2017 PCP INCENTIVE AWARD PROGRAM MEASURES & TIPS

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1 Childhood Immunization Status (CIS) Combo 10 Immunizations for Adolescents (IMA) Combo 1 Lead Screening in Children (LSC) Immunizations completed prior to a child turning 2 years of age in 2017 as follows: DTAP (4) PCV(4) HEPB (3) Hib (3) IPV(3) Rotavirus (2/3) VZV (1) Hep A (1) MMR (1) Influenza (2) The number in parentheses () represents the number of vaccinations required for completion. Requirements: Dates of immunizations are required for compliance. All events must occur 14 days apart (except MMR). DTaP, IPV, Hib, PCV, Rotavirus - Child must be 42 days old but <2 years old. Influenza - Child must be 180 days (6 months) old but <2 years old. Evidence Requirements: Evidence of antigen or combination vaccine (for all vaccinations in measure) if MMR, Hep A/B, VZW, OR Documented history of illness, OR a seropositive test result for each antigen Immunization DTAP 90700, 90698, HEPB 90744, 90723, IPV 90698, 90713, VZV 90716, MMR 90707, PCV 90670, 90669, G0009 HIB 90648, 90698, Rotavirus HEPA FLU 90685, 90655, For patients turning 13 years of age in 2017: 1. 1 or more meningococcal conjugate on or between the patient s 11th and 13th birthdays or more Tdap on or between the patient s 10th and 13th birthdays or more doses of the HPV vaccine between the patient s 9th and 13th birthdays. TDAP Meningitis For patients turning 2 years of age in 2017: 1 or more capillary OR venous lead blood tests on or before the patient s 2nd birthday. CPT Code Make use of standing orders and use every office visit as an opportunity to vaccinate. Send a claim for each visit AND for the relative immunization. The vaccines in this measure are covered under the vaccines for children program, therefore they will not be paid for; however, codes should be submitted with a $0 charge for compliance with quality measures and PCP incentive award program. Tdap and meningococcal vaccines can be given at the same visit. Consider administering in opposite arms. Make use of standing orders and use every office visit as an opportunity to vaccinate. The Tdap immunization is required for 6th grade entrance and, effective September 2016, the Meningococcal immunization is required for 7th grade entrance. Stress the importance of the HPV vaccine before becoming sexually active to help prevent cancer. Test all children regardless of history of living conditions or level of risk for lead poisoning. Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. EMB_PR_FLY_32000_PCP IncentAwardPrgm_MT 5/17

2 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents (WCC) Well-Child Visits in the First 15 Months of Life (W15) Medicaid/CHP Essential, Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) Adolescent Well-Care Visits (AWC) Documentation of the following for patients turning 3-17 years of age in 2017: 1. BMI percentile 2. Counseling for nutrition 3. Counseling for physical activity Include service and date in record. Physical BMI percentile Nutrition Activity ICD-10 ICD-10 Z6851 (BMI <5th percentile for age) Z713 Z6852 (BMI 5th to <85th percentile) Z6853 (BMI 85th to <95th percentile) G0447 Z6854 (BMI 95 th percentile) G0270 S9451 G0447 S9470 For patients turning 15 months of age in 2017, document and code each visit separately, ensuring five or more well-child visits from birth through 15 months old with a PCP Z For patients turning 3-6 years of age in 2017, document and code each visit separately, ensuring a well visit with a PCP each year. Medical record must include the following documentation: 1. A health history 2. A physical developmental history 3. A mental developmental history 4. A physical exam 5. Health education/anticipatory guidance Z Document and code each visit separately, ensuring at least 1 comprehensive well-care visit with a PCP or OB/GYN at any point during the year for children/adolescents turning years of age in Medical record must include the following documentation: 1. A health history 2. A physical developmental history 3. A mental developmental history 4. A physical exam 5. Health education/anticipatory guidance Z Use every visit as an opportunity to perform these assessments and vaccinate when appropriate. Schedule a well-child visit in advance and explain the plan of care to parents/guardians. Use this opportunity to vaccinate the child. Stress the importance of a wellchild visit once a year. Use this opportunity to vaccinate the child and counsel parents/ guardians when appropriate. Stress the importance of a well-child visit once a year. Use this opportunity to vaccinate the child and counsel parents/guardians when appropriate. Chlamydia Screening in Women (CHL) At least 1 chlamydia test during 2017 for sexually active female patients turning years of age in Screen before providing a prescription for birth control pills. 2

3 Medication Management for People with Asthma (MMA) Adult BMI Assessment (ABA) Annual Monitoring for Patients on Persistent Medications (MPM) Ensure patients with persistent asthma turning 5-64 years of age in 2017 remain on an asthma controller medication for 75% of their treatment period (PDC 75%). *Note: this measure is based on pharmacy claims. Document and code BMI for patients turning years of age who had an outpatient visit during 2016 OR Patients younger than 21 years of age should have height, weight, BMI percentile and date documented. Patients 21 years and older should have a BMI value, weight and date documented. Z68.2X Z68.3X Z68.4X For patients turning 18 years or older in 2017, and received 180 or more treatment days of ACE inhibitors, ARBs, diuretics or digoxin: 1 or more of the following monitoring events during 2017: 1. ACE Inhibitors, ARBS, diuretics one serum potassium and serum creatinine test 2. Digoxin one serum potassium, serum creatinine and serum digoxin test Medications CPT Code MPM_ACE or ARB MPM_Digoxin MPM_Diuretics Educate patient or parents/guardians on difference between controller and reliever medications; inhaled short-acting beta agonists, systemic corticosteroids, and oral and nasal preparations are not compliant for controller medication prescribing. Educate patient on proper technique for inhalers. Enforce importance of adherence with patient. Calculate BMI at all well and sick visits. Submit claims with BMI codes AND BMI value to reduce the number of medical records reviewed; Avoid issuing a refill prescription if the patient has not completed an annual monitoring test. Breast Cancer Screening (BCS) CHP, Essential, Health Exchange Plan 1 mammogram within the past 2 years for women turning years of age in HCPCS G0202 G0206 Strongly encourage screening and follow up with patient on completion of screening. Provide script for patient. Highlight the importance of early detection. Assess and help patients overcome any potential barriers to screening. Biopsies, breast ultrasounds, MRIs or tomosynthesis do not count towards compliance as they are not appropriate methods for primary breast cancer screening. 3

4 Care for Older Adults (COA) Documentation of the following for patients turning 66 or older in 2017: Medication review: includes a complete medication list Functional status assessment: includes BOTH activities of daily living (ADLs) and instrumental activities of daily living (iadls) Pain assessment: negative findings also qualify COA Medication Review COA Medication Review COA Medication List 1160F* 1159F* 90863* G8427* 99495** 99496** *These codes need to be billed with a medication list code on the same DOS. **These codes need to be on a DOS between 1/30/2017 and 1/22/2018. Use every visit as an opportunity to perform these assessments. Place completed assessments in patient s medical record. Colorectal Cancer Screening (COL) CHP, Essential, Health Exchange Plan Comprehensive Diabetes Care (CDC), Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) CHP, Essential COA Functional Status Assessment 1170F COA Pain Assessment 1126F 1125F For patients turning years of age in 2017: Fecal occult blood test (FOBT, gfobt, ifobt) annually, OR Flexible sigmoidoscopy during 2017 or during the 4 years prior to 2017, OR Colonoscopy during 2017 or during the 9 years prior to 2017, OR CT Colonography during 2017 or during the 4 years prior to 2017, OR FIT-DNA during 2017 or during the 2 years prior to Flexible Colonoscopy FOBT Sigmoidoscopy G For patients turning years of age in 2017: 1. HbA1c test (<7% = good control, <8%= adequate control, 9%= poor control). 2. A retinal or dilated eye exam by an optometrist or ophthalmologist during 2017 or a negative retinal or dilated eye exam by an optometrist or ophthalmologist for retinopathy in 2016 or a dilated retinal eye exam with a diagnosis of Diabetes without complications during Screening 3044F (HbA1c Level < 7.0) HbA1c Control 3045F (HbA1c Level ) 3046F (HbA1c Level > 9.0) Eye Exam 92014, 92012, ambulatory prescription dispensed for a disease-modifying anti-rheumatic drug (DMARD) during 2017 for patients with rheumatoid arthritis turning 18 or older in *Note: this measure is based on pharmacy claims. Strongly encourage screening, highlight the importance of early detection, provide script and follow up with patient on completion. Offer alternative methods of screening when appropriate. Assess and help overcome any potential barriers to screening. DO NOT use diabetes code when ruling out/screening for diabetes. Use specific rule out code (Z13.1). Review chart for missing gaps in care; discuss observed barriers. DO NOT use RA code (e.g., M06.9, M05.79, M05.89) when ruling out/screening for RA. Use specific rule out code (Z13.828). 4

5 Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD) Medicaid/CHP Osteoporosis Management in Women Who Had a Fracture (OMW) For patients turning years old in 2017: 1. HbA1c test 2. LDL-C test Testing HbA1c LDL-C F F For female patients turning years of age in 2017: Bone mineral density (BMD) test within six months of fracture, OR Osteoporosis medication therapy within six months of fracture BMD Testing Conduct blood draws in office or provide lab scripts. Educate the patient about the importance of these screenings, schedule a follow-up visit and involve family and other support to help patient complete blood work. Help patient overcome barriers if testing was not completed. Check patient s medication history and document any osteoporosis medications. 5

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