaccine (HPV): 90649, 90650, Meningococcal (1 dose): 108, 136, 147 CVX Codes Tdap (1): 115 Human Papillomavirus Vaccine (HPV): 62, 118, 137, 165 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC): Percentage of members 3 17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year. Ranges and thresholds do not meet criteria for this measure. A distinct BMI percentile is required for compliance.* The medical record must include height, weight and BMI percentile. Documentation of >99% or <1% meet criteria because a distinct BMI percentile is evident (i.e., 100% or 0%). Exclusion: Female members who have a diagnosis of pregnancy during the measurement year. *Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value. ICD-9-CM Diagnosis BMI Percentile: V85.51-V85.54 ICD-10-CM Diagnosis BMI Percentile: Z68.51, Z68.52, Z68.53, Z68.54 Counseling for Nutrition: Z71.3 Counseling for Physical Activity: Z02.5 (Sports physical), Z71.82 (Exercise Counseling) CPT Codes Counseling for Nutrition: Counseling for Nutrition: G0270, G0271, G0447, S9449, S9452, S9470 HCPCS Counseling for Physical Activity: G0447, S9451 Chlamydia Screening in Women (CHL): Percentage of women years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. CPT Codes 87110, 87270, 87320, 87490, 87491, 87492, HEDIS Pediatric Resource Guide 4

8 Utilization Well-Child Visits in the First 15 Months of Life (W15): Percentage of members who turned 15 months old during the measurement year and who had 6 or more well-child visits with a primary care provider during their first 15 months of life. Documentation must contain evidence of all of the following: health and developmental history (physical and mental), a physical exam, and health education/anticipatory guidance required. ICD-9-CM Diagnosis V20.2, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, ICD-10-CM Diagnosis Z02.89, Z02.9 CPT Codes 99381, 99382, 99391, 99392, HCPCS G0438, G0439 Well-Child Visits in the Third, Fourth, Fifth, and Sixth Year of Life (W34): Percentage of members who were three, four, five, or six years of age who received one or more well-child visits with a primary care provider during the measurement year. Documentation must contain evidence of all of the following: a health and developmental history (physical and mental), a physical exam, and health education/anticipatory guidance required. ICD-9-CM Diagnosis V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 ICD-10-CM Diagnosis Z00.121, Z00.129, Z00.5, Z00.8, Z02.0, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9 CPT Codes 99382, 99383, 99392, HCPCS G0438, G0439 Adolescent Well Visits (AWC): Percentage of members years of age who had at least one comprehensive well-care visit with a PCP or OB/GYN practitioner during the measurement year. Documentation must contain evidence of all of the following: health and developmental history (physical and mental), a physical exam, and health education/anticipatory guidance required. ICD-9-CM Diagnosis V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, ICD-10-CM Diagnosis Z02.81, Z02.82, Z02.83, Z02.89, Z02.9 CPT Codes 99384, 99385, 99394, HCPCS G0438, G0439 Access/Availability of Care Children & Adolescents Access to Primary Care Practitioners (CAP): Percentage of members 12 months 19 years of age who had a visit with a PCP. ICD-9-CM Diagnosis V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 ICD-10-CM Diagnosis Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9 CPT Codes , , , , , , , , 99411, 99412, HCPCS G0402, G0438, G0439, G0463, T1015 Annual Dental Visits (ADV): Percentage of members 2 20 years of age who had at least one dental visit during the measurement year. This measure applies only if dental care is a covered benefit in the organization's Medicaid contract. Refer your patients for dental screening annually HEDIS Pediatric Resource Guide 5

9 Prenatal and Postpartum Care (PPC): The percentage of deliveries of live births on or between November 6 of the year prior to the measurement year and November 5 of the measurement year. For these women, the measure assesses the following facets of prenatal and postpartum care. Timeliness of Prenatal Care: The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester, on the enrollment start date or within 42 days of enrollment in the organization. Postpartum Care: The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. Required Documentation: Timeliness of Prenatal Care A prenatal visit during the first trimester with an OB/GYN, midwife, family practitioner, or PCP, with a pregnancy-related diagnosis code, AND at least one of the following: A basic physical obstetrical examination that includes auscultation for fetal heart tone, or pelvic exam with obstetric observations, or measurement of fundus height (a standardized prenatal flow sheet may be used); Screening test in the form of an obstetric panel (e.g., hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO blood typing); An ultrasound (echocardiography) of the pregnant uterus; A TORCH antibody panel alone: Toxoplasma Rubella Cytomegalovirus Herpes simplex A rubella antibody test AND an ABO test on the same or different dates of service A rubella antibody test AND an Rh test on the same or different dates of service A rubella antibody test AND an ABO/Rh test on the same or different dates of service A prenatal visit during the first trimester on the same or different dates of service, AND with one of the following: A complete obstetrical history; OR A prenatal risk assessment and counseling/education; OR A prenatal visit with a pregnancy-related diagnosis code during the first trimester on the same or different dates of service, AND with a least one of the following: An obstetric panel; OR An ultrasound (echocardiography) of the pregnant uterus. ICD-9-CM Diagnosis 640.x3, 641.x3, 642.x3, 643.x3, 644.x3, 645.x3, 646.x3, 647x.3, 648.x3, 649.x3, 651.x3, 652.x3, 653.x3, 654.x3, 655. x3, 656.x3, , 658.x3, 659.x3, 678.x3, 679.x3, V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.42, V23.49, V23.5, V23.7, V23.81-V23.87, V23.89, V23.9, V28.0, V28.1, V28.2, V28.3, V28.4, V28.5, V28.6, V28.81, V28.82, V28.89, V28.9 ICD-9 Procedure Ultrasonography: Use appropriate code family: O ICD-10-CM Diagnosis Z03.71-Z03.75, Z03.79, Z34.00-Z34.03, Z34.80-Z34.83, Z34.90-Z34.93, Z36 ICD-10-CM Procedure Ultrasonography: BY49ZZZ, BY4BZZZ, BY4CZZZ, BY4DZZZ, BY4FZZZ, BY4GZZZ E/M: , , , OB Fetal Monitoring: 76801, 76805, 76811, 76813, , Prenatal Bundled Codes: 59400, 59425, 59426, 59510, 59610, CPT Codes CPT II Codes HCPCS OB Panel: 80055, TORCH: Toxoplasma: 86777, Cytomegalovirus: Herpes Simplex: 86694, 86695, F, 0501F, 0502F G0463, H1000-H1004, T1015, H1005 Rubella/ABO/Rh: Rubella: ABO: Rh: HEDIS Pediatric Resource Guide 6

10 Postpartum Care (PPC): The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. Postpartum visit to an OB/GYN practitioner or midwife, family practitioner, or other PCP. The medical record must include the date the visit occurred and at least one of the following: Pelvic exam, or Evaluation of weight, BP, breasts (notation of breast-feeding counts) and abdomen, or Notation of postpartum care, including, but not limited to: postpartum care, PP care, PP check, 6 week check or completion of a preprinted postpartum care form A Pap test alone is acceptable for the Postpartum Care rate. A colposcopy alone does not count. ICD-9-CM Diagnosis V24.1, V24.2, V25.11-V25.13, V72.31, V72.32, V76.2 Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2, O00.00, O00.01, O00.10, O00.11, O00.20, O00.21, O00.80, O00.81, ICD-10-CM Diagnosis O00.90, O00.91 ICD-10-PCS 10D00Z0-10D00Z2, 10D07Z3-10D07Z8, 10E0XZZ 57170, 58300, 59430, , 88147, 88148, 88150, , , 88174, 88175, CPT Codes Postpartum Bundled Services: 59400, 59410, 59510, 59515, 59610, 59614, 59618, CPT II Codes 0503F HCPCS G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 Respiratory Conditions Appropriate Testing for Children With Pharyngitis (CWP): Percentage of children 3 18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing). ICD-9-CM Diagnosis 034.0, 462, 463 ICD-10-CM Diagnosis J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91 Strep Test Codes 87070, 87071, 87081, 87430, , Appropriate Treatment for Children with Upper Respiratory Infection (URI): Percentage of children 3 months 18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. ICD-9-CM Diagnosis 460, 465.0, 465.8, ICD-10-CM Diagnosis J00, J06.0, J06.9 Medication Management for People with Asthma (MMA): Percentage of members 5 64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported: Percentage of members who remained on an asthma controller medication for at least 50% of their treatment period. Percentage of members who remained on an asthma controller medication for at least 75% of their treatment period. Note: For Medicaid, report only members 5 64 years of age. ICD-9-CM Diagnosis , , , , , , J45.20, J45.21, J45.22, J45.30, J45.31, J45.32, J45.40, J45.41, J45.42, J45.50, J45.51, J45.52, J45.901, J45.902, J45.909, ICD-10-CM Diagnosis J45.990, J45.991, J , , , , , 99238, 99239, , , CPT , 99291, , , , , 99411, 99412, 99429, 99455, HCPCS G0402, G0438, G0439, G0463, T1015 FDA-Approved Asthma Medications: For a complete list of medications and NDC codes, please visit Asthma Controller Medications Description Prescriptions Antiasthmatic combinations Antibody inhibitor Inhaled steroid combinations Dyphylline-guaifenesin Guaifenesin-theophylline Omalizumab Budesonide-formoterol Fluticasone-salmeterol Mometasone-formoterol Fluticasone-vilanterol 2018 HEDIS Pediatric Resource Guide 7

11 Inhaled corticosteroids Leukotriene modifiers Mast cell stabilizers Methylxanthines Beclomethasone Budesonide Ciclesonide Montelukast Zafirlukast Cromolyn Aminophylline Dyphylline Asthma Reliever Medications Description Prescriptions Short-acting, inhaled beta-2 agonists Albuterol Levalbuterol Pirbuterol Flunisolide Fluticasone CFC free Mometasone Zileuton Theophylline Asthma Medication Ratio (AMR): The percentage of members 5-64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year. ICD-9-CM Diagnosis , , , , , , ICD-10-CM Diagnosis J45.20, J45.21, J45.22, J45.30, J45.31, J45.32, J45.40, J45.41, J45.42, J45.50, J45.51, J45.52, J45.901, J45.902, J45.909, J45.990, J45.991, J CPT , , , , , 99238, 99239, , , , 99291, , , , , 99411, 99412, 99429, 99455, HCPCS G0402, G0438, G0439, G0463, T1015 Asthma Controller Medications: For the complete list of FDA-approved asthma medications and NDC codes, please visit Description Prescriptions Antiasthmatic combinations Antibody inhibitor Inhaled steroid combinations Inhaled corticosteroids Dyphylline-guaifenesin Guaifenesin-theophylline Omalizumab Budesonide-formoterol Fluticasone-salmeterol Beclomethasone Budesonide Ciclesonide Mometasone-formoterol Fluticasone-vilanterol Flunisolide Fluticasone CFC free Mometasone Leukotriene Montelukast Zafirlukast Zileuton modifiers Mast cell stabilizers Cromolyn Methylxanthines Aminophylline Dyphylline Theophylline Asthma Reliever Medications Description Prescriptions Short-acting, inhaled Albuterol Levalbuterol Pirbuterol beta-2 agonists Exclusion Criteria: Members with any diagnosis of emphysema, COPD, Obstructive Chronic Bronchitis, Chronic Respiratory Conditions Due to Fumes/Vapors, Cystic Fibrosis, Acute Respiratory Failure are excluded. Or, members who had no asthma controller medications dispensed during the measurement year HEDIS Pediatric Resource Guide 8

12 ICD-9-CM Diagnosis ICD-10-CM Diagnosis Behavioral Health Emphysema 492.0, COPD , 496 Obstructive Chronic Bronchitis Chronic Respiratory Conditions Due to Fumes/Vapors Cystic Fibrosis , Acute Respiratory Failure Other Emphysema 518.1, Emphysema J43.0, J43.1, J43.2, J43.8, J43.9 COPD J44.0, J44.1, J44.9 Chronic Respiratory Conditions J68.4 Due to Fumes/Vapors Cystic Fibrosis E84.0, E84.11, E84.19, E84.8, E84.9 Acute Respiratory Failure J96.00, J96.01, J96.02, J96.20, J96.21, J96.22 Other Emphysema J98.2, J98.3 Follow-Up After Hospitalization for Mental Illness (FUH): Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are reported: The percentage of discharges for which the member received follow-up within 30 days of discharge The percentage of discharges for which the member received follow-up within 7 days of discharge Does not include visits that occur on the date of discharge ICD-10-CM-Diagnosis Use the appropriate code family: F CPT HCPCS Follow-up visits identified by the following CPT or HCPCS codes must be with a mental health practitioner. Stand Alone Visits: , 99078, , , , , , , , , , 99411, 99412, Transitional Care: 99495, Telehealth Modifiers: 95, GT CPT POS Follow-up visits identified by the following CPT/POS codes must be with a mental health practitioner , 90792, , , 90845, 90847, 90849, 90853, , 90875, G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 WITH , , 99238, 99239, WITH 52, 53 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 Follow-Up After Emergency Department Visit for Mental Illness (FUM): The percentage of emergency department (ED) visits for members 6 years of age and older with a principal diagnosis of mental illness, who had a follow-up visit for mental illness. Two rates are reported: 1. The percentage of ED visits for which the member received follow-up within 30 days of the ED visit. 2. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit. The follow-up visit after the ED visit can be with any practitioner. Member must be 6 years or older on the date of the ED visit. ICD-10-CM Diagnosis Use the appropriate code family: F CPT HCPS Follow-up visits identified by the following CPT or HCPCS codes with any practitioner within 7 and 30 days of ED Visit. Stand Alone Visits: , 99078, , , , , , , , , , 99411, 99412, Telehealth Modifiers: 95, GT Stand Alone Visits: G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T HEDIS Pediatric Resource Guide 9

13 CPT Follow-up visits identified by the following CPT with POS codes with any practitioner within 7 and 30 days of ED Visit. Follow-Up Group 1: 90791, 90792, , , 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 WITH 90845, 90847, 90849, 90853, , 90875, Follow-Up Group 2: , , 99238, 99239, , 53 WITH Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA): The percentage of emergency department (ED) visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) dependence who had a follow-up visit for AOD. Two rates are reported: 1. The percentage of ED visits for which the member received follow-up within 30 days of the ED visit. 2. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit. The follow-up visit after the ED visit can be with any practitioner. Member must be 13 years or older on the date of the visit. ICD-10-CM Diagnosis Use the appropriate code family: F CPT HCPS Follow-up visits identified by the following CPT or HCPCS codes with any practitioner within 7 and 30 days of ED Visit. Stand-Alone Visits: , 99078, , , , , , , , , , 99408, 99409, 99411, 99412, Telephone Visits: , Online Assessments: 98969, Telehealth Modifiers: 95, GT CPT POS Stand-Alone Visits: G0155, G0176, G0177, G0396, G0397, G0409- G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0022, H0031, H0034-H0037, H0039, H0040, H0047, H2000, H2001, H2010-H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012, T1015 POS Follow-up visits identified by the following CPT with POS codes with any practitioner within 7 and 30 days of ED Visit. Follow-Up Group 1: 90791, 90792, , , 03, 05, 07, 09, 11-20, 22, 33, 49, 50, 52, 53, 57, 71, 72 WITH 90845, 90847, 90849, 90853, 90875, Follow-Up Group 2: , , 99238, 99239, Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC): Percentage of children and adolescents ages 1 17 who were on 2 or more concurrent antipsychotic medications for at least 90 consecutive days during the measurement year. (Note: A lower rate indicates better performance.) Antipsychotic Medications: For a complete list of medications and NDC codes, please visit Description Prescription Miscellaneous antipsychotic agents Phenothiazine antipsychotics Thioxanthenes Long-acting injections Aripiprazole Asenapine Brexpiprazole Cariprazine Clozapine Haloperidol Iloperidone Chlorpromazine Fluphenazine Perphenazine Perphenazine-amitriptyline Thiothixene Aripiprazole Fluphenazine decanoate Haloperidol decanoate WITH 52, 53 Loxapine Lurisadone Molindone Olanzapine Paliperidone Pimozide Quetiapine Prochlorperazine Thioridazine Trifluoperazine Olanzapine Paliperidone palmitate Risperidone Quetiapine fumarate Risperidone Ziprasidone 2018 HEDIS Pediatric Resource Guide 10

14 Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM): Percentage of children and adolescents ages 1 17 who had 2 or more antipsychotic prescriptions and had metabolic testing. Antipsychotic Medications: For a complete list of medications and NDC codes, please visit Description Prescription Miscellaneous antipsychotic agents Phenothiazine antipsychotics Thioxanthenes Long-acting injections Aripiprazole Asenapine Brexpiprazole Cariprazine Clozapine Haloperidol Iloperidone Chlorpromazine Fluphenazine Perphenazine Perphenazineamitriptyline Thiothixene Aripiprazole Fluphenazine decanoate Haloperidol decanoate Antipsychotic Combination Medications Description Prescription Psychotherapeutic combinations Cholesterol Tests Other Than LDL Fluoxetine-olanzapine Perphenazine-amitriptyline 82465, 83718, Loxapine Lurisadone Molindone Olanzapine Paliperidone Pimozide Quetiapine Prochlorperazine Thioridazine Trifluoperazine Olanzapine Paliperidone palmitate Risperidone Glucose Tests 80047, 80048, 80050, 80053, 80069, 82947, 82950, HbA1C Tests 83036, 83037, 3044F, 3045F, 3046F LDL-C Tests 80061, 83700, 83701, 83704, 83721, 3048F, 3049F, 3050F Quetiapine fumarate Risperidone Ziprasidone Follow-Up Care for Children Prescribed ADHD Medications (ADD): Percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported: Initiation Phase: The percentage of members 6 12 years of age as of the Index Prescription Start Date (IPSD) with an ambulatory prescription dispensed for ADHD medication who had one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase. Continuation and Maintenance (C&M) Phase: The percentage of members 6 12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended. Only one of the two visits (during the ) may be a telephone or telehealth visit with any practitioner. CPT Codes ICD-10CM HCPCS Stand-Alone Visits: , , 99078, , , , , , , , , , 99411, 99412, Telephone Visits: , Telehealth Modifier: 95, GT Chemical Dependency: Use the appropriate code family: F Mental Health Diagnosis: Use the appropriate code family F Narcolepsy: G47.411, G47.411, G47.419, G47.421, G G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T HEDIS Pediatric Resource Guide 11

15 CPT Follow-up visits identified by the following CPT/POS codes must be with a mental health practitioner. Follow-up Group 1: 90791, 90792, , , 90845, 90847, 90849, 90853, 90875, WITH Follow-up Group 2: , , 99238, 99239, WITH 52, 53 ADHD Medications: For a complete list of medications and NDC codes, please visit CNS Stimulants Alpha-2 receptor agonists Miscellaneous ADHD medications Amphetamine-dextroamphetamine Dexmethylphenidate Dextroamphetamine Clonidine Guanfacine Atomoxetine Medication Management and Care Coordination Lisdexamfetamine Methamphetamine Methylphenidate POS 03, 05, 07, 09, 11-20, 22, 33, 49, 50, 52, 53, 71, 72 First-Year Measure Transitions of Care (TRC): Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year. Four rates are reported: Notification of Inpatient Admission. Documentation of receipt of notification of inpatient admission on the day of admission or the following day. Receipt of Discharge Information. Documentation of receipt of discharge information on the day of discharge or the following day. Patient Engagement After Inpatient Discharge. Documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge. Medication Reconciliation Post-Discharge. Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days) , , , , , , , , 99411, 99412, 99429, 99455, TCM 7 Day: CPT Codes TCM 14 Day: Medical Reconciliation: CPT: 99495,99496 CPT II: 1111F Telephone Visits: , Telehealth Modifier: 95, GT HCPCS G0402, G0438, G0439, G0463, T1015 First-Year Measure Follow-Up After Emergency Department Visit for People With High Risk Multiple Chronic Conditions (FMC): Percentage of emergency department (ED) visits for members 18 years and older who have high-risk multiple chronic conditions who had a follow-up service within 7 days of the ED visit. Note: Members in hospice are excluded from the eligible population HEDIS Pediatric Resource Guide 12

16 ICD-10-CM Diagnosis CPT Codes HCPCS Asthma: J45.21, J45.22, J45.31, J45.32, J45.41, J45.42, J45.51, J45.52, J45.901, J45.902, J45.990, J45.991, J Atrial Fibrillation: I48.0, I48.2, I48.91 Chronic Heart Failure: I , I43, I50.1, I50.20-I50.23, I50.30-I50.33, I50.40-I50.43, I50.9 Chronic Kidney Disease: A18.11, A52.75, B52.0, C64.1, C64.2, C64.9, C68.9, D30.00-D30.02, D41.00-D41.02, D D41.12, D41.20-D41.22, D59.3, E08.21, E08.22, E08.29, E08.65, E09.21, 09.22, E09.29, E10.21, E10.22, E10.29, E10.65, E11.21, E11.22, E11.29, E11.65, E13.21, E13.22, E13.29, E74.8, I12.0,I13.11, I13.2, I70.1, I72.2, K76.7, M10.30, M10.311, M10.312, M10.319, M10.321, M10.322, M10.329, M10.331, M10.332, M10.339, M10.341, M10.342, M10.349, M10.351, M10.352, M10.359, M10.361,M10.362, M10.369, M10.371, M10.372, M10.379, M10.38, M10.39, M32.14, M32.15, M35.04, N00.0- N00.9, N01.0-N01.9, N02.0-N02.9, N03.0-N03.9, N04.0-N04.9, N05.0-N05.9, N06.0-N06.9, N07.0-N07.9, N08, N13.1, N13.2, N13.30, N13.39, N14.0-N14.4, N15.0, N15.8, N15.9, N16, N17.0, N17.2, N17.8, N17.9, N18.1-N18.6, N18.9, N19, N25.0, N25.1, N25.81, N25.89, N25.9, N26.1, N26.9, Q61.02, Q61.11,Q61.19, Q61.2-Q61.5, Q61.8, Q62.0, Q Q62.12, Q62.2, Q62.31, Q62.32, Q62.39, R94.4 COPD Diagnosis: J41.0, J41.1, J41.8, J42, J43.0-J43.2, J43.8, J43.9, J44.0, J44.1, J44.9, J47.0, J47.1, J47.9 Dementia: F01.50, F01.51, F02.81, F03.90, F03.91, F04, F10.27, F10.97, F13.97, F18.17, F18.27, F18.97, F19.17, F19.27, F19.97, G30.0, G30.1, G30.8, G30.9, G31.83 Dysthymic Disorder: F34.1 Frontotemporal Dementia: G31.01, G31.09 Heart Failure Diagnosis: I09.81, I11.0, I13.0, I13.2, I50.1, I50.20-I50.23, I50.30-I50.33, I50.40-I50.43, I50.9 Major Depression: F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9 MI: I21.01, I21.02, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I22.0, I22.1, I22.2, I22.8, 122.9, , Stroke: G45.0-G45.2, G45.8, G45.9, G46.0-G46.2, G97.31, G97.32, I60.00-I60.02, I61.0-I61.6, I61.8, I61.9, I63.00, I63.011, I63.012, I63.019, I63.02, I63.031, I63.032, I63.039, I63.09, I63.10, I I63.113, I63.119, I63.12, I I63.133, I63.I39, I63.19, I63.20, I I63.213, I63.219, I63.22, I I63.233, I63.239, I63.29, I63.30, I I63.313, I63.319, I63.321, I63.322, I63.323, I63.329, I I63.333, I63.339, I I63.343, I63.349, I63.39, I63.40, I I63.413, I63.419, I I63.423, I63.429, I I63.433, I63.439, I I63.443, I63.449, I63.49, I63.50, I63.511, I63.512, I63.513, I63.529, I I63.533, I63.539, I I63.543, I63.549, I63.59, I63.6, I63.8, I63.9, I66.01-I66.03, I66.09, I66.11-I66.13, I66.19, I66.21-I66.23, I66.29, I66.3, I66.8, I66.9, I67.841, I67.848, I67.89, I97.810, I97.811, I97.820, I Unspecified Bronchitis: J40 Acute Inpatient: , , 99238, 99239, , CM Encounter: Complex CM: 99487, 99489, ED: FUH Visits Group 1: 90791, 90792, , , 90845, 90847, 90849, 90853, 90867, 90868, 90869, 90870, 90875, FUH POS Group 1: 2, 3, 5, 7, 9, 11-20, 22, 24, 33, 49, 50, 52, 71, 72 FUH Visits Group 2: , , 99238, 99239, FUH POS Group 2: 2, 52, 53 FUH Stand-Alone Visits: , 99078, , , , , , 99347, 99350, , , , 99411, 99412, IET Visits Group 1: 90791, 90792, , 90840, 90846, 90847, 90849, 90853, 90875, IET POS Group 2: 3, 5, 7, 9, 11-20, 22, 33, 49, 50, 52, 53, 57, 71, 72 IET Visits Group 2: , , 99238, 99239, IET POS Group 2: 2, 52, 53 IET Stand-Alone Visits: , 99078, , , , , , , , , , 99408, 99409, 99411, 99412, Nonacute Inpatient: , 99315, 99316, 99318, , Observation: Outpatient: , , , , , , , , 99411, 99412, 99429, 99455, Transitional Care Management 7 Day: 99495, Telehealth Modifier: 95, GT Telephone Visits: , CM Encounter: T1016, T1017, T2022, T2023 Complex CM: G0506 FUH Stand-Alone Visits: G0155, G0176, G0177, G0409, G0410, G0411, G0463, H0002, H0004, H0031, H0034- H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 IET Stand-Alone Visits: G0155, G0176, G0177, G0396, G0397, G0409, G0410, G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0022, H0031, H0034-H0037, H0039, H0040, H0047, H2000, H2001, H2010-H2020, H2035, H036, M0064, S0201, S9480, S9484, S9485, T1006, T1012, T1015 Outpatient: G0402, G0438, G0439, G0463, T HEDIS Pediatric Resource Guide 13

17 Overuse/Appropriateness First-Year Measure Use of Opioids at High Dosage (UOD): For members 18 years and older, the rate per 1,000 receiving prescription opioids for 15 days during the measurement year at a high dosage (average morphine equivalent dose [MED] >120 mg). The average MED for all opioids dispensed during the treatment period. Identify all opioid dispensing events for members during the measurement year. Calculate the number of days covered for all dispensing events and determine who meets the threshold of 15 total days covered during the measurement year. NOTE: A lower rate indicates better performance Opioid Medications Buprenorphine Butorphanol Codeine Dihydrocodeine Fentanyl Hydrocodone Hydromorphone Levorphanol Meperidine 2018 HEDIS Pediatric Resource Guide 14 Methadone Morphine Opium Oxycodone Oxymorphone Pentazocine Tapentadol Tramadol First-Year Measure Use of Opioids From Multiple Providers (UOP): For members 18 years and older, the rate per 1,000 receiving prescription opioids for 15 days during the measurement year who received opioids from multiple providers. Three rates are reported. Multiple Prescribers: The rate per 1,000 members receiving prescriptions for opioids from four or more different prescribers during measurement year. Multiple Pharmacies: The rate per 1,000 members receiving prescriptions for opioids from four or more different pharmacies during the measurement year. Multiple Prescribers and Multiple Pharmacies: The rate per 1,000 members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year. NOTE: A lower rate indicated better performance for all three rates. Opioid Medications Buprenorphine Butorphanol Codeine Dihydrocodeine Fentanyl Hydrocodone Hydromorphone Levorphanol Meperidine Measures Collected Using Electronic Clinical Data Systems Methadone Morphine Opium Oxycodone Oxymorphone Pentazocine Tapentadol Tramadol First-Year Measure Depression Screening and Follow-Up for Adolescents and Adults (DSF): The percentage of members 12 years of age and older who were screened for clinical depression using an age-appropriate standardized tool and, if screened positive, who received follow-up care. Depression Screening: The percentage of members who were screened for clinical depression using a standardized tool. Follow-Up on Positive Screen: The percentage of members who screened positive for depression and received follow-up care within 30 days. Mental Illness: F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F21-F24, F25.0, F25.1, F25.8, F25.9, F28, F29, F30.10-F30.13, F30.2-F30.4, F30.8, F30.9, F31.0, F31.10-F31.13, F31.2, F31.30-F31.2, F31.4, F31.5, F31.60-F31.64, F31.70-F31.78, F31.81, F31.89, F31.9, F32.0-F32.5, F32.8, F32.81, F32.89, F33.0-F33.3, F33.40-F33.42, F33.42, F33.8, F33.9, F34.0, F34.1, F34.8, F34.81, F34.89, F34.9, F39, F42, F42.2-F42.4, F42.8, F42.9, F43.0, F43.10-F43.12, ICD-10-CM Diagnosis F43.20-F43.25, F43.29, F43.8, F43.9, F44.80, F53, F60.0-F60.7, F60.81, F60.89, F60.9, F63.0-F63.3, F63.81, F63.89, F63.9-F63.13, F68.8, F84.0, F84.2, F84.3, F84.5, F84.8, F84.9, F90.0-F90.2, F90.8, F90.0, F91.0-F91.3, F91.8, F91.9, F93.0, F93.8, F93.9, F , F94.8, F94.9 Mental Illness SNOWED: 1453 Depression: F01.51, F32.0-F32.5, F32.81, F32.89, F32.9, F33.0-F33.3, F33.42, F33.9, F34.1, F43.21, F43.23 Behavioral Health Encounter: 90791, 90792, , , , 90849, 90853, 90865, , 90875, 90876, 90880, ECDS Follow-Up: , 99078, , , , , CPT Codes 99345, , , , , 99411, Telephone Visits: , Telehealth Modifier: 95, GT Behavioral Health Encounter: G0155, G0176,G0177, G0409-G0411, G0502, G0503, G0507, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485 HCPCS ECDS Follow-up: G0463, T1015 Positive Depression Screen: G8431 Depression Screen: G8431, G8510, G8511

18 Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS): The percentage of members 12 years of age and older with a diagnosis of major depression or dysthymia who have a PHQ-9 tool administered at least once during a four-month period. Two rates are reported: ECDS Coverage: The percentage of members 12 and older with a diagnosis of major depression or dysthymia for whom a health plan can receive any electronic clinical quality data. Utilization of PHQ-9 Rate: The percentage of PHQ-9 utilization. Members with a diagnosis of major depression or dysthymia whose measure data are reportable using ECDS and had an outpatient encounter with a PHQ-9 score present in their record in the same assessment period as the encounter. The PHQ-9 assessment does not need to occur during a face-to-face encounter; for example, it can be completed over the telephone or through a web-based portal. Clinical Recommendation Statement Standardized instruments are useful in identifying meaningful change in clinical outcomes over time. Guidelines for adults recommend that providers establish and maintain regular follow-up with patients diagnosed with depression and use a standardized tool to track symptoms. 9 For adolescents, guidelines recommend systematic and regular tracking of treatment goals and outcomes, including assessing depressive symptoms. 10 The PHQ-9 tool assesses the nine DSM, Fourth Edition, Text Revision (DSM-IV-TR) criterion symptoms and effects on functioning, and has been shown to be highly accurate in discriminating patients with persistent major depression, partial remission and full remission. 9 Trangle, M., J. Gursky, R. Haight, J. Hardwig, T. Hinnenkamp, D. Kessler, N. Mack, M. Myszkowski. Institute for Clinical Systems Improvement. Adult Depression in Primary Care. Updated March Cheung, A.H., R.A. Zuckerbrot, P.S. Jensen, K. Ghalib, D. Laraque, R.E.K. Stein GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and Ongoing management. Pediatrics 120(5):e ICD-9-CM Diagnosis Major Depression and Dysthymia: , , ICD-10-CM Diagnosis Major Depression and Dysthymia: Use the appropriate code family: F CPT Depression Encounter: 90791, 90792, 90832, 90834, 90837, , 99078, , , , , , , , , , 99411, 99412, HCPCS Depression Encounter: G0155, G0176, G0177, G0409-G0411, G0463, G0502, G0503, G0507, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 LOINC PHQ Administered: , , , Depression Remission or Response for Adolescents and Adults (DRR): The percentage of members 12 years of age and older with a diagnosis of depression and an elevated PHQ-9 score, who had evidence of response or remission within 4 to 8 months of the elevated score. Four rates are reported: ECDS Coverage. The percentage of members 12 and older with a diagnosis of major depression or dysthymia for whom a health plan can receive any electronic clinical quality data. Follow-Up PHQ-9. The percentage of members who have a follow-up PHQ-9 score documented within the 4 to 8 months after the initial elevated PHQ-9 score. The PHQ-9 assessment does not need to occur during a face-to-face encounter; for example, it can be completed over the telephone or through a web-based portal. Depression Remission. The percentage of members who achieved remission within 4 to 8 months after the initial elevated PHQ-9 score. The score must be the most recent noted in the member s record during the depression follow-up period (i.e., if multiple PHQ-9 scores are present in the member record, the score closest to the end of the depression follow-up period is selected). Depression Response. The percentage of members who showed response within 4 to 8 months after the initial elevated PHQ-9 score. The score must be the most recent noted in the member s record during the depression follow-up period (i.e., if multiple PHQ-9 scores are present in the member record, the score closest to the end of the depression follow-up period is selected). ICD-9-CM Diagnosis Major Depression and Dysthymia: , , ICD-10-CM Diagnosis Major Depression and Dysthymia: Use the appropriate code family: F CPT Depression Encounter: 90791, 90792, 90832, 90834, 90837, , 99078, , , , , , , , , , 99411, 99412, HCPCS Depression Encounter: G0155, G0176, G0177, G0409-G0411, G0463, G0502, G0503, G0507, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 LOINC PHQ Administered: , , , HEDIS Pediatric Resource Guide 15

19 First Year Measure Unhealthy Alcohol Use Screening and Follow Up (ASF): The percentage of members 18 years of age and older who were screened for unhealthy alcohol use using a standardized tool and, if screened positive, received appropriate follow-up care. Unhealthy Alcohol Use Screening: The percentage of members who had a systematic screening for unhealthy alcohol use. Counseling or Other Follow-Up: The percentage of members who screened positive for unhealthy alcohol use and received brief counseling or other follow-up care within 2 months of a positive screening. ICD-10-CM Diagnosis Z71.41, Z71.89 Alcohol Counseling and Treatment: 99408, CPT Codes Alcohol Screening: 99408, CPTII: 3016F Alcohol Counseling and Treatment: G0396, G0397, G0443, H0005, H0007, H0015, H0016, H0022, H0050, H2035, H2036, T1006, T1012 HCPCS Alcohol Screening: G0396, G0397, G0442, H0001, H0049 Telehealth Modifier: 95, GT HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA) Source: HEDIS 2017 Volume 2 Technical Specifications Legal Disclaimer: Clinical practice guidelines made available by WellCare are informational in nature and are not a substitute for the professional medical judgment of treating physicians or other health care practitioners. These guidelines are based on information available at the time and may not be updated with the most current information available at subsequent times. Individuals should consult with their physician(s) regarding the appropriateness of care or treatment options to meet their specific needs or medical condition. Disclosure of clinical practice guidelines is not a guarantee of coverage. Members of WellCare health plans should consult their individual coverage documents for information regarding covered benefits. WellCare does not offer medical advice or provide medical care, and therefore cannot guarantee any results or outcomes. WellCare does not warrant or guarantee, and shall not be liable for any deficiencies in the information contained herein or for any inaccuracies or recommendations made by independent third parties from whom any of the information contained herein was obtained. The WellCare Group of Companies ~ Harmony Health Plan, Inc. ~ Easy Choice Health Plan, Inc. ~ WellCare of Connecticut, Inc. ~ WellCare of Florida, Inc. ~ WellCare of Georgia, Inc. ~ WellCare Health Insurance of Arizona, Inc. dba Ohana Health Plan, Inc. ~ WellCare Health Insurance Company of Kentucky, Inc. dba WellCare of Kentucky, Inc. ~ WellCare Health Plans of Kentucky, Inc. ~ WellCare Health Insurance of Arizona, Inc. ~ Missouri Care, Incorporated ~ WellCare of Nebraska, Inc. ~ WellCare Prescription Insurance, Inc. ~ WellCare Health Plans of New Jersey, Inc. ~ WellCare of New York, Inc. ~ WellCare of South Carolina, Inc. ~ WellCare of Texas, Inc HEDIS Pediatric Resource Guide 16

20 Recommendations for Preventive Pediatric Health Care Bright Futures/American Academy of Pediatrics Each child and family is unique; therefore, these Recommendations for Preventive Pediatric Health Care are designed for the care of children who are receiving competent parenting, have no manifestations of any important health problems, and are growing and developing in a satisfactory fashion. Developmental, psychosocial, and chronic disease issues for children and adolescents may require frequent counseling and treatment visits separate from preventive care visits. Additional visits also may become necessary if circumstances suggest variations from normal. These recommendations represent a consensus by the American Academy of Pediatrics (AAP) and Bright Futures. The AAP continues to emphasize the great importance of continuity of care in comprehensive health supervision and the need to avoid fragmentation of care. Refer to the specific guidance by age as listed in the Bright Futures Guidelines (Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017). The recommendations in this statement do not indicate an exclusive course of treatment or standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Copyright 2017 by the American Academy of Pediatrics, updated February No part of this statement may be reproduced in any form or by any means without prior written permission from the American Academy of Pediatrics except for one copy for personal use. INFANCY EARLY CHILDHOOD MIDDLE CHILDHOOD ADOLESCENCE AGE 1 Prenatal 2 Newborn d 4 By 1 mo 2 mo 4 mo 6 mo 9 mo 12 mo 15 mo 18 mo 24 mo 30 mo 3 y 4 y 5 y 6 y 7 y 8 y 9 y 10 y 11 y 12 y 13 y 14 y 15 y 16 y 17 y 18 y 19 y 20 y 21 y HISTORY Initial/Interval MEASUREMENTS Length/Height and Weight Head Circumference Weight for Length Body Mass Index 5 Blood Pressure 6 ê ê ê ê ê ê ê ê ê ê ê ê SENSORY SCREENING DEVELOPMENTAL/BEHAVIORAL HEALTH Vision 7 ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê Hearing 8 9 ê ê ê ê ê ê ê ê ê ê ê 10 Developmental Screening 11 Autism Spectrum Disorder Screening 12 Developmental Surveillance Psychosocial/Behavioral Assessment 13 Tobacco, Alcohol, or Drug Use Assessment 14 ê ê ê ê ê ê ê ê ê ê ê Depression Screening 15 Maternal Depression Screening 16 PHYSICAL EXAMINATION 17 PROCEDURES 18 Newborn Blood Newborn Bilirubin 21 Critical Congenital Heart Defect Immunization 23 Anemia 24 ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê Lead 25 ê ê or ê 26 ê or ê 26 ê ê ê ê Tuberculosis 27 ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê Dyslipidemia 28 ê ê ê ê ê ê ê ê ê Sexually Transmitted Infections 29 ê ê ê ê ê ê ê ê ê ê ê HIV 30 ê ê ê ê ê ê ê Cervical Dysplasia 31 ORAL HEALTH ê ê ê ê ê ê ê ê Fluoride Varnish 34 Fluoride Supplementation 35 ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ê ANTICIPATORY GUIDANCE 1. If a child comes under care for the first time at any point on the schedule, or if any items are not accomplished at the suggested age, the schedule should be brought up-to-date at the earliest possible time. 6. Blood pressure measurement in infants and children with specific risk conditions should be performed at visits before age 3 years. 12. Screening should occur per Identification and Evaluation of Children With Autism Spectrum Disorders ( 2. A prenatal visit is recommended for parents who are at high risk, for first-time parents, and for those who request a conference. The prenatal visit should include anticipatory guidance, pertinent medical history, and a discussion of benefits of breastfeeding and planned method of feeding, per The Prenatal Visit ( content/124/4/1227.full). 3. Newborns should have an evaluation after birth, and breastfeeding should be encouraged (and instruction and support should be offered). 4. Newborns should have an evaluation within 3 to 5 days of birth and within 48 to 72 hours after discharge from the hospital to include evaluation for feeding and jaundice. Breastfeeding newborns should receive formal breastfeeding evaluation, and their mothers should receive encouragement and instruction, as recommended in Breastfeeding and the Use of Human Milk ( Newborns discharged less than 48 hours after delivery must be examined within 48 hours of discharge, per Hospital Stay for Healthy Term Newborns ( 5. Screen, per Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report ( Supplement_4/S164.full). 7. A visual acuity screen is recommended at ages 4 and 5 years, as well as in cooperative 3-year-olds. Instrument-based screening may be used to assess risk at ages 12 and 24 months, in addition to the well visits at 3 through 5 years of age. See Visual System Assessment in Infants, Children, and Young Adults by Pediatricians ( org/content/137/1/e ) and Procedures for the Evaluation of the Visual System by Pediatricians ( 8. Confirm initial screen was completed, verify results, and follow up, as appropriate. Newborns should be screened, per Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs ( 9. Verify results as soon as possible, and follow up, as appropriate. 10. Screen with audiometry including 6,000 and 8,000 Hz high frequencies once between 11 and 14 years, once between 15 and 17 years, and once between 18 and 21 years. See The Sensitivity of Adolescent Hearing Screens Significantly Improves by Adding High Frequencies ( 11. See Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening ( 13. This assessment should be family centered and may include an assessment of child social-emotional health, caregiver depression, and social determinants of health. See Promoting Optimal Development: Screening for Behavioral and Emotional Problems ( and Poverty and Child Health in the United States ( 14. A recommended assessment tool is available at Recommended screening using the Patient Health Questionnaire (PHQ)-2 or other tools available in the GLAD-PC toolkit and at ScreeningChart.pdf. ) 16. Screening should occur per Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice ( 17. At each visit, age-appropriate physical examination is essential, with infant totally unclothed and older children undressed and suitably draped. See Use of Chaperones During the Physical Examination of the Pediatric Patient ( 18. These may be modified, depending on entry point into schedule and individual need. (continued) KEY: = to be performed ê = risk assessment to be performed with appropriate action to follow, if positive = range during which a service may be provided 2018 HEDIS Pediatric Resource Guide 17

21 (continued) 19. Confirm initial screen was accomplished, verify results, and follow up, as appropriate. The Recommended Uniform Newborn Screening Panel ( advisorycommittees/mchbadvisory/heritabledisorders/recommendedpanel/ uniformscreeningpanel.pdf), as determined by The Secretary s Advisory Committee on Heritable Disorders in Newborns and Children, and state newborn screening laws/regulations ( nbsdisorders.pdf) establish the criteria for and coverage of newborn screening procedures and programs. 20. Verify results as soon as possible, and follow up, as appropriate. 21. Confirm initial screening was accomplished, verify results, and follow up, as appropriate. See Hyperbilirubinemia in the Newborn Infant 35 Weeks Gestation: An Update With Clarifications ( content/124/4/1193). 22. Screening for critical congenital heart disease using pulse oximetry should be performed in newborns, after 24 hours of age, before discharge from the hospital, per Endorsement of Health and Human Services Recommendation for Pulse Oximetry Screening for Critical Congenital Heart Disease ( aappublications.org/content/129/1/190.full). 23. Schedules, per the AAP Committee on Infectious Diseases, are available at Every visit should be an opportunity to update and complete a child s immunizations. 24. See Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0 3 Years of Age) ( org/content/126/5/1040.full). 25. For children at risk of lead exposure, see Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention ( Final_Document_ pdf). 26. Perform risk assessments or screenings as appropriate, based on universal screening requirements for patients with Medicaid or in high prevalence areas. 27. Tuberculosis testing per recommendations of the AAP Committee on Infectious Diseases, published in the current edition of the AAP Red Book: Report of the Committee on Infectious Diseases. Testing should be performed on recognition of high-risk factors. 28. See Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents ( 29. Adolescents should be screened for sexually transmitted infections (STIs) per recommendations in the current edition of the AAP Red Book: Report of the Committee on Infectious Diseases. 30. Adolescents should be screened for HIV according to the USPSTF recommendations ( once between the ages of 15 and 18, making every effort to preserve confidentiality of the adolescent. Those at increased risk of HIV infection, including those who are sexually active, participate in injection drug use, or are being tested for other STIs, should be tested for HIV and reassessed annually. 31. See USPSTF recommendations ( uspstf/uspscerv.htm). Indications for pelvic examinations prior to age 21 are noted in Gynecologic Examination for Adolescents in the Pediatric Office Setting ( 32. Assess whether the child has a dental home. If no dental home is identified, perform a risk assessment ( and refer to a dental home. Recommend brushing with fluoride toothpaste in the proper dosage for age. See Maintaining and Improving the Oral Health of Young Children ( 33. Perform a risk assessment ( RiskAssessmentTool.pdf). See Maintaining and Improving the Oral Health of Young Children ( 34. See USPSTF recommendations ( uspstf/uspsdnch.htm). Once teeth are present, fluoride varnish may be applied to all children every 3 6 months in the primary care or dental office. Indications for fluoride use are noted in Fluoride Use in Caries Prevention in the Primary Care Setting ( 35. If primary water source is deficient in fluoride, consider oral fluoride supplementation. See Fluoride Use in Caries Prevention in the Primary Care Setting ( aappublications.org/content/134/3/626). Summary of Changes Made to the Bright Futures/AAP Recommendations for Preventive Pediatric Health Care (Periodicity Schedule) This schedule reflects changes approved in February 2017 and published in April For updates, visit For further information, see the Bright Futures Guidelines, 4th Edition, Evidence and Rationale chapter ( CHANGES MADE IN FEBRUARY 2017 HEARING Timing and follow-up of the screening recommendations for hearing during the infancy visits have been delineated. Adolescent risk assessment has changed to screening once during each time period. Footnote 8 has been updated to read as follows: Confirm initial screen was completed, verify results, and follow up, as appropriate. Newborns should be screened, per Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs ( Footnote 9 has been added to read as follows: Verify results as soon as possible, and follow up, as appropriate. Footnote 10 has been added to read as follows: Screen with audiometry including 6,000 and 8,000 Hz high frequencies once between 11 and 14 years, once between 15 and 17 years, and once between 18 and 21 years. See The Sensitivity of Adolescent Hearing Screens Significantly Improves by Adding High Frequencies ( PSYCHOSOCIAL/BEHAVIORAL ASSESSMENT Footnote 13 has been added to read as follows: This assessment should be family centered and may include an assessment of child social-emotional health, caregiver depression, and social determinants of health. See Promoting Optimal Development: Screening for Behavioral and Emotional Problems ( and Poverty and Child Health in the United States ( TOBACCO, ALCOHOL, OR DRUG USE ASSESSMENT The header was updated to be consistent with recommendations. DEPRESSION SCREENING Adolescent depression screening begins routinely at 12 years of age (to be consistent with recommendations of the US Preventive Services Task Force [USPSTF]). MATERNAL DEPRESSION SCREENING Screening for maternal depression at 1-, 2-, 4-, and 6-month visits has been added. Footnote 16 was added to read as follows: Screening should occur per Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice ( NEWBORN BLOOD Timing and follow-up of the newborn blood screening recommendations have been delineated. Footnote 19 has been updated to read as follows: Confirm initial screen was accomplished, verify results, and follow up, as appropriate. The Recommended Uniform Newborn Screening Panel ( heritabledisorders/recommendedpanel/uniformscreeningpanel.pdf), as determined by The Secretary s Advisory Committee on Heritable Disorders in Newborns and Children, and state newborn screening laws/regulations ( genes-r-us/files/nbsdisorders.pdf) establish the criteria for and coverage of newborn screening procedures and programs. Footnote 20 has been added to read as follows: Verify results as soon as possible, and follow up, as appropriate. NEWBORN BILIRUBIN Screening for bilirubin concentration at the newborn visit has been added. Footnote 21 has been added to read as follows: Confirm initial screening was accomplished, verify results, and follow up, as appropriate. See Hyperbilirubinemia in the Newborn Infant 35 Weeks Gestation: An Update With Clarifications ( DYSLIPIDEMIA Screening for dyslipidemia has been updated to occur once between 9 and 11 years of age, and once between 17 and 21 years of age (to be consistent with guidelines of the National Heart, Lung, and Blood Institute). SEXUALLY TRANSMITTED INFECTIONS Footnote 29 has been updated to read as follows: Adolescents should be screened for sexually transmitted infections (STIs) per recommendations in the current edition of the AAP Red Book: Report of the Committee on Infectious Diseases. HIV A subheading has been added for the HIV universal recommendation to avoid confusion with STIs selective screening recommendation. Screening for HIV has been updated to occur once between 15 and 18 years of age (to be consistent with recommendations of the USPSTF). Footnote 30 has been added to read as follows: Adolescents should be screened for HIV according to the USPSTF recommendations ( once between the ages of 15 and 18, making every effort to preserve confidentiality of the adolescent. Those at increased risk of HIV infection, including those who are sexually active, participate in injection drug use, or are being tested for other STIs, should be tested for HIV and reassessed annually. ORAL HEALTH Assessing for a dental home has been updated to occur at the 12-month and 18-month through 6-year visits. A subheading has been added for fluoride supplementation, with a recommendation from the 6-month through 12-month and 18-month through 16-year visits. Footnote 32 has been updated to read as follows: Assess whether the child has a dental home. If no dental home is identified, perform a risk assessment ( and refer to a dental home. Recommend brushing with fluoride toothpaste in the proper dosage for age. See Maintaining and Improving the Oral Health of Young Children ( Footnote 33 has been updated to read as follows: Perform a risk assessment ( RiskAssessmentTool.pdf). See Maintaining and Improving the Oral Health of Young Children ( content/134/6/1224). Footnote 35 has been added to read as follows: If primary water source is deficient in fluoride, consider oral fluoride supplementation. See Fluoride Use in Caries Prevention in the Primary Care Setting ( content/134/3/626) HEDIS Pediatric Resource Guide 18

22 Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, UNITED STATES, 2017 This schedule includes recommendations in effect as of January 1, Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement for detailed recommendations, available online at Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online ( or by telephone ( ). Suspected cases of vaccinepreventable diseases should be reported to the state or local health department. Additional information, including precautions and contraindications for vaccination, is available from CDC online ( contraindications.html) or by telephone (800-CDC-INFO [ ]). The Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger are approved by the Advisory Committee on Immunization Practices ( American Academy of Pediatrics ( American Academy of Family Physicians ( American College of Obstetricians and Gynecologists ( U.S. Department of Health and Human Services Centers for Disease Control and Prevention 2018 HEDIS Pediatric Resource Guide 19

23 Figure 1. Recommended immunization schedule for children and adolescents aged 18 years or younger United States, (FOR THOSE WHO FALL BEHIND OR START LATE, SEE THE CATCH-UP SCHEDULE [FIGURE 2]). These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the green bars in Figure 1. To determine minimum intervals between doses, see the catch-up schedule (Figure 2). School entry and adolescent vaccine age groups are shaded in gray. Vaccine Birth 1 mo 2 mos 4 mos 6 mos 9 mos 12 mos 15 mos 18 mos mos 2-3 yrs 4-6 yrs 7-10 yrs yrs yrs 16 yrs yrs Hepatitis B 1 (HepB) 1 st dose 2 nd dose 3 rd dose Rotavirus 2 (RV) RV1 (2-dose series); RV5 (3-dose series) 1 st dose 2 nd dose See footnote 2 Diphtheria, tetanus, & acellular pertussis 3 (DTaP: <7 yrs) 1 st dose 2 nd dose 3 rd dose 4 th dose 5 th dose Haemophilus influenzae type b 4 (Hib) 1 st dose 2 nd dose See footnote 4 3 rd or 4 th dose, See footnote 4 Pneumococcal conjugate 5 (PCV13) 1 st dose 2 nd dose 3 rd dose 4 th dose Inactivated poliovirus 6 (IPV: <18 yrs) 1 st dose 2 nd dose 3 rd dose 4 th dose Influenza 7 (IIV) Annual vaccination (IIV) 1 or 2 doses Annual vaccination (IIV) 1 dose only Measles, mumps, rubella 8 (MMR) See footnote 8 1 st dose 2 nd dose Varicella 9 (VAR) 1 st dose 2 nd dose Hepatitis A 10 (HepA) 2-dose series, See footnote 10 Meningococcal 11 (Hib-MenCY >6 weeks; MenACWY-D >9 mos; MenACWY-CRM 2 mos) See footnote 11 1 st dose 2 nd dose Tetanus, diphtheria, & acellular pertussis 12 (Tdap: >7 yrs) Tdap Human papillomavirus 13 (HPV) See footnote 13 Meningococcal B 11 See footnote 11 Pneumococcal polysaccharide 5 (PPSV23) See footnote 5 Range of recommended ages for all children Range of recommended ages for catch-up immunization Range of recommended ages for certain high-risk groups NOTE: The above recommendations must be read along with the footnotes of this schedule. Range of recommended ages for non-high-risk groups that may receive vaccine, subject to individual clinical decision making No recommendation 2018 HEDIS Pediatric Resource Guide 20

24 FIGURE 2. Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind United States, The figure below provides catch-up schedules and minimum intervals between doses for children whose vaccinations have been delayed. A vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Use the section appropriate for the child s age. Always use this table in conjunction with Figure 1 and the footnotes that follow. Children age 4 months through 6 years Vaccine Minimum Age for Dose 1 Hepatitis B 1 Birth 4 weeks Rotavirus 2 6 weeks 4 weeks 4 weeks 2 Minimum Interval Between Doses Dose 1 to Dose 2 Dose 2 to Dose 3 Dose 3 to Dose 4 Dose 4 to Dose 5 8 weeks and at least 16 weeks after first dose. Minimum age for the final dose is 24 weeks. Diphtheria, tetanus, and acellular pertussis 3 6 weeks 4 weeks 4 weeks 6 months 6 months 3 Haemophilus influenzae type b 4 6 weeks Pneumococcal 5 6 weeks 4 weeks if first dose was administered before the 1 st birthday. 8 weeks (as final dose) if first dose was administered at age 12 through 14 months. No further doses needed if first dose was administered at age 15 months or older. 4 weeks if first dose administered before the 1 st birthday. 8 weeks (as final dose for healthy children) if first dose was administered at the 1 st birthday or after. No further doses needed for healthy children if first dose was administered at age 24 months or older. 4 weeks 4 if current age is younger than 12 months and first dose was administered at younger than age 7 months, and at least 1 previous dose was PRP-T (ActHib, Pentacel, Hiberix) or unknown. 8 weeks and age 12 through 59 months (as final dose) 4 if current age is younger than 12 months and first dose was administered at age 7 through 11 months; OR if current age is 12 through 59 months and first dose was administered before the 1 st birthday, and second dose administered at younger than 15 months; OR if both doses were PRP-OMP (PedvaxHIB; Comvax) and were administered before the 1 st birthday. No further doses needed if previous dose was administered at age 15 months or older. 4 weeks if current age is younger than 12 months and previous dose given at <7 months old. 8 weeks (as final dose for healthy children) if previous dose given between 7-11 months (wait until at least 12 months old); OR if current age is 12 months or older and at least 1 dose was given before age 12 months. No further doses needed for healthy children if previous dose administered at age 24 months or older. 8 weeks (as final dose) This dose only necessary for children age 12 through 59 months who received 3 doses before the 1 st birthday. 8 weeks (as final dose) This dose only necessary for children aged 12 through 59 months who received 3 doses before age 12 months or for children at high risk who received 3 doses at any age. Inactivated poliovirus 6 6 weeks 4 weeks 6 4 weeks 6 6 months 6 (minimum age 4 years for final dose). Measles, mumps, rubella 8 12 months 4 weeks Varicella 9 12 months 3 months Hepatitis A months 6 months Meningococcal 11 (Hib-MenCY 6 weeks; MenACWY-D 9 mos; 6 weeks 8 weeks 11 See footnote 11 See footnote 11 MenACWY-CRM 2 mos) Children and adolescents age 7 through 18 years Meningococcal 11 (MenACWY-D 9 mos; MenACWY-CRM 2 mos) Not Applicable (N/A) 8 weeks 11 Tetanus, diphtheria; tetanus, diphtheria, and 7 years 12 4 weeks acellular pertussis 12 4 weeks if first dose of DTaP/DT was administered before the 1 st birthday. 6 months (as final dose) if first dose of DTaP/DT or Tdap/Td was administered at or after the 1 st birthday. Human papillomavirus 13 9 years Routine dosing intervals are recommended months if first dose of DTaP/DT was administered before the 1 st birthday. Hepatitis A 10 N/A 6 months Hepatitis B 1 N/A 4 weeks 8 weeks and at least 16 weeks after first dose. Inactivated poliovirus 6 N/A 4 weeks 4 weeks 6 6 months 6 Measles, mumps, rubella 8 N/A 4 weeks Varicella 9 N/A 3 months if younger than age 13 years. 4 weeks if age 13 years or older. NOTE: The above recommendations must be read along with the footnotes of this schedule HEDIS Pediatric Resource Guide 21

25 Figure 3. Vaccines that might be indicated for children and adolescents aged 18 years or younger based on medical indications VACCINE INDICATION Pregnancy Immunocompromised status (excluding HIV infection) HIV infection CD4+ count (cells/μl) <15% of total CD4 cell count 15% of total CD4 cell count Kidney failure, endstage renal disease, on hemodialysis Heart disease, chronic lung disease CSF leaks/ cochlear implants Asplenia and persistent complement component deficiencies Chronic liver disease Diabetes Hepatitis B 1 Rotavirus 2 SCID* Diphtheria, tetanus, & acellular pertussis 3 (DTaP) Haemophilus influenzae type b 4 Pneumococcal conjugate 5 Inactivated poliovirus 6 Influenza 7 Measles, mumps, rubella 8 Varicella 9 Hepatitis A 10 Meningococcal ACWY 11 Tetanus, diphtheria, & acellular pertussis 1 2 (Tdap) Human papillomavirus 13 Meningococcal B 11 Pneumococcal polysaccharide 5 Vaccination according to the routine schedule recommended Recommended for persons with an additional risk factor for which the vaccine would be indicated Vaccination is recommended, and additional doses may be necessary based on medical condition. See footnotes. No recommendation Contraindicated Precaution for vaccination *Severe Combined Immunodeficiency NOTE: The above recommendations must be read along with the footnotes of this schedule HEDIS Pediatric Resource Guide 22

26 Footnotes Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, UNITED STATES, 2017 For further guidance on the use of the vaccines mentioned below, see: For vaccine recommendations for persons 19 years of age and older, see the Adult Immunization Schedule. Additional information For contraindications and precautions to use of a vaccine and for additional information regarding that vaccine, vaccination providers should consult the ACIP General Recommendations on Immunization and the relevant ACIP statement, available online at For purposes of calculating intervals between doses, 4 weeks = 28 days. Intervals of 4 months or greater are determined by calendar months. Vaccine doses administered 4 days before the minimum interval are considered valid. Doses of any vaccine administered 5 days earlier than the minimum interval or minimum age should not be counted as valid doses and should be repeated as age-appropriate. The repeat dose should be spaced after the invalid dose by the recommended minimum interval. For further details, see Table 1, Recommended and minimum ages and intervals between vaccine doses, in MMWR, General Recommendations on Immunization and Reports / Vol. 60 / No. 2, available online at mmwr/pdf/rr/rr6002.pdf. Information on travel vaccine requirements and recommendations is available at wwwnc.cdc.gov/travel/. For vaccination of persons with primary and secondary immunodeficiencies, see Table 13, Vaccination of persons with primary and secondary immunodeficiencies, in General Recommendations on Immunization (ACIP), available at and Immunization in Special Clinical Circumstances, (American Academy of Pedatrics). In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2015: The National Vaccine Injury Compensation Program (VICP) is a no-fault alternative to the traditional legal system for resolving vaccine injury petitions. Created by the National Childhood Vaccine Injury Act of 1986, it provides compensation to people found to be injured by certain vaccines. All vaccines within the recommended childhood immunization schedule are covered by VICP except for pneumococcal polysaccharide vaccine (PPSV). For more information; see 1. Hepatitis B (HepB) vaccine. (Minimum age: birth) Routine vaccination: At birth: Administer monovalent HepB vaccine to all newborns within 24 hours of birth. For infants born to hepatitis B surface antigen (HBsAg)- positive mothers, administer HepB vaccine and 0.5 ml of hepatitis B immune globulin (HBIG) within 12 hours of birth. These infants should be tested for HBsAg and antibody to HBsAg (anti-hbs) at age 9 through 12 months (preferably at the next well-child visit) or 1 to 2 months after completion of the HepB series if the series was delayed. If mother s HBsAg status is unknown, within 12 hours of birth, administer HepB vaccine regardless of birth weight. For infants weighing less than 2,000 grams, administer HBIG in addition to HepB vaccine within 12 hours of birth. Determine mother s HBsAg status as soon as possible and, if mother is HBsAg-positive, also administer HBIG to infants weighing 2,000 grams or more as soon as possible, but no later than age 7 days. Doses following the birth dose: The second dose should be administered at age 1 or 2 months. Monovalent HepB vaccine should be used for doses administered before age 6 weeks. Infants who did not receive a birth dose should receive 3 doses of a HepB-containing vaccine on a schedule of 0, 1 to 2 months, and 6 months, starting as soon as feasible (see figure 2). Administer the second dose 1 to 2 months after the first dose (minimum interval of 4 weeks); administer the third dose at least 8 weeks after the second dose AND at least 16 weeks after the first dose. The final (third or fourth) dose in the HepB vaccine series should be administered no earlier than age 24 weeks. Administration of a total of 4 doses of HepB vaccine is permitted when a combination vaccine containing HepB is administered after the birth dose. Catch-up vaccination: Unvaccinated persons should complete a 3-dose series. A 2-dose series (doses separated by at least 4 months) of adult formulation Recombivax HB is licensed for use in children aged 11 through 15 years. For other catch-up guidance, see Figure Rotavirus (RV) vaccines. (Minimum age: 6 weeks for both RV1 [Rotarix] and RV5 [RotaTeq]) Routine vaccination: Administer a series of RV vaccine to all infants as follows: 1. If Rotarix is used, administer a 2-dose series at ages 2 and 4 months. 2. If RotaTeq is used, administer a 3-dose series at ages 2, 4, and 6 months. 3. If any dose in the series was RotaTeq or vaccine product is unknown for any dose in the series, a total of 3 doses of RV vaccine should be administered. Catch-up vaccination: The maximum age for the first dose in the series is 14 weeks, 6 days; vaccination should not be initiated for infants aged 15 weeks, 0 days, or older. The maximum age for the final dose in the series is 8 months, 0 days. For other catch-up guidance, see Figure Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks. Exception: DTaP- IPV [Kinrix, Quadracel]: 4 years) Routine vaccination: Administer a 5-dose series of DTaP vaccine at ages 2, 4, 6, 15 through 18 months, and 4 through 6 years. The fourth dose may be administered as early as age 12 months, provided at least 6 months have elapsed since the third dose. Inadvertent administration of fourth DTaP dose early: If the fourth dose of DTaP was administered at least 4 months after the third dose of DTaP and the child was 12 months of age or older, it does not need to be repeated. Catch-up vaccination: The fifth dose of DTaP vaccine is not necessary if the fourth dose was administered at age 4 years or older. For other catch-up guidance, see Figure Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks for PRP-T [ActHIB, DTaP-IPV/Hib (Pentacel), Hiberix, and Hib-MenCY (MenHibrix)], PRP- OMP [PedvaxHIB]) Routine vaccination: Administer a 2- or 3-dose Hib vaccine primary series and a booster dose (dose 3 or 4, depending on vaccine used in primary series) at age 12 through 15 months to complete a full Hib vaccine series. The primary series with ActHIB, MenHibrix, Hiberix, or Pentacel consists of 3 doses and should be administered at ages 2, 4, and 6 months. The primary series with PedvaxHIB consists of 2 doses and should be administered at ages 2 and 4 months; a dose at age 6 months is not indicated. One booster dose (dose 3 or 4, depending on vaccine used in primary series) of any Hib vaccine should be administered at age 12 through 15 months. For recommendations on the use of MenHibrix in patients at increased risk for meningococcal disease, refer to the meningococcal vaccine footnotes and also to MMWR February 28, 2014 / 63(RR01):1-13, available at gov/mmwr/pdf/rr/rr6301.pdf HEDIS Pediatric Resource Guide 23

27 Catch-up vaccination: If dose 1 was administered at ages 12 through 14 months, administer a second (final) dose at least 8 weeks after dose 1, regardless of Hib vaccine used in the primary series. If both doses were PRP-OMP (PedvaxHIB or COMVAX) and were administered before the first birthday, the third (and final) dose should be administered at age 12 through 59 months and at least 8 weeks after the second dose. If the first dose was administered at age 7 through 11 months, administer the second dose at least 4 weeks later and a third (and final) dose at age 12 through 15 months or 8 weeks after second dose, whichever is later. If first dose is administered before the first birthday and second dose administered at younger than 15 months, a third (and final) dose should be administered 8 weeks later. For unvaccinated children aged months, administer only 1 dose. For other catch-up guidance, see Figure 2. For catch-up guidance related to MenHibrix, see the meningococcal vaccine footnotes and also MMWR February 28, 2014 / 63(RR01):1-13, available at rr6301.pdf. Vaccination of persons with high-risk conditions: Children aged 12 through 59 months who are at increased risk for Hib disease, including chemotherapy recipients and those with anatomic or functional asplenia (including sickle cell disease), human immunodeficiency virus (HIV ) infection, immunoglobulin deficiency, or early component complement deficiency, who have received either no doses or only 1 dose of Hib vaccine before age 12 months, should receive 2 additional doses of Hib vaccine, 8 weeks apart; children who received 2 or more doses of Hib vaccine before age 12 months should receive 1 additional dose. For patients younger than age 5 years undergoing chemotherapy or radiation treatment who received a Hib vaccine dose(s) within 14 days of starting therapy or during therapy, repeat the dose(s) at least 3 months following therapy completion. Recipients of hematopoietic stem cell transplant (HSCT) should be revaccinated with a 3-dose regimen of Hib vaccine starting 6 to 12 months after successful transplant, regardless of vaccination history; doses should be administered at least 4 weeks apart. A single dose of any Hib-containing vaccine should be administered to unimmunized* children and adolescents 15 months of age and older undergoing an elective splenectomy; if possible, vaccine should be administered at least 14 days before procedure. Hib vaccine is not routinely recommended for patients 5 years or older. However, 1 dose of Hib vaccine should be administered to unimmunized* persons aged 5 years or older who have anatomic or functional asplenia (including sickle cell disease) and unimmunized* persons 5 through 18 years of age with HIV infection. * Patients who have not received a primary series and booster dose or at least 1 dose of Hib vaccine after 14 months of age are considered unimmunized. 5. Pneumococcal vaccines. (Minimum age: 6 weeks for PCV13, 2 years for PPSV23) Routine vaccination with PCV13: Administer a 4-dose series of PCV13 at ages 2, 4, and 6 months and at age 12 through 15 months. Catch-up vaccination with PCV13: Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not completely vaccinated for their age. For other catch-up guidance, see Figure 2. Vaccination of persons with high-risk conditions with PCV13 and PPSV23: All recommended PCV13 doses should be administered prior to PPSV23 vaccination if possible. For children aged 2 through 5 years with any of the following conditions: chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma if treated with high-dose oral corticosteroid therapy); diabetes mellitus; cerebrospinal fluid leak; cochlear implant; sickle cell disease and other hemoglobinopathies; anatomic or functional asplenia; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; solid organ transplantation; or congenital immunodeficiency: 1. Administer 1 dose of PCV13 if any incomplete schedule of 3 doses of PCV13 was received previously. 2. Administer 2 doses of PCV13 at least 8 weeks apart if unvaccinated or any incomplete schedule of fewer than 3 doses of PCV13 was received previously. 3. The minimum interval between doses of PCV13 is 8 weeks. 4. For children with no history of PPSV23 vaccination, administer PPSV23 at least 8 weeks after the most recent dose of PCV13. For children aged 6 through 18 years who have cerebrospinal fluid leak; cochlear implant; sickle cell disease and other hemoglobinopathies; anatomic or functional asplenia; congenital or acquired immunodeficiencies; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; generalized malignancy; solid organ transplantation; or multiple myeloma: For further guidance on the use of the vaccines mentioned below, see: 1. If neither PCV13 nor PPSV23 has been received previously, administer 1 dose of PCV13 now and 1 dose of PPSV23 at least 8 weeks later. 2. If PCV13 has been received previously but PPSV23 has not, administer 1 dose of PPSV23 at least 8 weeks after the most recent dose of PCV If PPSV23 has been received but PCV13 has not, administer 1 dose of PCV13 at least 8 weeks after the most recent dose of PPSV23. For children aged 6 through 18 years with chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure), chronic lung disease (including asthma if treated with high-dose oral corticosteroid therapy), diabetes mellitus, alcoholism, or chronic liver disease, who have not received PPSV23, administer 1 dose of PPSV23. If PCV13 has been received previously, then PPSV23 should be administered at least 8 weeks after any prior PCV13 dose. A single revaccination with PPSV23 should be administered 5 years after the first dose to children with sickle cell disease or other hemoglobinopathies; anatomic or functional asplenia; congenital or acquired immunodeficiencies; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; generalized malignancy; solid organ transplantation; or multiple myeloma. 6. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks) Routine vaccination: Administer a 4-dose series of IPV at ages 2, 4, 6 through 18 months, and 4 through 6 years. The final dose in the series should be administered on or after the fourth birthday and at least 6 months after the previous dose. Catch-up vaccination: In the first 6 months of life, minimum age and minimum intervals are only recommended if the person is at risk of imminent exposure to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak). If 4 or more doses are administered before age 4 years, an additional dose should be administered at age 4 through 6 years and at least 6 months after the previous dose. A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6 months after the previous dose. If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child s current age. If only OPV was administered, and all doses were given prior to age 4 years, 1 dose of IPV should be given at 4 years or older, at least 4 weeks after the last OPV dose. IPV is not routinely recommended for U.S. residents aged 18 years or older HEDIS Pediatric Resource Guide 24

28 For further guidance on the use of the vaccines mentioned below, see: For other catch-up guidance, see Figure Influenza vaccines. (Minimum age: 6 months for inactivated influenza vaccine [IIV], 18 years for recombinant influenza vaccine [RIV]) Routine vaccination: Administer influenza vaccine annually to all children beginning at age 6 months. For the season, use of live attenuated influenza vaccine (LAIV) is not recommended. For children aged 6 months through 8 years: For the season, administer 2 doses (separated by at least 4 weeks) to children who are receiving influenza vaccine for the first time or who have not previously received 2 doses of trivalent or quadrivalent influenza vaccine before July 1, For additional guidance, follow dosing guidelines in the ACIP influenza vaccine recommendations (see MMWR August 26, 2016;65(5):1-54, available at For the season, follow dosing guidelines in the ACIP influenza vaccine recommendations. For persons aged 9 years and older: Administer 1 dose. 8. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months for routine vaccination) Routine vaccination: Administer a 2-dose series of MMR vaccine at ages 12 through 15 months and 4 through 6 years. The second dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose. Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the United States for international travel. These children should be revaccinated with 2 doses of MMR vaccine, the first at age 12 through 15 months (12 months if the child remains in an area where disease risk is high), and the second dose at least 4 weeks later. Administer 2 doses of MMR vaccine to children aged 12 months and older before departure from the United States for international travel. The first dose should be administered on or after age 12 months and the second dose at least 4 weeks later. Catch-up vaccination: Ensure that all school-aged children and adolescents have had 2 doses of MMR vaccine; the minimum interval between the 2 doses is 4 weeks. 9. Varicella (VAR) vaccine. (Minimum age: 12 months) Routine vaccination: Administer a 2-dose series of VAR vaccine at ages 12 through 15 months and 4 through 6 years. The second dose may be administered before age 4 years, provided at least 3 months have elapsed since the first dose. If the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid. Catch-up vaccination: Ensure that all persons aged 7 through 18 years without evidence of immunity (see MMWR 2007;56[No. RR-4], available at ) have 2 doses of varicella vaccine. For children aged 7 through 12 years, the recommended minimum interval between doses is 3 months (if the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid); for persons aged 13 years and older, the minimum interval between doses is 4 weeks. 10. Hepatitis A (HepA) vaccine. (Minimum age: 12 months) Routine vaccination: Initiate the 2-dose HepA vaccine series at ages 12 through 23 months; separate the 2 doses by 6 to 18 months. Children who have received 1 dose of HepA vaccine before age 24 months should receive a second dose 6 to 18 months after the first dose. For any person aged 2 years and older who has not already received the HepA vaccine series, 2 doses of HepA vaccine separated by 6 to 18 months may be administered if immunity against hepatitis A virus infection is desired. Catch-up vaccination: The minimum interval between the 2 doses is 6 months. Special populations: Administer 2 doses of HepA vaccine at least 6 months apart to previously unvaccinated persons who live in areas where vaccination programs target older children, or who are at increased risk for infection. This includes persons traveling to or working in countries that have high or intermediate endemicity of infection; men having sex with men; users of injection and non-injection illicit drugs; persons who work with HAV-infected primates or with HAV in a research laboratory; persons with clotting-factor disorders; persons with chronic liver disease; and persons who anticipate close, personal contact (e.g., household or regular babysitting) with an international adoptee during the first 60 days after arrival in the United States from a country with high or intermediate endemicity. The first dose should be administered as soon as the adoption is planned, ideally, 2 or more weeks before the arrival of the adoptee. 11. Meningococcal vaccines. (Minimum age: 6 weeks for Hib-MenCY [MenHibrix], 2 months for MenACWY-CRM [Menveo], 9 months for MenACWY-D [Menactra], 10 years for serogroup B meningococcal [MenB] vaccines: MenB- 4C [Bexsero] and MenB-FHbp [Trumenba]) Routine vaccination: Administer a single dose of Menactra or Menveo vaccine at age 11 through 12 years, with a booster dose at age 16 years. For children aged 2 months through 18 years with highrisk conditions, see Meningococcal conjugate ACWY vaccination of persons with high-risk conditions and other persons at increased risk and Meningococcal B vaccination of persons with high-risk conditions and other persons at increased risk of disease below. Catch-up vaccination: Administer Menactra or Menveo vaccine at age 13 through 18 years if not previously vaccinated. If the first dose is administered at age 13 through 15 years, a booster dose should be administered at age 16 through 18 years, with a minimum interval of at least 8 weeks between doses. If the first dose is administered at age 16 years or older, a booster dose is not needed. For other catch-up guidance, see Figure 2. Clinical discretion: Young adults aged 16 through 23 years (preferred age range is 16 through 18 years) who are not at increased risk for meningococcal disease may be vaccinated with a 2-dose series of either Bexsero (0, 1 month) or Trumenba (0, 6 months) vaccine to provide short-term protection against most strains of serogroup B meningococcal disease. The two MenB vaccines are not interchangeable; the same vaccine product must be used for all doses. If the second dose of Trumenba is given at an interval of <6 months, a third dose should be given at least 6 months after the first dose; the minimum interval between the second and third doses is 4 weeks. Meningococcal conjugate ACWY vaccination of persons with high-risk conditions and other persons at increased risk: Children with anatomic or functional asplenia (including sickle cell disease), children with HIV infection, or children with persistent complement component deficiency (includes persons with inherited or chronic deficiencies in C3, C5-9, properdin, factor D, factor H, or taking eculizumab [Soliris]): Menveo ɱ Children who initiate vaccination at 8 weeks. Administer doses at ages 2, 4, 6, and 12 months. ɱ Unvaccinated children who initiate vaccination at 7 through 23 months. Administer 2 primary doses, with the second dose at least 12 weeks after the first dose AND after the first birthday. ɱ Children 24 months and older who have not received a complete series. Administer 2 primary doses at least 8 weeks apart. MenHibrix ɱ Children who initiate vaccination at 6 weeks. Administer doses at ages 2, 4, 6, and 12 through 15 months. ɱ If the first dose of MenHibrix is given at or after age 12 months, a total of 2 doses should be given at least 8 weeks apart to ensure protection against serogroups C and Y meningococcal disease HEDIS Pediatric Resource Guide 25

29 For further guidance on the use of the vaccines mentioned below, see: Menactra ɱ Children with anatomic or functional asplenia or HIV infection ʲ Children 24 months and older who have not received a complete series. Administer 2 primary doses at least 8 weeks apart. If Menactra is administered to a child with asplenia (including sickle cell disease) or HIV infection, do not administer Menactra until age 2 years and at least 4 weeks after the completion of all PCV13 doses. ɱ Children with persistent complement component deficiency ʲ Children 9 through 23 months. Administer 2 primary doses at least 12 weeks apart. ʲ Children 24 months and older who have not received a complete series. Administer 2 primary doses at least 8 weeks apart. ɱ All high-risk children ʲ If Menactra is to be administered to a child at high risk for meningococcal disease, it is recommended that Menactra be given either before or at the same time as DTaP. Meningococcal B vaccination of persons with high-risk conditions and other persons at increased risk of disease: Children with anatomic or functional asplenia (including sickle cell disease) or children with persistent complement component deficiency (includes persons with inherited or chronic deficiencies in C3, C5-9, properdin, factor D, factor H, or taking eculizumab [Soliris]): Bexsero or Trumenba ɱ Persons 10 years or older who have not received a complete series. Administer a 2-dose series of Bexsero, with doses at least 1 month apart, or a 3-dose series of Trumenba, with the second dose at least 1 2 months after the first and the third dose at least 6 months after the first. The two MenB vaccines are not interchangeable; the same vaccine product must be used for all doses. For children who travel to or reside in countries in which meningococcal disease is hyperendemic or epidemic, including countries in the African meningitis belt or the Hajj: Administer an age-appropriate formulation and series of Menactra or Menveo for protection against serogroups A and W meningococcal disease. Prior receipt of MenHibrix is not sufficient for children traveling to the meningitis belt or the Hajj because it does not contain serogroups A or W. For children at risk during an outbreak attributable to a vaccine serogroup: For serogroup A, C, W, or Y: Administer or complete an age- and formulation-appropriate series of MenHibrix, Menactra, or Menveo. For serogroup B: Administer a 2-dose series of Bexsero, with doses at least 1 month apart, or a 3-dose series of Trumenba, with the second dose at least 1-2 months after the first and the third dose at least 6 months after the first. The two MenB vaccines are not interchangeable; the same vaccine product must be used for all doses. For MenACWY booster doses among persons with high-risk conditions, refer to MMWR 2013;62(RR02):1-22, at www. cdc.gov/mmwr/preview/mmwrhtml/rr6202a1.htm, MMWR June 20, 2014 / 63(24): , at pdf/wk/mm6324.pdf, and MMWR November 4, 2016 / 65(43): , at pdfs/mm6543a3.pdf. For other catch-up recommendations for these persons and complete information on use of meningococcal vaccines, including guidance related to vaccination of persons at increased risk of infection, see meningococcal MMWR publications, available at: Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. (Minimum age: 10 years for both Boostrix and Adacel) Routine vaccination: Administer 1 dose of Tdap vaccine to all adolescents aged 11 through 12 years. Tdap may be administered regardless of the interval since the last tetanus and diphtheria toxoid-containing vaccine. Administer 1 dose of Tdap vaccine to pregnant adolescents during each pregnancy (preferably during the early part of gestational weeks 27 through 36), regardless of time since prior Td or Tdap vaccination. Catch-up vaccination: Persons aged 7 years and older who are not fully immunized with DTaP vaccine should receive Tdap vaccine as 1 dose (preferably the first) in the catch-up series; if additional doses are needed, use Td vaccine. For children 7 through 10 years who receive a dose of Tdap as part of the catch-up series, an adolescent Tdap vaccine dose at age 11 through 12 years may be administered. Persons aged 11 through 18 years who have not received Tdap vaccine should receive a dose, followed by tetanus and diphtheria toxoids (Td) booster doses every 10 years thereafter. Inadvertent doses of DTaP vaccine: If administered inadvertently to a child aged 7 through 10 years, the dose may count as part of the catch-up series. This dose may count as the adolescent Tdap dose, or the child may receive a Tdap booster dose at age 11 through 12 years. If administered inadvertently to an adolescent aged 11 through 18 years, the dose should be counted as the adolescent Tdap booster. For other catch-up guidance, see Figure Human papillomavirus (HPV) vaccines. (Minimum age: 9 years for 4vHPV [Gardasil] and 9vHPV [Gardasil 9]) Routine and catch-up vaccination: Administer a 2-dose series of HPV vaccine on a schedule of 0, 6-12 months to all adolescents aged 11 or 12 years. The vaccination series can start at age 9 years. Administer HPV vaccine to all adolescents through age 18 years who were not previously adequately vaccinated. The number of recommended doses is based on age at administration of the first dose. For persons initiating vaccination before age 15, the recommended immunization schedule is 2 doses of HPV vaccine at 0, 6-12 months. For persons initiating vaccination at age 15 years or older, the recommended immunization schedule is 3 doses of HPV vaccine at 0, 1 2, 6 months. A vaccine dose administered at a shorter interval should be readministered at the recommended interval. In a 2-dose schedule of HPV vaccine, the minimum interval is 5 months between the first and second dose. If the second dose is administered at a shorter interval, a third dose should be administered a minimum of 12 weeks after the second dose and a minimum of 5 months after the first dose. In a 3-dose schedule of HPV vaccine, the minimum intervals are 4 weeks between the first and second dose, 12 weeks between the second and third dose, and 5 months between the first and third dose. If a vaccine dose is administered at a shorter interval, it should be readministered after another minimum interval has been met since the most recent dose. Special populations: For children with history of sexual abuse or assault, administer HPV vaccine beginning at age 9 years. Immunocompromised persons*, including those with human immunodeficiency virus (HIV) infection, should receive a 3-dose series at 0, 1 2, and 6 months, regardless of age at vaccine initiation. Note: HPV vaccination is not recommended during pregnancy, although there is no evidence that the vaccine poses harm. If a woman is found to be pregnant after initiating the vaccination series, no intervention is needed; the remaining vaccine doses should be delayed until after the pregnancy. Pregnancy testing is not needed before HPV vaccination. *See MMWR December 16, 2016;65(49): , available at CS C 2018 HEDIS Pediatric Resource Guide 26

30 Pediatric HEDIS Measures This document outlines the required medical record documentation needed to demonstrate compliance with pediatric HEDIS measures. This information is from 2018 Technical Specifications for Health Plans. Measure Description Required Documentation Key Notes Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) Members 3 17 years of age who had an outpatient visit with a PCP or OB/GYN and who had the following in the current year: BMI percentile documentation Counseling for nutrition Counseling for physical activity BMI percentile or BMI percentile plotted on an age-growth chart for members 3-17 years old. Discussion of current nutrition and physical activity behaviors (eating habits, dieting behaviors, exercise routine, participation in sports, exam for sports participation), checklist indicating nutrition and physical activity was addressed, counseling or referral for nutrition education and physical activity, member received educational materials on nutrition and physical activity, anticipatory guidance for nutrition and physical activity. For nutritional counseling: Services that do not count: Notes of health education, or anticipatory guidance without specific mention of nutrition; counseling/education before or after the measurement year; no notes for counseling/education on nutrition, appetite and diet; or, a physical exam finding alone (e.g., well-nourished) because it doesn t indicate counseling for nutrition. For physical activity counseling: Services that do not count: Notes of cleared for gym class, health education, anticipatory guidance, or computer or TV time or anticipatory guidance related solely to safety without specific mention of physical activity; counseling/education before or after the measurement year; or, no notes for counseling/education on physical activity. For both nutritional and physical activity counseling: Services may be rendered during a visit other than a well-child visit but services specific to the assessment or treatment of an acute or chronic condition do not count toward the Counseling for Nutrition and Counseling for Physical Activity indicators. For example, notation that a member has decreased appetite as a result of an acute or chronic condition or notation that a member has exercise-induced asthma. Childhood Immunization Status (CIS) Children 2 years of age who had the following vaccines by their 2 nd birthday: 4 DTaP 3 IPV 1 MMR 3 HiB 3 Hepatitis B 1 VZV 1 Hepatitis A 2 Influenza 4 Pneumococcal conjugate Rotavirus 2 doses of the 2-dose vaccine, or 1 dose of the 2-dose vaccine and 2 doses of the 3-dose vaccine, or 3 doses of the 3-dose vaccine A note indicating the name of the specific antigen and the date of the immunization, or a certificate of immunization prepared by a health care provider and contains the dates and types of immunizations given. For rotavirus, vaccine must be on different dates of service. A note that says, Immunizations are up to date does not count. Document history of specific disease, anaphylactic reactions, or contraindications for a specific vaccine. This measure follows CDC and ACIP guidelines for immunizations. Changes to the guidelines (e.g., new vaccine recommendations) are implemented after 3 years to account for the measure s look-back period and to allow the industry time to adapt HEDIS Pediatric Resource Guide 27

31 Measure Description Required Documentation Key Notes Immunizations for Adolescents (IMA) The percentage of adolescents 13 years of age who had one dose of meningococcal conjugate vaccine, one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine and have completed the human papillomavirus (HPV) vaccine series by their 13 th birthday. The measure calculates a rate for each vaccine and two combination rates. A note indicating the name of the specific antigen and the date of the immunization, or a certificate of immunization prepared by a health care provider and contains the dates and types of immunizations given. A note that says Immunizations are up to date does not count. This measure follows CDC and ACIP guidelines for immunizations. Changes to the guidelines (e.g., new vaccine recommendations) are implemented after 3 years to account for the measure s look-back period and to allow the industry time to adapt. Lead Screening in Children (LSC) Percentage of children who are turning 2 years of age who had one or more capillary or venous lead blood test for lead poisoning. Test must be performed by their 2 nd birthday. A note indicating the date the test was performed, and the result or finding Chlamydia Screening (CHL) Women years of age who were identified as sexually active and who had at least one test for chlamydia in the current year. A note indicating the date the test was performed, and the result or finding Well-Child Visits in the First 15 Months of Life (W15) Members who turned 15 months old in the current year and who had 6 or more well-child visits with a PCP during the first 15 months of life. Documentation of a visit to a PCP, the date of the visit and all of the following: A health and developmental history (physical and mental) A physical exam Health education/anticipatory guidance Services specific to the assessment or treatment of an acute or chronic condition do not count toward this measure. Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (W34) Members 3 6 years of age who had one or more well-child visits with a PCP in the current year. Documentation of a visit to a PCP, the date of the visit and all of the following: A health and developmental history (physical and mental) A physical exam Health education/ anticipatory guidance Services specific to the assessment or treatment of an acute or chronic condition do not count toward this measure HEDIS Pediatric Resource Guide 28

32 Measure Description Required Documentation Key Notes Adolescent Well Visits (AWC) Members years of age who had at least one comprehensive well visits with a PCP or OB/GYN. The medical record must include a note indicating a visit to a PCP or OB/GYN practitioner, the date when the well visit occurred and the evidence of all the following: A health and developmental history (physical and mental) A physical exam Health education/anticipatory guidance including tobacco use, drugs & alcohol use, sexual activity, and depression Services specific to the assessment or treatment of an acute or chronic condition do not count toward this measure. First-Year Measure Transitions of Care (TRC): First-Year Measure Follow-Up After Emergency Department Visit for People With High Risk Multiple Chronic Conditions (FMC): Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year. Percentage of emergency department (ED) visits for members 18 years and older who have high risk multiple chronic conditions who had a follow-up service within 7 days of the ED visit. Four rates are reported: Notification of Inpatient Admission. Documentation of receipt of notification of inpatient admission on the day of admission or the following day. Receipt of Discharge Information. Documentation of receipt of discharge information on the day of discharge or the following day. Patient Engagement After Inpatient Discharge. Documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge. Medication Reconciliation Post-Discharge. Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days). Follow up post discharge to complete coordination of care and complete medication reconciliation through 30 days (31 total days) after discharge. Follow up care can include office, home, and telehealth visits. Within 7 days of discharge Schedule the 7 day follow-up visit within 5 days to allow flexibility in rescheduling, if necessary. Involve the patient s caregiver regarding the follow-up plan after discharge. Follow-Up After Hospitalization For Mental Illness (FUH) Members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner within 30 days and 7 days after discharge. Two rates are reported: Within 30 days of discharge Within 7 days of discharge Schedule the 7 Day Follow-Up visit within 5 days to allow flexibility in rescheduling, if necessary. Involve the patient s caregiver regarding the follow-up plan after IP discharge. If the member s appointment does not occur within the first 7 days post-discharge, please schedule the appointment to occur within 30 days post-discharge HEDIS Pediatric Resource Guide 29

33 Measure Description Required Documentation Key Notes Follow-up Care for Children Prescribed ADHD Medication (ADD) Children who were newly prescribed ADHD medication who had a least three follow up care visits within a 10 month period, one which was within 30 days of when the first ADHD drug was dispensed. Two rates are reported: Initiation Phase members 6 12 years of age that had a follow-up visit within 30 days of the prescription written Continuation and Maintenance Phase members 6 12 years of age with an ambulatory prescription for ADHD medication, who remained on the medication for 210 days and who in addition to the 30 day visit had a least 2 follow-up visits with 270 days (9 months) after the initiation phase Members must have the following: 30 day follow-up visit after the initial prescription 2 additional follow-up visits after the 30- day visits within 270 days (9 months) Only one of the two visits (during days ) may be a telephone visit or a telehealth visit. When prescribing a new medication to your patient, be sure to schedule a follow-up visit within 30 days to assess how the medication is working and to address side effect issues. Schedule this visit (allow for time to reschedule prior to 30 days, if necessary) while your patient is still in the office. Schedule two more visits in the 9 months after the 30 day Initiation Phase to continue to monitor your patient s progress. (At least two follow-up visits on different dates of service. Only one of the two visits may be a telephone visit or a telehealth visit.) Follow-Up After Emergency Department (ED) Visit For Mental Illness (FUM) Members 6 years of age and older who had an ED visit with a principal diagnosis of mental illness and who had outpatient visit, an intensive outpatient encounter or partial hospitalization with any practitioner within 30 days and 7 days after the ED visit. Two rates are reported: The percentage of ED visits for which the member received follow-up within 30 days of the ED visit. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit If the member s appointment does not occur within the first 7 days post-ed visit, please schedule the appointment to occur within 30 days post-ed visit. Follow-Up After Emergency Department Visit For Alcohol And Other Drug Abuse or Dependence (FUA) Members 13 years of age and older who had an ED visit with a principal diagnosis of alcohol or other drug (AOD) dependence and who outpatient visit, an intensive outpatient encounter or partial hospitalization with any practitioner within 30 days and 7 days after the ED visit. Two rates are reported: The percentage of ED visits for which the member received follow-up within 30 days of the ED visit. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit. If the member s appointment does not occur within the first 7 days post-ed visit, please schedule the appointment to occur within 30 days post-ed visit HEDIS Pediatric Resource Guide 30

34 Measure Description Required Documentation Key Notes Utilization of the PHQ- 9 to Monitor Depression Symptoms for Adolescents and Adults (DMS) The percentage of members 12 years of age and older with a diagnosis of major depression or dysthymia, who have a PHQ-9 tool administered at least once during a four-month period Two rates are reported. ECDS Coverage. For those members 12 and older with a diagnosis of major depression or dysthymia for whom a health plan can receive any electronic clinical quality data. Utilization of PHQ-9. The percentage of PHQ-9 utilization. Members with a diagnosis of major depression or dysthymia whose measure data are reportable using ECDS and, had an outpatient encounter with a PHQ-9 score present in their record in the same assessment period as the encounter. Selection of the appropriate assessment should be based on the age of the member. PHQ-9: For 13 years of age and above. PHQ-9 Modified for Teens: For ages The PHQ-9 assessment does not need to occur during a face-to-face encounter; for example, it can be completed over the telephone or through a Web-based portal Depression Remission or Response for Adolescents and Adults (DRR) Members 12 years and older with a diagnosis of depression and an elevated PHQ-9 score who had a response or remission within 4-8 months of the elevated score. Four rates are reported: ECDS Coverage: Members for whom a health plan can receive any electronic clinical quality data. Follow-Up PHQ-9: The percentage of member who have a follow-up PHQ-9 score documented within the four to eight months after the initial elevated PHQ-9 score. Selection of the appropriate assessment should be based on the age of the member. PHQ-9: For 13 years of age and above. PHQ-9 Modified for Teens: For ages The PHQ-9 assessment does not need to occur during a face-to-face encounter; for example, it can be completed over the telephone or through a Web-based portal. Depression Remission: Members who achieve remission of depression symptoms as noted by a PHQ-9 depression response score of <5 recorded in the ECDS during the depression follow-up period. Must be the most recent score recorded. Depression Response: Members who indicate a response to depression treatment as noted by a PHQ-9 depression response score at least 50% lower than the PHQ-9 score associated with the Index Episode Start Date (IESD), recorded in the ECDS during the depression follow-up period. Must be the most recent score recorded HEDIS Pediatric Resource Guide 31

35 Measure Description Required Documentation Key Notes A lower rate indicates better performance First-Year Measure Use of Opioids at High Dosage (UOD) For members 18 years and older, the rate per 1,000 receiving prescription opioids for 15 days during the measurement year at a high dosage (average morphine equivalent dose [MED] > 120 mg). The average MED for all opioids despensed during the treatment period. Calculate the number of days covered for all dispensing events and determine who meets the threshold of (greater or equal to (symbol) 15 total days covered during the measurement year. Guideline on opioid prescribing for chronic, non-malignant pain recommend the use of additional precautions when prescribing dosages 50 morphine equivalent dose (MED) and recommends avoiding increasing dosages 90mg MED or to carefully justify dosages 90mg MED (CDC, 2016). For members who are already taking doses 90mg MED, the CDC recommends that providers should explain in a nonjudgmental manner the risks and benefits of continuing high-dose opioids, and should offer these members the opportunity to taper to a safer, lower dose. First-Year Measure Use of Opioids From Multiple Providers (UOP) For members 18 years and older, the rate per 1,000 receiving prescription opioids for 15 days during the measurement year who received opioids from multiple providers. Three rates are reported: Multiple Prescribers: The rate per 1,000 of members receiving prescriptions for opioids from four or more different prescribers during measurement year. Multiple Pharmacies: The rate per 1,000 of members receiving prescriptions for opioids from four or more different pharmacies during the measurement year. Multiple Prescribers and Multiple Pharmacies: The rate per 1,000 of member receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year. NOTE: A lower rate indicated better performance for all three rates. Guideline on opioid prescribing for chronic, non-malignant pain recommend the use of additional precautions when prescribing dosages 50 morphine equivalent dose (MED) and recommends avoiding increasing dosages 90mg MED or to carefully justify dosages 90mg MED (CDC, 2016). For members who are already taking doses 90mg MED, the CDC recommends that provider should explain in a nonjudgmental manner the risks and benefits of continuing high-dose opioids, and should offer these members the opportunity to taper to a safer, lower dose HEDIS Pediatric Resource Guide 32

36 Measure Description Required Documentation Key Notes First-Year Measure Depression Screening and Follow-Up for Adolescents and Adults (DSF) The percentage of members 12 years of age and older who were screened for clinical depression using a standardized tool and, if screened positive, who received follow-up care Depression Screening: The percentage of members who were screened for clinical depression using a standardized tool. Follow-Up on Positive Screen: The percentage of members who screened positive for depression and received follow-up care within 30 days. Selection of the appropriate assessment should be based on the age of the member. PHQ-9 For 13 years of age and above. PHQ-9 Modified for Teens ages The PH-Q-9 assessment does not need to occur during a face- to face encounter; for example, it can be completed over the telephone or through a Web-based portal. Schedule follow-up appointment for members with positive screen to receive appropriate care. First-Year Measure Unhealthy Alcohol Use Screening and Follow Up (ASF) The percentage of members 18 years of age and older who were screened for unhealthy alcohol use using a standardized tool and, if screened positive, received appropriate follow-up care. Unhealthy Alcohol Use Screening: The percentage of members who had a systematic screening for unhealthy alcohol use. Counseling or Other Follow-Up: The percentage of members who screened positive for unhealthy alcohol use and received brief counseling or other follow-up care within 2 months of a positive screening. The assessment does not need to occur during a face-to face encounter; for example, it can be completed over the telephone or through a Web-based portal. Schedule follow-up appointment for members with positive screen to receive appropriate care HEDIS Pediatric Resource Guide 33

37 Pregnancy-Related HEDIS Measures This document outlines the required medical record documentation needed to demonstrate compliance with pregnancy related HEDIS measures. This information is from 2018 Technical Specifications for Health Plans. Measure Description Required Documentation Prenatal and Postpartum Care (PPC) Prenatal and Postpartum Care (PPC): The percentage of deliveries of live births on or between November 6 of the prior to the measurement year and November 5 of the measurement year. For these women, the measure assesses the following facets of prenatal and postpartum care. Timeliness of Prenatal Care: The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester, on the enrollment start date or within 42 days of enrollment in the organization. Postpartum Care: The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. Timeliness of Prenatal Care A prenatal visit during the first trimester, with an OB/GYN, midwife, family practitioner, or PCP, with a pregnancy-related diagnosis code, AND at least one of the following: A basic physical obstetrical examination that includes auscultation for fetal heart tone, or pelvic exam with obstetric observations, or measurement of fundus height (a standardized prenatal flow sheet may be used); Screening test in the form of an obstetric panel (e.g., hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO blood typing); An ultrasound (echocardiography) of the pregnant uterus; A TORCH antibody panel alone: Toxoplasma Rubella Cytomegalovirus Herpes simplex A rubella antibody test AND an ABO test on the same or different dates of service A rubella antibody test AND an Rh test on the same or different dates of service A rubella antibody test AND an ABO/Rh test on the same or different dates of service. A prenatal visit during the first trimester, on the same or different dates of service, AND with one of the following: A complete obstetrical history; OR A prenatal risk assessment and counseling/education; OR A prenatal visit with a pregnancy-related diagnosis code during the first trimester, on the same or different dates of service, AND with a least one of the following: An obstetric panel; OR An ultrasound (echocardiography) of the pregnant uterus. Postpartum Care Postpartum visit to an OB/GYN practitioner or midwife, family practitioner, or other PCP on or between 21 and 56 days after delivery. The medical record must include the date the visit occurred and at least one of the following: Pelvic exam, or Evaluation of weight, BP, breasts (notation of breastfeeding counts) and abdomen, or Notation of postpartum care, including but not limited to: postpartum care, PP care, PP check, 6 week check or completion of a preprinted postpartum care form 2018 HEDIS Pediatric Resource Guide 34

38 2018 HEDIS Pediatric Resource Guide 35

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40 Quality care is a team effort. Thank you for playing a starring role! PRO_04235E Internal Approved WellCare 2017