QBPC Claims Based Provider Quick Reference Guide

QBPC Claims Based Provider Quick Reference Guide Category: Diabetes Chronic Suite ICD-10-CM diagnosis HbA1c Test Codes LOINC Evidence of Treatment for Nephropathy Codes E10; E11; E13 83036-37 17856-6, 4548-4, 4549-2 Comprehensive Diabetes Care - CDC Definition: Percentage of members ages 18-75 with diabetes (Types 1 and 2) who had each of the following: HbA1c testing Eye exam (retinal) performed Medical Attention for Nephropathy Codes to Identify Diabetes ICD- 10 Diagnosis Urine Protein Test Codes LOINC E08.21, E08.22, E08.29, E09.21, E09.22, E09.29, E10.21, E10.22, E10.29, E11.21, E11.22, E11.29, E13.21, E13.22, E13.29, I12.0, I12.9, I13.0, I13.10, I13.11, I13.2, I15.0, I15.1, N00.0, N00.1, N00.2, N00.3, N00.4, N00.5, N00.6, N00.7, N00.8, N00.9, N01.0, N01.1, N01.2, N01.3, N01.4, N01.5, N01.6, N01.7, N01.8, N01.9, N02.0, N02.1, N02.2, N02.3, N02.4, N02.5, N02.6, N02.7, N02.8, N02.9, N03.0, N03.1, N03.2, N03.3, N03.4, N03.5, N03.6, N03.7, N03.8, N03.9, N04.0, N04.1, N04.2, N04.3, N04.4, N04.5, N04.6, N04.7, N04.8, N04.9, N05.0, N05.1, N05.2, N05.3, N05.4, N05.5, N05.6, N05.7, N05.8, N05.9, N06.0, N06.1, N06.2, N06.3, N06.4, N06.5, N06.6, N06.7, N06.8, N06.9, N07.0, N07.1, N07.2, N07.3, N07.4, N07.5, N07.6, N07.7, N07.8, N07.9, N08, N14.0, N14.1, N14.2, N14.3, NH14.4, N17.0, N17.1, N17.2, N17.8, N17.9, N18.1, N18.2, N18.3, N18.4, N18.5, N18.6, N18.9, N19, N25.0, N25.1, N25.81, N25.89, N25.9, N26.1, N26.2, N26.9, Q60.0, Q60.1, Q60.2, Q60.3, Q60.4, Q60.5, Q60.6, Q61.00, Q61.01, Q61.02, Q61.11, Q61.19, Q61.2, Q61.3, Q61.4. Q61.5, Q61.8, Q61.9, R80.0, R80.1, R80.2, R80.3, R80.8, R80.9 81000-03, 81005, 82042-44, 84156 11218-5, 12842-1, 13705-9, 13801-6, 14585-4, 14956-7, 14957-5, 14958-3, 14959-1, 1753-3, 1754-1, 1755-8, 1757-4, 18373-1, 20454-5, 20621-9, 21059-1, 21482-5, 26801-1, 27298-9, 2887-8, 2888-6, 2889-4, 2890-2, 30000-4, 30001-2, 30003-8, 32209-9, 32294-1, 32551-4, 34366-5, 35663-4, 40486-3, 40662-9, 40663-7, 43605-5, 43606-3, 43607-1, 44292-1, 47558-2, 49023-5, 50561-0, 50949-7, 53121-0, 53525-2, 53530-2, 53531-0, 53532-8, 56553-1, 57369-1, 57735-3, 5804-0, 58448-2, 58992-9, 59159-4, 60678-0, 63474-1, 76401-9, 77158-4, 77253-3, 77254-1, 9318-7 and is incorporated as Louisiana Health Service Indemnity Company. 1

Diabetic Eye Exam Codes HCPCS 67028, 67030-31, 67036, 67039-43, 67101, 67105, 67107-08, 67110, 67112-13, 67121, 67141, 67145, 67208, 67210, 67218, 67220-21, 67227-28, 92002, 92004, 92012, 92014, 92018-19, 92134, 92225-28, 92230, 92235, 92240, 92250, 92260, 99203-05, 99213-15, 99242-45 S0620, S0621, S3000 Members in hospice any time during the measurement period Members with no diagnosis of diabetes in any setting AND a diagnosis of gestational diabetes or steroid-induced diabetes any time during the measurement or the year prior to the measurement period. Members 66 years of age or older with advanced illness and frailty Each of the following for diabetic members ages 18-75: 1. HbA1c test performed every year. 2. Dilated or retinal eye exam / fundal photography: 3. Medical Attention for Nephropathy: Retinal or dilated eye exam by an eye care professional (optometrist or opthamologist) every year. A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior. Bilateral eye enucleation anytime during the member's history through the end of the measurement period. Has had one of the following during the year: Nephropathy screening or monitoring (urine protein test), evidence of treatment for nephropathy or ACE/ARB therapy, evidence of stage 4 CKD, evidence of ESRD, evidence of kidney transplant, visit with nephrologist or at least one ACE/ARB dispensing event. Or if member has any of the following diagnosis: o Acute renal failure o Albuminuria o Chronic kidney disease o Chronic renal failure Urine test for protein or albumin: o 24-hour urine to test or albumin or protein o Timed urine to test for albumin or protein o Spot urine/ dipstick to test for albumin or protein o Urine to test for albumin/creatinine ratio o 24-hour urine to test for total protein o Random urine to test for protein/creatinine ratio Glomerular filtration rate (GFR) test does NOT meet criteria for nephropathy screening. o Diabetic nephropathy o Dialysis o End-stage renal disease (ESRD) o Hemodialysis o Peritoneal dialysis o Proteinuria o Renal dysfunction o Renal insufficiency Glucophage/Metformin as a solo agent will not identify member as diabetic since it is used to treat conditions other than diabetes. Members with diabetes on these medications are identified through diagnosis codes only. and is incorporated as Louisiana Health Service Indemnity Company. 2

Category: Diabetes Chronic Suite ICD-10-CM diagnosis Statin Therapy for Patients with Diabetes (SPD) Definition: The percentage of members 40-75 years of age with Diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria (only first rate of HEDIS measure used for Claims Based program ): 1. Received Statin Therapy. Members who were dispensed at least one statin medication of any intensity during the measurement period. Codes to Identify Diabetes Statin Medications E10; E11; E13 High-Intensity Statin Therapy Atorvastatin 40-80 mg Rosuvastatin 20-40 mg Amlodipine-atorvastatin 40-80 mg Simvastatin 80 mg Ezetimibe-simvastatin 80 mg Moderate-Intensity Statin Therapy Atorvastatin 10-20 mg Ezetimibe-simvastatin 20-40 mg Simvastatin 20-40 mg Pravastatin 40-80 mg Pitavastatin 2-4 mg Lovastatin 40 mg Rosuvastatin 5-10 mg Amlodipine-atorvastatin 10-20 mg Fluvastatin XL 80 mg Fluvastatin 40 mg bid Low-Intensity Statin Therapy Simvastatin 10 mg Lovastatin 20 mg Ezetimibe-simvastatin 10 mg Fluvastatin 20-40 mg Pravastatin 10-20 mg Pitavastatin 1 mg Members in hospice any time during the measurement period. Members with cardiovascular disease identified by event- MI, CABG, PCI, or other revascularization during the year prior to the measurement period or by diagnosis of IVD during the measurement period or the year prior to the measurement period. Female members with a diagnosis of pregnancy during the measurement period or the year prior to the measurement period. In vitro fertilization in the measurement period or year prior to the measurement period. Dispensed at least one prescription for clomiphene (Estrogen Agonist) during the measurement period or the year prior to the measurement period. ESRD during the measurement period or the year prior to the measurement period. Cirrhosis during the measurement period or the year prior to the measurement period. Myalgia, Myositis, myopathy or rhabdomyolysis during the measurement period. Members who do not have a diagnosis of diabetes in any setting during the measurement period or year prior AND who had a diagnosis of gestational diabetes or steroid-induced diabetes in any setting during the measurement period or year prior. Members 66 years of age or older with advanced illness and frailty. Ensure diabetic members ages 40-75 receive statin therapy. to Help Close the Gap in Care Assess all patients with a diagnosis of diabetes for statin therapy treatment and medication adherence through medication reconciliation at each visit and discuss importance of statin therapy. and is incorporated as Louisiana Health Service Indemnity Company. 3

Members are identified by having at least two visits on different dates of service with a diagnosis of hypertension during the measurement year or the year prior to the measurement year (count services that occur over both years). Visit type need not be the same for the two visits. Only one of the two visits may be a telephone visit, an online assessment or a telehealth visit. Category: Hypertension Chronic Suite ICD-10-CM Outpatient Visit Without UBREV HCPCS Codes CPT Modifier Telephone Visit Online Assessment Nonacute Inpatient encounter UBREV Codes Codes to Identify Diastolic Blood Pressure CPT-CAT II Codes Codes to Identify Systolic Blood Pressure CPT-CAT II Codes 99201-99205; 99211-99215; 99241-99245; 99341-99345; 99347-99350; 99381-99387; 99391-99397; 99401-99404; 99411-99412; 99429; 99455-99456 G0402; G0438; G0439; G0463; T1015 95; GT 98966-98968; 99441-99443 98969; 99444 Controlling High Blood Pressure (CBP) Definition: 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 period. Hypertension Diagnosis Codes Telehealth Modifier Members in hospice any time during the measurement period. Members 66-80 years of age or older with advanced illness and frailty. Members 81 years of age or older with frailty. I10 - Essential (primary) hypertension 99304-99310; 99315-99316; 99318; 99324-99328; 99334-99337 0118; 0128; 0138; 0148; 0158; 0190-0194; 0199; 0524-0525; 0550-0552; 0559-0663; 0669 3079F - Most recent diastolic blood pressure 80-89 mm Hg (HTN, CKD, CAD) (DM) 3080F - Most recent diastolic blood pressure greater than or equal to 90 mm Hg (HTN, CKD, CAD) (DM) 3078F - Most recent diastolic blood pressure less than 80 mm Hg (HTN, CKD, CAD) (DM) 3075F - Most recent systolic blood pressure 130-139 mm Hg (HTN, CKD, CAD) (DM) 3077F - Most recent systolic blood pressure greater than or equal to 140 mm Hg (HTN, CKD, CAD) (DM) 3074F - Most recent systolic blood pressure less than 130 mm Hg (HTN, CKD, CAD) (DM) and is incorporated as Louisiana Health Service Indemnity Company. 4

Ensure hypertensive follow up visit for patients 18 years or older and use CPT II codes accordingly. The member is not compliant if the BP is 140/90 mm Hg, if there is no BP reading during the measurement period or if the reading is incomplete. *Any outpatient diagnosis of hypertension will qualify the member for this measure. For instance, urgent care, specialist, etc *Compliance of the measure is specific to a PCP/TIN. It is a best practice to follow up with hypertensive members every 6 months to assess a BP reading if controlled and more frequently if uncontrolled according to clinic protocol. Take two B/P readings during the visit, one at the start of the exam and one at the end of the exam. Nurse visits (99211) will satisfy measure but visit will not be eligible for reduced copay for QBPC Claims based members. Category: Preventative HCPCS Codes UBREV Anytime during the member's history through the end of measurement period: Bilateral mastectomy (ICD-10 0HTV0ZZ) Unilateral mastectomy with a bilateral modifier on same claim (CPT 19180, 19200, 19220, 19240, 19303-19307 with modifier 50 or 9950) Two unilateral mastectomies with service dates 14 or more days apart (CPT 19180, 19200, 19220, 19240, 19303-19307) Unilateral mastectomy with right side modifier on same claim Unilateral mastectomy with left side modifier on same claim Absence of left or right breast (Z90.12 or Z90.11) Left or right unilateral mastectomies (0HTU0ZZ or 0HTT0ZZ) Any combination of codes that indicate a mastectomy on both the left and right sides on the same or different dates of service. NOTE: It is also important to submit the appropriate ICD-10 diagnosis code that reflects a member s history of bilateral mastectomy, Z90.13. If a member is a new patient and the diagnosis is discovered during the history and physical, the code should be submitted with the initial claim. *USPSTF also recommends biennial screening mammography for females ages 50-74 Breast Cancer Screening - BCS Definition: Percentage of female members ages 50-74 who had a mammogram to screen for breast cancer. Mammography Codes Members in hospice anytime during the measurement period. 77055, 77056, 77057, 77061, 77062, 77063, 77065, 77066, 77067 G0202, G0204, G0206 0401, 0403 If a member is not a new patient, but the member s chart has a documented history of the diagnosis, the ICD-10 diagnosis code should be submitted on any visit claim. Mammogram performed every 2 years for females ages 50-74. and is incorporated as Louisiana Health Service Indemnity Company. 5

Educate patients about the importance of early detection and encourage testing. Increase patient compliance by: Scheduling a mammogram for the patient or send/give patient a referral/script if needed Have a list of mammogram facilities available to share with the patient Discuss possible fears the patient may have about mammograms and inform the patient of available testing methods Because the measure denominator does not remove women at higher risk of breast cancer, all types and methods of mammograms (screening, diagnostic, film, digital or digital breast tomosynthesis) count towards numerator compliance. Do NOT count MRIs, ultrasounds or biopsies towards the numerator. Even though these procedures may be indicated for evaluating women at higher risk for breast cancer or for diagnostic purposes, they should be performed as an adjunct to mammography and do not count towards the numerator if done alone. Definition: Percentage of female members ages 21-64 who were screened for cervical cancer using either of the following criteria: 1) Women ages 21-64 who had cervical cytology performed every three years OR 2) Women ages 30-64 who had cervical cytology/ Human papillomavirus (HPV) co-testing performed every five years Category: Preventative Cervical Cytology Codes HCPCS LOINC UBREV HPV Test Codes HCPCS LOINC ICD-10: 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ, Q51.5, Z90.710, Z90.712 Cervical Cancer Screening - CCS 88141-43, 88147-48, 88150, 88152-54, 88164-67, 88174-75 G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091 10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5 923 87620-22, 87624-25 G0476 21440-3, 30167-1, 38372-9, 49896-4, 59263-4, 59264-2, 59420-0, 69002-4, 71431-1, 75406-9, 75694-0, 77379-6, 77399-4, 77400-0 Members in hospice any time during the measurement period Hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix any time in a member's history through the end of the measurement period. NOTE: It is important to submit the appropriate codes to identify absence of cervix: : 51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-94, 58548, 58550, 58552-54, 58570-73, 58951, 58953, 58954, 58956, 59135. and is incorporated as Louisiana Health Service Indemnity Company. 6

Cervical Cytology every 3 years for women ages 21-64 OR Cervical cytology AND HPV co-testing every 5 years for women 30-64 *USPSTF recommends screening women ages 21-29 for cervical cancer every 3 years and for women 30-65 recommends either screening every 3 years with cervical cytology alone or every 5 years with high-risk HPV testing. Educate patients about the importance of early detection and encourage testing. Biopsies are diagnostic and therapeutic, and not valid for primary cervical cancer screening Don t miss opportunities. Complete pap tests during regularly-scheduled well woman visits, sick visits, urine pregnancy tests, UTI, and Chlamydia/STI screenings when appropriate. Category: Efficiency/Overutilization Member died during hospital stay. Female member with a principal diagnosis of pregnancy. 30-Day All-Cause Readmission Rate (Plan All-Cause Readmission - PCR) Definition: For members 18-64 years of age, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days. A principal diagnosis of a condition originating in the perinatal period on the discharge claim. Planned admissions for any of the following: principal diagnosis of maintenance chemotherapy, principal diagnosis of rehabilitation, organ transplant, or potentially planned procedure without a principal acute diagnosis. Follow up with patients within 14 days post-discharge for thorough medication reconciliation and red flag teach backs. Acute Admission per 1000 (custom BCBSLA measure) Definition: For members 18 years of age or older - the number of acute admissions per 1000 attributed eligible members with medical coverage per measurement year. Acute admission identifies admissions that took place in an acute inpatient setting. Observation stays are not considered acute admissions. Continuous or overlapping stays within the same facility will be counted as one admission. Transfers from one acute facility to another acute facility will be counted as two or more separate admissions. Category: Efficiency/Overutilization None Follow up with patients regularly, in particular chronic patients, to help prevent further complications related to disease. and is incorporated as Louisiana Health Service Indemnity Company. 7

Category: Efficiency/Overutilization ER visits which result in an inpatient admission are excluded. Offer same day appointments or extended hours. Ambulatory ER Visits per 1000 (custom BCBSLA measure) Definition: For members 18 years of age or older - the average number of ambulatory emergency room facility visits provided under medical coverage, per 1000 members with medical coverage per measurement year. The visit count is based on the following combination: 1. Patient, 2. ER facility, 3. Primary diagnosis, and 4. Date of service. Discuss appropriate resource utilization and different diagnosis or medical conditions/symptoms that would constitute an ER visit vs Urgent Care vs same day/next day appointment with PCP. and is incorporated as Louisiana Health Service Indemnity Company. 8