Provider STAR Ratings Quick Reference Guide 2016 Dates of Service Updated January 20, 2016
Adult BMI (Body Mass Index) Assessment (ABA) EXCLUSIONS: Members who have a diagnosis of pregnancy during the measurement year or the year prior CPT for Office Visit < 70% 70% to < 81% 81% to < 90% 90% to < 96% 96% 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456 DESCRIPTION: Percentage of members 18-74 years of age who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior to the measurement year. or year prior AND ICD -10 CM Diagnosis for Z68.1, Z68.20 - Z68.39, Z68.41-Z68.45 Breast Cancer Screening (BCS) (Administrative- Claims Data Only) DESCRIPTION: Percentage of women 50-74 years of age as of December 31 who had a mammogram to screen for breast cancer during the measurement year or the year prior to the measurement year. DATES OF SERVICE: October 1, 2014- December 31, 2016 EXCLUSIONS: Women who had a bilateral mastectomy, or two unilateral mastectomies. Note: The Purpose of this measure is to evaluate primary screening. Do not count biopsies, breast ultrasounds or MRIs for this measure because they are not appropriate methods for primary breast cancer screening. CPT for Mammo HCPCS for Mammo UBREV < 39% 39% to < 63% 63% to < 74% 74% to < 80% 80% 77055 77057 G0202, G0204, G0206 401, 403 Page 2
No Thresholds applicable* DESCRIPTION: Documentation in the medical record of functional status assessment in current year. Notations for a complete functional status assessment must include one of the following: 1. Assessment of instrumental activities of daily living (IADL) such as shopping for groceries, driving, using public transportation, using the telephone, meal preparation, housework, home repair, laundry, taking medications or handling finances, etc. 2. Assessment of activities of daily living (ADL) such as bathing, dressing, eating, transferring (i.e., getting in and out of chairs), using the toilet and walking 3. Results using a standardized functional status assessment tool 4. Assessment of three of the following four components A) Cognitive status B) Ambulation status C) Sensory ability ( must include hearing, vision, and speech) D) Other functional independence (e.g., exercise, ability to perform job) 5. A functional status assessment limited to an acute or single condition, event, or body system (e.g., lower back, leg) NOT meet criteria for a comprehensive functional status assessment. CPT Category II for FSA < 24% 24% to < 54% 54% to < 67% 67% to < 86% 86% Care for Older Adults (COA)- Advance Care Planning (SNP only) DESCRIPTION: Percent of adults 66 years old and older who have active advance care planning such as Advanced directive, Living will, Power of attorney, Health care proxy, Actionable medical decision maker or surrogate decision maker. Evidence of advance care planning must include: 1. An advance care plan in the medical record 2. Advance care planning discussion with the provider documented and dated 3. Notation that the member has previously executed an advanced care plan that meets criteria. THIS IS NOT A STAR RATINGS MEASURE CPT Category II for ACP 1157F ACP present in the medical record 1158F ACP discussion documented in medical record Care for Older Adults (COA)- Functional Status Assessment (SNP only) HPCPS for ACP S0257 1170F Page 3
< 47% 47% to < 60% 60% to < 77% 77% to < 87% 87% Care for Older Adults (COA)- Medication Review (SNP only) CPT for Med Review 90863, 99605, 99606 CPT Category II for Med List 1159F DESCRIPTION: At least one medication review conducted by a prescribing practitioner or clinical pharmacist during the measurement year AND the presence of a medication list in the medical record. AND CPT Category II for Med Review 1160F HCPCS for Med List G8427 Care for Older Adults (COA)- Pain Screening (SNP only) Numeric rating scales (verbal or written) Face, Legs, Activity, Cry Consolability (FLACC) scale. Verbal descriptor scales (5 7 Word Scales, Present Pain Inventory). Pain Thermometer Pictorial Pain Scales (Faces Pain Scale, Wong-Baker Pain Scale) < 30% 30% to < 62% 62% to < 78% 78% to < 95% 95% Visual analogue scale DESCRIPTION: Documentation that the patient was assessed for pain (which may include positive or negative findings for pain). Result of assessment using a standardized pain assessment tool, not limited to: Brief Pain Inventory Chronic Pain Grade PROMIS Pain Intensity Scale Pain Assessment in Advanced Dementia (PAINAD) Scale CPT Category II for Pain Present 1125F CPT Category II for No Pain Present 1126F Page 4
Colorectal Cancer Screening (COL) DESCRIPTION: Percentage of members 51-75 years of age who had appropriate screening for colorectal cancer. FOBT: Jan 01- Dec 31 of CY or Flexible Sigmoidoscopy: Jan 01- Dec 31 of CY, or 4 years prior or Colonoscopy: Jan 01- Dec 31 of CY, or 9 years prior Exclusions: Members with a diagnosis of colorectal cancer or total colectomy CPT for FOBT 82270, 82274 CPT for Flex Sigmoidoscopy 45330-45335, 45337-45342, 45345 HCPCS for FOBT G0328 HCPCS for Flex Sigmoidoscopy G0104 < 51% 51% to < 63% 63% to < 71% 71% to < 78% 78% CPT for Colonoscopy HCPCS for Colonoscopy 45384-45387, 45391, 45392 G0105, G0121 Comprehensive Diabetes Care (CDC) Blood Sugar Controlled / HbA1c Controlled DESCRIPTION: Percentage of plan members with diabetes who had an A1c lab test during the year that showed their average blood sugar is under control (<9%). CPT for HbA1c Test LOINC for HbA1c Test <49% 49% to < 60% 60% to < 71% 71% to < 84% 84% 3044F 83036, 83037 4548-4, 4549-2, 17856-6 AND CPT Category II for HbA1c Value Level Less Than 7.0 Level 7.0-9.0 Level Greater Than 9.0 3045F 3046F Page 5
Comprehensive Diabetes Care (CDC) Diabetes Care Eye Exam < 53% 53% to < 65% 65% to < 75% 75% to < 82% 82% < 85% 85% to < 89% 89% to < 93% 93% to < 97% 97% Note: Only 1 of the following actions are required for compliance: Nephropathy screening or Urine microalbumin test or Evidence of treatment for nephropathy. CPT for Nephropathy screening 82042, 82043, 82044, 84156 DESCRIPTION: Percentage of plan members with diabetes who had an eye exam to check for damage from diabetes during the measurement year. or year prior Note: For eye exam performed in the year prior to the measurement year, a copy of the exam must be available and documented as part of the medical record indicating a negative result for Diabetic Retinopathy. CPT for Diabetic Retinal Screening 67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225-92228, 92230, 92235, 92240, 92250,92260, 99203-99205, 99213-99215, 99242-99245 Comprehensive Diabetes Care (CDC) Kidney Disease Monitoring CPT for Urine microalbumin test 81000-81003, 81005 CPT for Evidence of treatment for nephropathy (ESRD) 36147, 36800, 36810, 36815, 36818-36821, 36831-36833, 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512 CPT II for Diabetic Retinal Screening 2022F, 2024F, 2026F, 3072F 3060F, 3061F CPT Category II for Urine 3062F HCPCS for Diabetic Retinal Screening S0620, S0621, S0625, S3000 DESCRIPTION: Percentage of plan members with diabetes with diabetes (type 1 and type 2) who had a urine microalbumin test during the measurement year or who had received medical attention for nephropathy during the measurement year. CPT II for Nephropathy screening CPT Category II for Evidence of treatment for nephropathy 3066F, 4010F Page 6
Controlling High Blood Pressure (CBP) (Hybrid 100% Medical Record Review) DESCRIPTION: Percentage of plan members who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90) during the measurement year. ICD-10 CM Diagnosis for HTN CPT Category II for BP < 47% 47% to < 62% 62% to < 75% 75% to < 82% 82% Systolic Less Than 130 3074F I10 AND Systolic Less Than 130-139 Systolic > 140 Diastolic Less Than 80 Diastolic 80-89 Diastolic > 90 3075F 3077F 3078F 3079F 3080F Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) (Administrative Claim/Encounter) DESCRIPTION: Percentage of members who were diagnosed with rheumatoid arthritis and were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD). EXCLUSIONS: Members diagnosed with HIV or who are pregnant < 64% 64% to < 75% 75% to < 82% 82% to < 86% 86% IF Member Diagnosed with one of the below Codes: ICD -10-CM Diagnosis for Rheumatoid Arthritis M069, M05.00, M05.10, M05.60 Then Prescribe member one of the following DMARD's as recommended by CMS First Line Therapy Medications Methotrexate Cyclophosphamide Sulfasalazine Hydroxychloroquine Azathioprine Minocycline Cyclosporine Leflunomide Gold Sodium Thiomalate Page 7
Osteoporosis Management in Women who had a Fracture (OMW) DESCRIPTION: Percentage of female members who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis within 180 days post fracture. Fracture Date Range: July 01 of prior year - Jun 30 of CY Test Performed/Prescription by: July 1st of prior year - Dec 31 of CY < 20% 20% to < 32% 32% to < 51% 51% to < 75% 75% HCPCS (J Codes) for Osteoporosis Therapy J0630, J0897, J1740, J3110, J3487, J3488, J3489, J0630, Q2051 CPT for BMD 76977, 77078, 77080, 77081, 77082, 77085 (Administrative Claim/Encounter) For Fractures please prescribe the member one of the following medications as recommended by CMS Prescription Drug Ibandronate, Alendronate, Risedronate, Raloxifene HCPCS for BMD G0130 ICD 10-PCS Procedure for BMD BP48ZZ1, B49ZZ1, BP4GZZ1, BP4HZZ1, BP4LZZ1, BP4MZZ1, BP4NZZ1, BP4PZZ1, BQ00ZZ1 Plan All-Cause Readmissions (PCR) DESCRIPTION: Percentage of members discharged from hospital stays, who were readmitted to a hospital within 30 days, either for the same condition as their recent hospital stay or for a different reason. > 17% > 11% to 17% > 9% to 11% > 6% to 9% 6% (Administrative Claims/Encounter) Discharge during: Jan 01- Dec 1 of CY Readmission: within 30 days of discharge Exclusions: Hospital stays where the admission day is the same as the discharge date Any acute inpatient stays with a discharge date in the 30 days prior to the admission date Inpatient stays with discharges for death; acute inpatient stays for pregnancy Page 8
Medication Adherence Oral Diabetes Medications Pharmacy (Part D) Measures (Prescription Drug Event (PDE) Data) DESCRIPTION: Percent of plan members with an oral diabetes and/or hypertension, and/or cholesterol prescription who fill their prescription to cover 80% or more of the time they are supposed to be taking the medication. DATES OF SERVICE : Jan 01- Dec 31 of CY EXCLUSIONS: Members who have one or more prescriptions for insulin in the CY Targeted Population Recommended Adherence Monitoring < 60% 60% to < 69% 69% to < 75% 75% to < 82% 82% Members taking oral diabetes medications in the Biguanides, sulfonylureas, thiazolidinediones, DiPeptidyl Peptidase (DPP)-IV Inhibitors, Meglitinides, or Incretin mimetic agents Ensure Members are taking their medication as directed Hypertension (ACEI & ARBs) < 58% 58% to < 73% 73% to < 77% 77% to < 81% 81% Targeted Population Members taking hypertension medications in ACE (Angiotensin the following Converting therapeutic Enzyme), classes: ARB (Angiotensin Receptor Blocker), or Direct Renin Inhibitors Recommended Adherence Monitoring Ensure Members are taking their medication as directed Cholesterol (Statins) < 50% 50% to < 61% 61% to < 73% 73% to < 79% 79% Targeted Population Members taking a cholesterol medication in the following therapeutic class: Statin Recommended Adherence Monitoring Ensure Members are taking their medication as directed Page 9
HEDIS 2016 EXCLUSION CODES HEDIS MEASURE EXCLUSION DESCRIPTION ICD10 HCPCS CPT (ABA) Adult BMI Pregnancy Z03.71-Z03.75, Z03.79, Z33.1, Z33.2, Z34.00- Z34.03, Z34.80-Z34.83, Z34.90-Z34.93, Z36 (BCS) Breast Cancer Screening (COL) Colorectal Cancer Screening Bilateral Mastectomy Unilateral Mastectomy With Modifier Colorectal Cancer 0HTU0ZZ 0HTU0ZZ 50, 9950 C18.0-C18.9, C19-C21.2, C21.8, C78.5, Z85.038, Z85.048 G0213- G0215, G0231 Total Colectomy 0DTE0ZZ, 0DTE4ZZ 0DTE7ZZ, 0DTE8ZZ 44150-44153, 44155-44158, 44210-44212 (CBP) Controlling Blood Pressure ESRD (ICD10CM) N18.5, N18.6, Z91.15, Z99.2 (ICD10PCS) 3E1M39Z, 5A1D00Z, 5A1D60Z (CDC) Comprehensive Diabetes Care Diabetes Exclusions E08.00, E08.01, E08.10, E08.11, E08.21, E08.22, E08.29, E08.311, E08.319, E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359, E08.36, E08.39, E08.40, E08.41-E08.44, E08.49, E08.51, E08.52, E08.59, E08.610, E08.618, E08.620-E08.622, E08.628, E08.630, E08.638, E08.641, E08.649, E08.65, E08.69, E08.8, E08.9, E09.00, E09.01, E09.10, E09.11, E09.21, E09.22, E09.29, E09.311, E09.319, E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E09.359, E09.36, E09.39-E09.44, E09.49, E09.51, E09.52, E09.59, E09.610, E09.618, E09.620-E09.622, E09.628, E09.630, E09.638, E09.641, E09.649, E09.65, E09.69, E09.8, E09.9, O24.410, O24.414, O24.419, O24.420, O24.424, O24.429, O24.430, O24.434, O24.439, O24.911, O24.912, O24.913, O24.919, O24.92, O24.93 G0257, S9339 36147, 36800, 36810, 36815, 36818-36821, 36831-36833, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512 (ART) Rheumatoid Arthritis Management HIV Pregnancy B20, Z21 Z03.71-Z03.75, Z03.79, Z33.1, Z33.2, Z34.00- Z34.03, Z34.80-Z34.83, Z34.90-Z34.93, Z36 UPDATED 1/20/2016