Prevention and Screening Adolescent Preventive Care Measures (ADL) The percentage of adolescents 12-17 years of age who had at least one outpatient visit with a PCP or OB/ GYN practitioner during the measurement year and received the following four components of care during the measurement year: Assessment or counseling or education on risk behaviors and preventive actions associated with sexual activity Assessment or counseling or education for depression Assessment or counseling or education about the risks of tobacco usage and Assessment or counseling or education about the risks of substance use (including alcohol and excluding tobacco) It is recommended an adolescent receive the above preventive care measures at least once per year for ages 12-17 ***Measure Compliance may be determined using the Hybrid Data Collection method (Chart Review) ** Ensure all diagnosis codes submitted are also included in the medical record Counseling related to Sexual Activity: Z30.011-Z30.019, Z30.2, Z30.9, Z71.7, Z71.89; 4293F Depression screening: 1220F, 3351F-3354F, 3725F; G0444 Tobacco Cessation Counseling: Z71.6; 4000F, 4001F, 4004F; 99406, 99407 Alcohol and Substance Use Counseling: Z71.41, Z71.51; 3016F, 4306F, 4320F; G0443 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents (WCC) The percentage of members 3-17 years of age who had an outpatient visit with a PCP or OB/ GYN practitioner and who had evidence of the following during the measurement year: BMI percentile documentation Counseling for nutrition Counseling for physical activity It is recommended a child receive weight assessment and counseling for nutrition and physical activity at least once per year during each of their 3 rd 17 th years of life ***Measure Compliance may be determined using the Hybrid Data Collection method (Chart Review) BMI percentile: Z68.51, Z68.52, Z68.53, Z68.54 Nutrition: Z71.3 Physical Activity: Z71.82 ** Ensure all diagnosis codes submitted are also included in the medical record VBP Adult-Peds (Rev 9/18) Page 1
Immunizations for Adolescents (Combo 2) (IMA) Adolescents 13 years of age who have had the following immunizations by their 13th birthday: 1 dose of meningococcal conjugate vaccine and 1 tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine and Completed the human papillomavirus (HPV) vaccine series At least one meningococcal conjugate vaccine on or between the member s 11 th and 13 th birthday At least one Tdap vaccine on or between the member s 10 th and 13 th birthday At least three HPV vaccinations with different dates of service on or between the member s 9 th and 13 th birthday OR At least two HPV vaccines with different dates of service on or between the member s 9 th and 13 th birthdays (there must be at least 146 days between the first and second dose of the HPV vaccine) The claim for each vaccine administered must include the vaccination supply code in addition to the administration code Vaccine codes: Refer to NYS Vaccines for Children (VFC) Program Exclusion: Anaphylactic reaction to the vaccine or its components any time on or before the member's 13 th birthday Breast Cancer Screening (BCS) The percentage of women 50 74 years of age who had a mammogram to screen for breast cancer One or more mammograms any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year Valid CPT codes for : 77061-77063, 77065-77067 Cervical Cancer Screening (CCS) The percentage of women 21 64 years of age who were screened for cervical cancer using either of the following criteria: Women age 21 64 who had cervical cytology performed every 3 years Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years Documentation in the medical record must include: The result or finding The date when the cervical cytology was performed or when the cervical cytology and the HPV test was performed 88141-88143, 88147, 88148, 88150, 88152-88153, 88155, 88164-88167, 88174, 88175 VBP Adult-Peds (Rev 9/18) Page 2
Colorectal Cancer Screening (COL) The percentage of members 50 75 years of age who had appropriate screening for colorectal cancer Screening for colorectal cancer by one of the following: Fecal occult blood test (FOBT) during the measurement year OR Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year OR Colonoscopy during the measurement year or the nine years prior to the measurement year OR CT colonography during the measurement year or the four years prior to the measurement year OR FIT-DNA test during the measurement year or the two years prior to the measurement year FOBT: 82270, 82274, G0328 Flexible Sigmoidoscopy: 45330-45335, 45337-45338, 45346, 45340-45342, 45347, 45349-45350, G0104 Colonoscopy: 44388-44392, 44401, 44394, 44402-44408, 45378-45382, 45388, 45384-45386, 45389, 45391-45392, 45390, 45393, 45398, G0105, G0121 CT colonography: 74261-74263 FIT-DNA: 81528, G0464 Chlamydia Screening in Women (CHL) The percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. Report two age stratifications and a total rate: 16-20 years 21-24 years Urine chlamydia tests are non-invasive and widely acceptable for this screening Chlamydia is most prevalent among adolescent (15-19) and young adult (20-24) women 87110, 87270, 87320, 87490-87492, 87810 Screening is essential because the majority of females who have the condition do not experience symptoms VBP Adult-Peds (Rev 9/18) Page 3
Cardiovascular Conditions Controlling High Blood Pressure (CBP) The percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (< 140/90 mm Hg) during the measurement year Representative BP: The most recent BP reading during the measurement year as long as it occurred after the diagnosis of hypertension. ** A BP reading > 140/90 is non-compliant. A repeat BP reading is recommended. CPT II codes: Systolic: 3074F-3075F; 3077F Diastolic: 3078F-3080F ** Both a systolic code and a diastolic code need to be added to the claim Statin Therapy for Patients with Cardiovascular Disease (SPC) The percentage of males 21-75 years of age and females 40-75 years of age during the measurement year, who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria: Statin Adherence 80%: Members who remained on a high-intensity or moderate-intensity statin medication for at least 80% of the treatment period Males 21-75 years as of December 31 of the measurement year Females 40-75 years as of December 31 of the measurement year High-intensity or moderate-intensity statin medications VBP Adult-Peds (Rev 9/18) Page 4
Respiratory Conditions Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) The percentage of members 40 years and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry testing to confirm the diagnosis Spirometry testing is required to confirm a new or newly active diagnosis of COPD (includes the diagnosis of emphysema and chronic bronchitis) Report at least one spirometry test result for each new or newly active diagnosis of COPD Spirometry testing is indicated for patients who received a COPD diagnosis from an office visit; urgent care visit; ED/ Observation visit; or acute inpatient stay to confirm the diagnosis of COPD Only document a diagnosis code of COPD when the diagnosis has been confirmed by spirometry testing Spirometry testing codes: 94010, 94014-94016, 94060, 94070, 94375 Medication Management for People With Asthma (MMA) The 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 The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period According to New York State quality guidelines, persistent asthma is defined as: At least one ED visit, with a principal diagnosis of asthma, OR At least one acute inpatient encounter, with a principal diagnosis of asthma, OR 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 for any controller medication or reliever medication, OR At least four asthma medication dispensing events for any controller medication or reliever medication Individuals with emphysema, COPD, or other respiratory conditions should NOT get diagnosed or coded as having asthma VBP Adult-Peds (Rev 9/18) Page 5
Diabetes Comprehensive Diabetes Care: (CDC) Two (2) point weighted measure Retinal Eye Exam The percentage of members 18 75 years of age with diabetes (type 1 and type 2) who had a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or had a negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year Documentation in the medical record must include the result or finding as well as when the retinal eye exam was performed S0620-S0621, 92002, 92004, 92012, 92014, 92250, 92227, 92228 Include all diagnosis codes related to diabetic retinal screening exam Hemoglobin A1c (HbA1c) Testing The percentage of members 18 75 years of age with diabetes (type 1 and type 2) who had an Hemoglobin A1c (HbA1c) test performed during the measurement year Documentation in the medical record must include the result or finding as well as the date when the Hemoglobin A1c (HbA1c) test was performed ** Hemoglobin A1c (HbA1c) control <8.0% is considered compliant 83036, 83037, 3044F-3046F ** The date of service reported for CPT II codes 3044F-3046F and the date of service of the test result must be no more than seven days apart Medical Attention for Nephropathy The percentage of members 18 75 years of age with diabetes (type 1 and type 2) who had medical attention for nephropathy during the measurement year ONE of the following: A nephropathy screening or monitoring test Evidence of treatment for nephropathy or ACE/ARB therapy Evidence of stage 4 chronic kidney disease Evidence of ESRD Evidence of kidney transplant A visit with a nephrologist At least one ACE inhibitor or ARB dispensing event 81000-81003, 81005, 82042-82044, 84156, 3060F-3062F, 3066F, 4010F For providers with dual specialties (that include Nephrology); Submit the appropriate taxonomy code to indicate the nephrology specialty on the claim VBP Adult-Peds (Rev 9/18) Page 6
Behavioral Health Antidepressant Medication Management (AMM) The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported: Effective Acute Phase Treatment - The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks) Effective Continuation Phase Treatment - The percentage of members who remained on an antidepressant medication for at least 180 days (6 months) The diagnosis of major depression may be from the following types of encounters: Outpatient visit ED visit Telehealth Intensive outpatient encounter Partial hospitalization F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9 Have you coded your visit to the highest degree of specificity? Diabetic Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) The percentage of members 18-64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year At least one acute inpatient encounter with any diagnosis of schizophrenia or bipolar disorder At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED or non-acute inpatient setting, on different dates of service, with any diagnosis of schizophrenia At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED or non-acute inpatient setting, on different dates of service, with any diagnosis of bipolar disorder Diabetic screening: a glucose test or an HbA1c test performed during the measurement year Diagnosis codes for schizophrenia and bipolar disorder: F30.10-F30.9; F31.10-F31.78; F31.81; F31.89; F31.9; F20.0- F20.9; F25.0-F25.9 Diabetic screening: 80047-80048, 80050, 80053, 80069, 82947, 82950-82951, 83036-83037; 3044F-3046F VBP Adult-Peds (Rev 9/18) Page 7
Utilization Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) The percentage of children 3-6 years of age who had one or more well child visits with a PCP during the measurement year It is recommended a child receive, at minimum, one preventive visit during each of their 3 rd, 4 th, 5 th and 6 th years of life YourCare will reimburse for preventive visits appropriately performed, documented, and billed by a PCP type specialty Z00.121, Z00.129, Z00.8, Z02.0, Z02.71, Z02.79, Z02.82 99382, 99383, 99392, 99393 Adolescent Well-Care Visits (AWC) The percentage of adolescents 12-21 years of age who had at least one comprehensive well-care visit with a PCP or OB/ GYN practitioner during the measurement year At minimum, one preventive visit during the 12 th 21 st years of life is recommended YourCare will reimburse for preventive visits appropriately performed, documented, and billed by a PCP or OB/GYN type specialty Z00.00, Z00.01, Z00.121, Z00.129, Z00.8, Z02.0-Z02.5, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9 99384, 99385, 99394, 99395 VBP Adult-Peds (Rev 9/18) Page 8