HEDIS/QARR 2018 Quick Reference Guide ALL MEASURES

Transcription

1 2018 HEDIS Codes

2 HEDIS/QARR 2018 Quick Reference Guide ALL MEASURES Code Age Band Denominator Event Numerator Requirement ADL AAB AAP ABA ADV Adolescent Preventive Care Avoidance of Antibiotic in Adults with Acute Bronchitis Adults Access to Preventive/ Ambulatory Health Services Adult BMI Assessment Follow-Up Care for Children Prescribed ADHD Medication Annual Dental Visit Entire eligible population Adults are identified for the eligible population: Diagnosed with acute bronchitis through outpatient or ED visit between January 1 December 24, of the measurement year. 20+ Entire eligible population Adults who had an outpatient visit during the measurement year or the year prior to the measurement year. Children with newly prescribed medication for attention-deficit/hyperactivity disorder (ADHD) Entire eligible population Adolescents years old should have the following documented during measurement year: 1. Assessment/Counseling/Education on risk behaviors and preventive actions associated with Sexual Activity 2. Assessment/Counseling/Education for Depression 3. Assessment/Counseling/Education about the risk factors of Tobacco Usage 4. Assessment/Counseling/Education about the risk factors of Substance Abuse (including alcohol, excluding tobacco) Antibiotics should not be prescribed for adults with a diagnosis of acute bronchitis. Adults ages 20 years and older should have at least one ambulatory or preventive care visit. Adults years old should have a BMI documented at least once per year: Members 20 years of age or older on the date of service, should have a BMI value during the measurement year or the year prior to the measurement year Members younger than 20 years of age on the date of service should have a BMI percentile during the measurement year or the year prior to the measurement year At least three follow-up care visits within a 10-month period, one of which should be within 30 days of when the first ADHD medication was dispensed. Two rates are reported: 1. Initiation Phase: Children with an ambulatory prescription dispensed for ADHD medication, should have one follow-up visit with a practitioner with prescribing authority during the 30-day Initiation Phase 2. Phase: Children with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days should have two or more follow-up visits with a practitioner from 31 to 300 days after the ADHD medication was newly prescribed Children 2 20 years old should have an annual preventive dental visit with a dental practitioner. All Dental claims MUST be summitted to DentaQuest. Line of Business Medicaid Medicare FIDA EP Medicaid HARP QHP EP Medicaid Medicare FIDA HARP EP Medicaid Medicare FIDA QHP EP Medicaid HARP QHP EP Medicaid HARP QHP 2 Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies.

3 HEDIS/QARR 2018 Quick Reference Guide ALL MEASURES Code Age Band Denominator Event Numerator Requirement AMM AMR APC APM APP ART Antidepressant Medication Management Asthma Medication Ratio Use of Multiple Concurrent Antipsychotics in Children and Adolescents Metabolic Monitoring for Children and Adolescents on Antipsychotics Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis Adults who: Were treated with antidepressant medication, and had a diagnosis of major depression and remained on an antidepressant medication treatment. Children and adults with at least one of the following criteria during both the measurement year and the year prior to the measurement year: 1. At least one ED visit, with a principal diagnosis of asthma. 2. At least one acute inpatient encounter, with a principal diagnosis of asthma. 3. At least four outpatient visits or observation visits, on different dates of service, with any diagnosis of asthma and at least two asthma medication dispensing events. Visit type need not be the same for the four visits. 4. At least four asthma medication dispensing events. Children and adolescents with 90 days of continous antipsychotic medication treatment during the measurement year. Children and adolescents who were on two or more antipsychotic prescriptions. Children and adolescents who had a new prescription for an antipsychotic medication during the measurement year. Adults are identified for the eligible population by any two of the following events on different dates of service between January 1 and November 30th of the measurement year: 1. Outpatient visit with a any diagnosis of rheumatoid arthritis or 2. Nonacute inpatient discharge with any diagnosis of rheumatoid arthritis. Two rates are reported: 1. Effective Acute Phase - The percentage of members who remained on an antidepressant medication for at least 84 days 2. Effective Continuation Phase -The percentage of members who remained on an antidepressant medication for at least 180 days Children and adults ages 5 64 diagnosed with persistent asthma should have a ratio of controller medications to total asthma medications of 0.50 or greater. Children and adolescents on two or more concurrent antipsychotic medications for at least 90 consecutive days during the measurement year. * LOWER RATE IS BETTER Children and adolescents on two or more antipsychotic medications should have both of the following during the measurement year: 1. At least one test for blood glucose or HbA1c 2. At least one test for LDL-C or cholesterol Children and adolescents who had a new prescription dispensed for an antipsychotic medication should have documentation of psychosocial care in the 121-day period from 90 days prior to the earliest antipsychotic medication dispensing event through 30 days after the earliest antipsychotic medication dispensing event. Adults 18 years and older diagnosed with Rheumatoid Arthritis should be dispensed at least one prescription for a disease modifying anti-rheumatic drug (DMARD). DO NOT use Rheumatoid Arthritis diagnosis codes when Ruling Out the disease. Line of Business Medicaid Medicare FIDA HARP QHP EP Medicaid HARP EP Medicaid HARP EP Medicaid HARP EP Medicaid HARP EP Medicaid Medicare FIDA HARP EP Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies. 3

4 HEDIS/QARR 2018 Quick Reference Guide ALL MEASURES Code Age Band Denominator Event Numerator Requirement AWC BCS CAP CBP CCS CDC CHL CIS Adolescent Well Care Breast Cancer Screening Children and Adolescents Access to Primary Care Practitioners Controlling High Blood Pressure Cervical Cancer Screening Comprehensive Diabetes Care Chlamydia Screening in Women Childhood Immunizations Status Entire eligible population Adolescents should have at least one comprehensive well-care visit annually with a PCP or an OB/GYN practitioner Entire eligible population Women years old should have a mammogram every 2 years. 12 months 19 years old Entire eligible population Adults are identified as hypertensive by: One outpatient visit with a diagnosis of hypertension during the first six months of the measurement year Entire eligible population Adults are indentified as having diabetes by claim/ encounter data during the measurement year or year prior: 1. At least two outpatient visits, observation, ED visits or nonacute inpatient encounters or 2. At least one acute inpatient encounter with a diagnosis of diabetes 3. Pharmacy data: Members who were dispensed insulin or hypoglycemics/ antihyperglycemics on an ambulatory basis Women identified as sexually active Birth 2yrs. Children who turn 2 years old during the measurement year. Children 12 months - 19 years old should have an annual visit with their PCP. Adults years old should have their Blood Pressure documented at least once per year: Members Goal: <140/90mm Hg (most recent reading) Members with a diagnosis of diabetes Goal: <140/90mm Hg (most recent reading) Members without a diagnosis of diabetes Goal: <150/90mm Hg (most recent reading) Women years old should be screened for cervical cancer using either of the following: years old - cervical cytology every 1 3 years years old - cervical cytology with HPV co-testing every 1 5 years Adults years old diagnosed with diabetes (type 1 and 2) should have each of the following at least annually: 1. HbA1c testing - Goal: <7.0% (most recent in measurement year) 2. Blood Pressure - Goal: <140/90mm HG (most recent in measurement year) 3. Medical Attention for : Urine Protein test, or ACE/ ARB prescription or Evidence of treatment for nephropathy 4. Dilated or retinal eye exam by an eye care professional (annually) or negative for retinopathy in the year prior to the measurement year Women years old identified as sexually active should be screened annually for Chlamydia. Children should have complete Immunizations on or before their 2nd birthday (events must be at least 14 days apart): 4 - DTaP 3 - IPV 3 - Hep B 2 - Influenza 3 - Hib 4 - PCV 2 or 3 - Rotavirus 1 - Hep A 1 - VZV 1 - MMR Line of Business Medicaid HARP EP Medicaid Medicare FIDA HARP QHP EP Medicaid HARP EP Medicaid Medicare FIDA QHP EP Medicaid QHP EP Medicaid Medicare FIDA HARP QHP EP Medicaid HARP QHP EP Medicaid QHP EP 4 Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies.

5 HEDIS/QARR 2018 Quick Reference Guide ALL MEASURES Code Age Band Denominator Event Numerator Requirement COA COL CWP DAE DDE Care for Older Adults Colorectal Cancer Screening Appropriate Testing for Children with Pharyngitis Use of High-Risk Medications in the Elderly Potentially Harmful Drug-Disease Interactions in the Elderly Follow-Up After Emergency Department Visit for People With High-Risk Multiple Chronic Conditions 66+ Entire eligible population - Medicare SNP Entire eligible population 3 18 Children with a diagnosis of pharyngitis who were dispensed an antibiotic. 66+ Entire eligible population 65+ Entire eligible population 18+ The 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. Adults 66 years and older should have the following documented at least annually: 1. Advance Care Planning 2. Medication List and Review 3. Functional Status Assessment 4. Pain Assessment Adults aged should be screened for colorectal cancer by one of the following: 1. Fecal occult blood test (FOBT, gfobt, ifobt) every year, or 2. Flexible sigmoidoscopy during the measurement year or 4 years prior, or 3. Colonoscopy during the measurement year or 9 years prior, or 4. CT colonography during the measurement year or 4 years prior 5. FIT-DNA test during the measurement year or 2 years prior Children 3 18 yrs old should receive a strep test (rapid strep test and/or throat culture) on or between 3 days prior to 3 days after an antibiotic is dispensed for a pharyngitis disgnosis. Adults aged 66+ years old should be screened for use of high-risk medications in the elderly. Two rates are reported: 1. Members who received at least one dispensing event for a highrisk medication during the measurement year 2. Members who received with at least two dispensing events for the same high-risk medication during the measurement year * LOWER RATES ARE BETTER Adults aged 65+ years old who have evidence of an underlying disease, condition or health concern and who were dispensed an ambulatory prescription for a potentially harmful medication, concurrent with or after the diagnosis. * LOWER RATE IS BETTER Adults who have high-risk multiple chronic conditions should have a follow-up service within 7 days after the ED visit (8 total days). Include visits that occur on the date of the ED visit. Line of Business Medicare FIDA Medicaid Medicare FIDA QHP EP Medicaid HARP QHP EP Medicare FIDA Medicare FIDA Medicare FIDA HARP Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies. 5

6 HEDIS/QARR 2018 Quick Reference Guide ALL MEASURES Code Age Band Denominator Event Numerator Requirement IMA LBP Follow-Up After Emergency Department Visit for Alcohol and Other Drug Follow-Up After Hospitalization for Follow-Up After Emergency Department Visit for Initiation and Engagement of Alcohol and or Immunizations for Adolescents Use of Imaging Studies for Low Back Pain Children and Adults with emergency department (ED) visits with a prinicipal diagnosis of alcohol or other drug (AOD) dependence. The denominator for this measure is based on ED visits, not members. If members have more than one ED visit for AOD, all ED visits on or between January 1 and December 1 (no more than one visit per 31 day period) in the measurement year will be included. Children and adults who were hospitalized for treatment of selected mental illness diagnoses. Children and Adults with emergency department (ED) visits with a prinicipal diagnosis of mental illness. The denominator for this measure is based on ED visits, not members. If members have more than one ED visit for mental illness, all ED visits on or between January 1 and December 1 (no more than one visit per 31 day period) in the measurement year will be included. Adolescent and adult members with a new episode of alcohol or other drug (AOD) dependence between January 1 - November 14 of the measurement year. Adolescents who turn 13 years old during the measurement year. Adults are identified for the eligible population from an outpatient or ED visit with a primary diagnosis of lower back pain during the measurement year. Children and adults who have emergency department (ED) 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 who received follow-up within 30 days of the ED visit 2. The percentage of ED visits who received follow-up within 7 days of the ED visit Children and adults should have a follow-up outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner after discharge. Two rates are reported: 1. The percentage of members who received follow-up within 30 days of discharge 2. The percentage of members who received follow-up within 7 days of discharge Children and adults who have emergency department (ED) visits 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 who received follow-up within 30 days of the ED visit 2. The percentage of ED visits who received follow-up within 7 days of the ED visit Adolescent and adults members with a new episode of AOD dependence should initiate treatment within 14 days of the diagnosis and should receive two or more additional services within 34 days of the initiation visit. Two rates are reported: 1. Initiation of AOD : the percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis 2. Engagement of AOD : the percentage of members who initiated treatment and who had two or more additional services with a diagnosis of AOD within 34 days of the initiation visit Adolscents should have the following immunizations on for before their 13th birthday: 1. Meningococcal on or between 11th and 13th birthdays 2. Tdap on or between 10th and 13th birthdays 3. HPV vaccines on or between 9th and 13th birthdays Adults years with a primary diagnosis of low back pain who did not have an imaging study (plain x-ray, MRI, CT scan) within 28 days of diagnosis unless clinically indicated. Line of Business Medicaid Medicare FIDA HARP EP Medicaid Medicare FIDA HARP QHP EP Medicaid Medicare FIDA HARP EP Medicaid Medicare FIDA HARP QHP EP Medicaid QHP EP Medicare FIDA HARP QHP EP 6 Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies.

7 HEDIS/QARR 2018 Quick Reference Guide ALL MEASURES Code Age Band Denominator Event Numerator Requirement LCS MMA MPM MRP NCS Lead Screening in Children Medication Management for People with Asthma Annual Monitoring for Patients on Persistent Medications Medication Reconciliation Post Discharge Non- Recommended Cervical Cancer Screening in Adolescent Females Birth to 2yrs Children who turn 2 years old during the measurement year. Children and adults are identified for the eligible population by one of the following criteria during both the measurement year and the year prior to the measurement year: 1. At least one ED visit, with a principal diagnosis of asthma. 2. At least one acute inpatient encounter, with a principal diagnosis of asthma. 3. At least four outpatient visits or observation visits, on different dates of service, with any diagnosis of asthma and at least two asthma medication dispensing events. Visit type need not be the same for the four visits. 4. At least four asthma medication dispensing events. Adults who received at least 180 treatment days of the following medication therapy during the measurement year: 1. ACE inhibitors or ARBs 2. Diuretic Adults are identified for the eligible population by an acute or nonacute inpatient discharge on or between January 1 and December 1 of the measurement year. The denominator for this measure is based on discharges, not members. If members have more than one discharge, all discharges on or between January 1 and December 1 in the measurement year will be included Entire eligible population Children should have at least one lead capillary or venous blood test on or before their second birthday. Children and Adults ages 5 64 who were identified as having persistent asthma and were dispensed appropriate medications must remain on an asthma controller for at least 75% of the treatment period. Two rates are reported: 1. The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period 2. The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period Adults 18 years and older who received at least 180 days of ambulatory medication therapy for select therapeutic agents should have at least one therapeutic monitoring event annually: 1.ACE/ARB and Diuretics - lab panel; or one serum potassium and a serum creatinine Adults 18 years and older should have medications reconciled by outpatient provider within 30 days of discharge. Adolescent females years old should not be screened for cervical cancer. * LOWER RATE IS BETTER Line of Business Medicaid EP Medicaid HARP QHP EP Medicaid Medicare FIDA Medicaid HARP EP Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies. 7

8 HEDIS/QARR 2018 Quick Reference Guide ALL MEASURES Code Age Band Denominator Event Numerator Requirement OMW PBH PCE PPC PPC PSA SAA Osteoporosis Management in Women Who Had a Fracture Persistence of Beta-Blocker After a Heart Attack Pharmacotherapy Management of COPD Exacerbation Postpartum Care (PPC-P) Prenatal Timeliness of First Visit (PPC-T) Non- Recommended Prostate-Specific Antigen (PSA) Screening in Older Men Adherence to Antipsychotic Medications for Individuals With Schizophrenia n/a n/a Women are identified for the eligible population by claims/encounter data: 1. An outpatient, ED, or observation visit for a fracture 2. Acute or nonacute inpatient discharges with a diagnosis of a fracture between July 1 of the year prior to the measurement year and June 30 of the measurement year. Adults are indentified for the eligible population by a hospitalization and discharge with a diagnosis of AMI, from July 1 of the year prior to the measurement year and June 30 of the measurement year. A COPD exacerbation is identified by claims/ encounter data: 1. An acute inpatient discharge or 2. ED encounter with a principal diagnosis of COPD during January 1 thru November 30th of the measurement year. The eligible population for this measure is based on acute inpatient discharges and ED visits, not members. It is possible for the denominator to include multiple events for the same individual. Live births -Deliveries on or between November 6 of the year prior to the measurement year and November 5 of the measurement year Live births -Deliveries on or between November 6 of the year prior to the measurement year and November 5 of the measurement year 70+ Entire eligible population Adults with schizophrenia who were dispensed an antipsychotic medication. Individuals identified for the eligible population by claims/encounter data: 1. At least one acute inpatient encounter with any diagnosis of schizophrenia 2. At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED or nonacute inpatient setting, on different dates of services, with any diagnosis of schizophrenia Women years of age who suffered a fracture should have a bone mineral density test or be dispensed a drug to treat or prevent osteoporosis within 6 months after the fracture. Adults 18 years and older who were hospitalized and discharged with a diagnosis of AMI should be dispensed persistent beta-blocker treatment for six months after discharge. Adults 40 years and older who had an acute inpatient discharge or ED encounter for COPD exacerbation should be dispensed the following medications: 1. A systemic corticosteroid within 14 days of discharge 2. A bronchodilator within 30 days of discharge Postpartum Care visit must occur between days after delivery. Timeliness of Prenatal Care: initial prenatal visit must be within first trimester or within 42 days of enrollment with health plan. Men 70 years and older should not receive PSA based screening, unless clinically appropriate * LOWER RATE IS BETTER Adults with schizophrenia who were dispensed an antipsychotic medication should remain on an antipsychotic medication for at least 80% of their treatment period. Line of Business Medicare FIDA Medicaid Medicare FIDA HARP EP Medicaid Medicare FIDA HARP EP Medicaid QHP EP Medicaid QHP EP Medicare FIDA Medicaid HARP 8 Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies.

9 HEDIS/QARR 2018 Quick Reference Guide ALL MEASURES Code Age Band Denominator Event Numerator Requirement SMC SMD SPC SPD SPR Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia Diabetes Monitoring for People With Diabetes and Schizophrenia Statin Therapy for Patients With Cardiovascular Disease Statin Therapy for Patients With Diabetes Use of Spirometry Testing in the Assessment and of COPD Adults with schizophrenia and cardiovascular disease. Individuals identified for the eligible population by claims/encounter data: 1. At least one acute inpatient encounter with any diagnosis of schizophrenia 2. At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED or nonacute inpatient setting, on different dates of services, with any diagnosis of schizophrenia Adults with schizophrenia and diabetes. Individuals identified for the eligible population by claims/ encounter data: 1. At least one acute inpatient encounter with any diagnosis of schizophrenia 2. At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED or nonacute inpatient setting, on different dates of services, with any diagnosis of schizophrenia Males years of age and Females years of age during the measurement year who were identified as having clinical atherosclerotic cardiovascular diesease (ASCVD) Adults years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) Adults are identified for the eligible population by an outpatient, ED or acute inpatient visit with a diagnosis of COPD between July 1, of the year prior to the measurement year and June 30, of the measurement year. Adults with schizophrenia and cardiovascular disease should have a LDL-C test during the measurement year. Adults with schizophrenia and diabetes should have the following tests during the measurement year: 1. LDL-C test 2. HbA1c test Males and Females with ASCVD should meet the following: 1. Received Statin Therapy: At least one dispensing event for a high or moderate-intensity statin medication during the measurement year 2. Statin Adherence: Remained on a high or moderate-intensity statin medication for at least 80% of the treatment period Adults with diabetes who do not have ASCVD should meet the following: 1. Received Statin Therapy: At least one dispensing event for a high or moderate-intensity statin medication during the measurement year 2. Statin Adherence: Remained on a high or moderate-intensity statin medication for at least 80% of the treatment period Adults 40 years and older with a new diagnosis of COPD or newly active COPD should have appropriate spirometry testing between 2 years prior through 6 months after diagnosis. Line of Business Medicaid HARP Medicaid HARP Medicaid Medicare FIDA HARP EP Medicaid Medicare FIDA HARP EP Medicaid Medicare FIDA HARP EP Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies. 9

10 HEDIS/QARR 2018 Quick Reference Guide ALL MEASURES Code Age Band Denominator Event Numerator Requirement SSD Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications TRC Transitions of Care 18+ UOD Use of Opioids at High Dosage 18+ Adults with schizophrenia or bipolar disorder and were dispensed an antipsychotic medication. Individuals identified for the eligible population by claims/encounter data: 1. At least one acute inpatient encounter with any diagnosis of schizophrenia or bipolar disorder 2. At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED or nonacute inpatient setting, on different dates of services, with any diagnosis of schizophrenia 3. At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED or nonacute inpatient setting, on different dates of services, with any diagnosis of bipolar disorder An acute or nonacute inpatient discharge on or between January 1 and December 1 of the measurement year. Adults rate per 1,000 who received prescription opioids for greater than or equal to 15 days during the measurement year at a high dosage (average morphine equivalent dose [MED] >120 mg.) Adults with schizophrenia or bipolar disease who were dispensed an antipsychotic should have a glucose screening test or an HbA1c screening test during the measurement year. Adults who are discharged from an acute or nonacute inpatient facility should have the following documentation in their outpatient medical record: 1. Notification of Inpatient Admission. Documentation of receipt of notification of inpatient admission on the day of admission or the following day. 2. Receipt of Discharge Information. Documentation of receipt of discharge information on the day of discharge or the following day. 3. Patient Engagement After Inpatient Discharge. Documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge. 4. Medication Reconciliation Post-Discharge. Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days). Adults 18 years and older whose average MED was > 120 mg during the treatment period * LOWER RATE IS BETTER Line of Business Medicaid HARP Medicare FIDA HARP Medicaid Medicare FIDA HARP QHP EP 10 Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies.

11 HEDIS/QARR 2018 Quick Reference Guide ALL MEASURES Code Age Band Denominator Event Numerator Requirement UOP URI W15 W34 WCC Use of Opioids From Multiple Providers Appropriate Testing for Children with Upper Respiratory Infection Well Child 0-15 Months Well Child 3-6 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents months 18 years old 0 15 months Adults rate per 1,000 who received prescription opioids for greater than or equal to 15 days during the measurement year who received opioids from multiple providers. Children and adolescents are identified for the eligible population: diagnosed with upper respiratory infection with no comorbid or competing conditions. Thru outpatient or ED visit between July 1, of the year prior to the measurement year and June 30, of the measurement year. Children who turn 15 months of age during the measurement year. Children who are 3 to 6 years of age during the measurement year. Children and adolescents 3 17 with a PCP or OB/ GYN outpatient visit during the measurement year. Adults 18 years and older who received opioids from multiple providers. Three rates are reported: 1. Multiple Prescribers: The rate per 1,000 of members receiving prescriptions for opioids from four or more different prescribers during the measurement year 2. Multiple Pharmacies: The rate per 1,000 of members receiving prescriptions for opioids from four or more different pharmacies during the measurement year 3. Multiple Prescribers and Multiple Pharmacies: The rate per 1,000 of members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year * LOWER RATES ARE BETTER Antibiotics should not be prescribed for children ages 3 months 18 years old with a diagnosis of URI. Children who turn 15 months of age should have 6 or more wellchild visits from birth through 15 months old (visits must be at least 14 days apart). Children 3 6 years old ahould have one well child visit annually. Children and Adolescents 3 17 years old should have following documented during measurement year: 1. BMI Percentile only 2. Counseling for Nutrition 3. Counseling for Physical Activity Line of Business Medicaid Medicare FIDA HARP QHP EP Medicaid HARP QHP EP Medicaid HARP QHP EP Medicaid HARP QHP EP Medicaid QHP EP Healthfirst is the brand name used for products and services provided by one or more of the Healthfirst group of affiliated companies. 11

12 AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Value Set Code Definition Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Code System CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT 12 Back to 2018 HEDIS Codes Quick Links

13 AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Value Set Code Definition Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory Ambulatory G0402 Ambulatory G0438 Ambulatory G0439 Ambulatory G0463 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment (G0402) Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit (G0438) Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit (G0439) Hospital outpatient clinic visit for assessment and management of a patient (G0463) Code System Back to 2018 HEDIS Codes Quick Links 13 CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT Ambulatory T1015 Clinic visit/encounter, all-inclusive (T1015)

14 AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Value Set Code Definition Code System [Z00.00] Encounter for general adult medical examination without Ambulatory Z00.00 abnormal findings [Z00.01] Encounter for general adult medical examination with abnormal Ambulatory Z00.01 findings [Z00.121] Encounter for routine child health examination with abnormal Ambulatory Z findings [Z00.129] Encounter for routine child health examination without Ambulatory Z abnormal findings Ambulatory Z00.5 [Z00.5] Encounter for examination of potential donor of organ and tissue Ambulatory Z00.8 [Z00.8] Encounter for other general examination Ambulatory Z02.0 [Z02.0] Encounter for examination for admission to educational institution Ambulatory Z02.1 [Z02.1] Encounter for pre-employment examination Ambulatory Z02.2 [Z02.2] Encounter for examination for admission to residential institution Ambulatory Z02.3 [Z02.3] Encounter for examination for recruitment to armed forces Ambulatory Z02.4 [Z02.4] Encounter for examination for driving license Ambulatory Z02.5 [Z02.5] Encounter for examination for participation in sport Ambulatory Z02.6 [Z02.6] Encounter for examination for insurance purposes Ambulatory Z02.71 [Z02.71] Encounter for disability determination Ambulatory Z02.79 [Z02.79] Encounter for issue of other medical certificate Ambulatory Z02.81 [Z02.81] Encounter for paternity testing Ambulatory Z02.82 [Z02.82] Encounter for adoption services Ambulatory Z02.83 [Z02.83] Encounter for blood-alcohol and blood-drug test Ambulatory Z02.89 [Z02.89] Encounter for other administrative examinations Ambulatory Z02.9 [Z02.9] Encounter for administrative examinations, unspecified Ambulatory V20.2 Routine infant or child health check ICD9CM Ambulatory V70.0 Routine general medical examination at a health care facility ICD9CM Ambulatory V70.3 Other general medical examination for administrative purposes ICD9CM Ambulatory V70.5 Health examination of defined subpopulations ICD9CM Ambulatory V70.6 Health examination in population surveys ICD9CM 14 Back to 2018 HEDIS Codes Quick Links

15 AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Value Set Code Definition Code System Ambulatory V70.8 Other specified general medical examinations ICD9CM Ambulatory V70.9 Unspecified general medical examination ICD9CM Ambulatory 0510 Ambulatory 0511 Ambulatory 0512 Ambulatory 0513 Ambulatory 0514 Ambulatory 0515 Ambulatory 0516 Ambulatory 0517 Ambulatory 0519 Ambulatory 0520 Ambulatory 0521 Ambulatory 0522 Ambulatory 0523 Ambulatory 0526 Ambulatory 0527 Ambulatory 0528 Ambulatory 0529 Ambulatory 0982 Ambulatory 0983 Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV UBREV CPT CPT CPT CPT Back to 2018 HEDIS Codes Quick Links 15

16 AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP AAP Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Adults Access to Preventive/ Ambulatory Health Services (AAP) Value Set Code Definition Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory Other Ambulatory S0620 Other Ambulatory S0621 Other Ambulatory 0524 Other Ambulatory 0525 Routine ophthalmological examination including refraction; new patient (S0620) Routine ophthalmological examination including refraction; established patient (S0621) Code System CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT CPT UBREV UBREV 16 Back to 2018 HEDIS Codes Quick Links

17 Value Set Code Definition Code System ABA Adult BMI Assessment BMI Z68.1 [Z68.1] Body mass index (BMI) 19.9 or less, adult ABA Adult BMI Assessment BMI Z68.20 [Z68.20] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.21 [Z68.21] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.22 [Z68.22] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.23 [Z68.23] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.24 [Z68.24] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.25 [Z68.25] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.26 [Z68.26] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.27 [Z68.27] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.28 [Z68.28] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.29 [Z68.29] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.30 [Z68.30] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.31 [Z68.31] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.32 [Z68.32] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.33 [Z68.33] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.34 [Z68.34] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.35 [Z68.35] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.36 [Z68.36] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.37 [Z68.37] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.38 [Z68.38] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.39 [Z68.39] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.41 [Z68.41] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.42 [Z68.42] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.43 [Z68.43] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.44 [Z68.44] Body mass index (BMI) , adult ABA Adult BMI Assessment BMI Z68.45 [Z68.45] Body mass index (BMI) 70 or greater, adult ABA Adult BMI Assessment BMI V85.0 Body Mass Index less than 19, adult ICD9CM ABA Adult BMI Assessment BMI V85.1 Body Mass Index between 19-24, adult ICD9CM ABA Adult BMI Assessment BMI V85.21 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.22 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.23 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.24 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.25 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.30 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.31 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.32 Body Mass Index , adult ICD9CM Back to 2018 HEDIS Codes Quick Links 17

18 Value Set Code Definition Code System ABA Adult BMI Assessment BMI V85.33 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.34 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.35 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.36 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.37 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.38 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.39 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.41 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.42 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.43 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.44 Body Mass Index , adult ICD9CM ABA Adult BMI Assessment BMI V85.45 Body Mass Index 70 and over, adult ICD9CM ABA Adult BMI Assessment BMI Percentile Z68.51 [Z68.51] Body mass index (BMI) pediatric, less than 5th percentile for age ABA Adult BMI Assessment BMI Percentile Z68.52 ABA Adult BMI Assessment BMI Percentile Z68.53 ABA Adult BMI Assessment BMI Percentile Z68.54 [Z68.52] Body mass index (BMI) pediatric, 5th percentile to less than 85th percentile for age [Z68.53] Body mass index (BMI) pediatric, 85th percentile to less than 95th percentile for age [Z68.54] Body mass index (BMI) pediatric, greater than or equal to 95th percentile for age ABA Adult BMI Assessment BMI Percentile V85.51 Body Mass Index, pediatric, less than 5th percentile for age ICD9CM ABA Adult BMI Assessment BMI Percentile V85.52 ABA Adult BMI Assessment BMI Percentile V85.53 ABA Adult BMI Assessment BMI Percentile V85.54 Body Mass Index, pediatric, 5th percentile to less than 85th percentile for age Body Mass Index, pediatric, 85th percentile to less than 95th percentile for age Body Mass Index, pediatric, greater than or equal to 95th percentile for age ICD9CM ICD9CM ICD9CM 18 Back to 2018 HEDIS Codes Quick Links

19 Value Set Code Definition Code System Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Initiation Phase Stand Alone CPT Back to 2018 HEDIS Codes Quick Links 19