NCC Pediatrics Continuity Clinic Curriculum: Medical Home Module 2 Well Visits Overall Goal: To identify strategies for providing comprehensive care during a well visit. The provision of comprehensive care is a key element of an optimized medical home. Medical homes provide comprehensive care by providing one-stop shopping to patients and families during a clinic visit. The provision of comprehensive care requires pre-appointment preparation, proactive and creative thinking about how best to satisfy the needs of the patient, and cooperation among multiple members of the medical home team. Pre-Meeting Preparation: Review Bright Futures guidelines (flashback to Health Maintenance modules) Review the Immunization schedules (flashback to Immunizations module) Review Pediatric-specific HEDIS Measures & WR-B Rolling Data (enclosed) Prepare for the following simulated patient, who is presenting for a 12 month-old well baby visit: QQQPEDIATRICS, DAUGHTER (DOB 4 Jul 2011). For the purposes of the simulation, assume the patient turned 12 months on 4 Oct 2014. Think about what services the medical home should provide to this patient during her well visit. Conference Agenda: This will be an interactive session that simulates activities that should take place before and during a well visit during which a medical home team provides comprehensive care. Part 1: Open Patient Appointment Search for QQQPEDIATRICS, DAUGHTER, DOB 4Jul2011. Walk patient in for appointment under your Med Home Team (list reason for visit as test patient continuity clinic ). Double click on patient to open encounter. Click on previous encounters and copy-forward data from the patient s last visit (16Oct2015 with Dr. Gardner which was her 9 month well baby visit ) Developed by LCDR James Demitrack. Edited by LCDR Ruth Gardner & LT Krystin Engelhardt (2015)
Part 2: Pre-appointment Preparation for 12 month well-baby visit 1. What should be done prior to the visit in order to save time on the day of the visit? Can any orders be entered? Should the clinic staff contact the patient in advance to give them any instructions, information, or questionnaires? 2. Consider any chronic medical conditions that the patient might have. What services specific to this chronic condition should the medical home provide during the well visit? Part 3: Appointment Strategizing 1. What are the major goals of this visit? What issues should be addressed? 2. What elements of the visit could be accomplished by a non-physician screener prior to the physician entering the exam room? [Hint: Consider TB, lead screening, spot vision, ASQ, etc,] 3. Is there anything the medical home will need to follow-up on after the visit? Part 4: HEDIS Measures One of the HEDIS (Healthcare Effectiveness Data and Information Set) measures on which our medical home is measured is well-child checks. [See attached table for complete list of Pediatric HEDIS Measures]. According to the HEDIS measure, a child should have 6 well-baby visits by 15 months of age (cutoff is exactly 15 months 0 days). Keep in mind that only 1 visit counts in the first month of life either the 2 day newborn f/u OR the 2 week well-baby (please note that these visits have new ICD10 codes: Z00.110 Health examination for newborn under 8 days of age; Z00.11 Health examination for newborn 8-28 days old). 1. If this child is currently 12 months old, how many prior well-baby visits should she have? 2. What measures can the clinic do to improve the well-baby HEDIS measure? [See attached spreadsheet with WRNMMC 12mo rolling data for current stats]
Part 5: Additional Well-Check Planning If there is time, identify what services are provided at the following visits, and think about how these services can be most efficiently integrated into a single 20-30 minute visit: 24 month 5 year well 11 year well with asthma
HEDIS Quick Reference Guide PEDIATRICS Updated to reflect NCQA HEDIS 2015 Technical Specifications Managed Health Services (MHS) strives to provide quality healthcare to our membership as measured through HEDIS quality metrics. HEDIS is a set of measures regarded as the industry standard for calculating and comparing health plan performance in providing quality of care to our members, your patients. To assist your practice with increasing your HEDIS rates, we have created the HEDIS Quick Reference Guide. This guide describes key HEDIS measures and provides guidance on how to bill appropriately. Please always follow the State and/or CMS billing guidance and ensure the HEDIS codes are covered prior to submission. What is HEDIS? HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows direct, objective comparison of quality across health plans. NCQA develops the HEDIS measures through a committee represented by purchasers, consumers, health plans, health care providers and policy makers. HEDIS allows for standardized measurement, standardized reporting and accurate, objective side-by-side comparisons. Consult NCQA s website for more information: www.ncqa.org What are the scores used for? As both State and Federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual provider as well. State purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a health insurance company s ability to demonstrate an improvement in preventive health outreach to its members. Physician-specific scores are being used as evidence of preventive care from primary care office practices. These rates then serve as a basis for physician incentive programs such as pay for performance and quality bonus funds. These programs pay providers an increased premium based on their individual scoring of quality indicators such as those used in HEDIS. How are the rates calculated? HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/ encounter data. Accurate and timely claim/encounter data reduces the necessity of medical record review. How can I improve my HEDIS scores? Submit claim/encounter data for each and every service rendered. Chart documentation must reflect services billed. All providers must bill (or report by encounter submission) for services delivered, regardless of contract status. Claim/encounter data is the most clean and efficient way to report HEDIS. If services are not billed or not billed accurately they are not included in the calculation. Accurate and timely submission of claim/encounter data will positively reduce the number of medical record reviews required for HEDIS rate calculation. Consider including II codes to reduce medical record requests. These codes provide details currently only found in the chart such as BMI screenings and lab results. Annual Dental Visit Measure evaluates the percentage of members ages 2-21 who had at least one dental exam with a dental practitioner in the past year. Appropriate Testing for Children With Pharyngitis Measure evaluates the percentage of children age 2-18 diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing). Rapid strep tests in the office are acceptable and should be billed. 87070, 87071, 87081, 87430, 87650-87652, 87880 Appropriate Treatment for Children with Upper Respiratory Infection Measure evaluates the percentage of children age 3 months 18 years who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. Ensure any secondary diagnoses indicating the need for an antibiotic are submitted on the claim. Children and Adolescents Access to Primary Care Practitioners Measure evaluates the percent of members age 12 months-19 years who had an outpatient visit. Description HCPCS ICD-9-CM Diagnosis Office or other outpatient services 99201-99205, 99211-99215, 99241-99245 Home services 99341-99345, 99347-99350 Preventive medicine 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429 G0402, G0438, G0439, G0463 General medical examination V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Chlamydia Screening in Women Measure evaluates the percentage of women ages 16 to 24 who are sexually active who had at least one test for Chlamydia per year. Chlamydia tests can be completed using any method, including a urine test. Sexually active is defined as a woman who has had a pregnancy test or testing for any other sexually transmitted disease or has been prescribed birth control. Lead Screening in Children Measure evaluates the percentage of children who had a screening test for lead poisoning at least once prior to their second birthday. A lead screening completed in the practitioner office is also allowable. 87110, 87270, 87320, 87490-87492, 87810 83655 Medication Management for People With Asthma Measure evaluates the percentage of members age 5-64 who were identified as having persistent asthma and were dispensed appropriate medications which they remained on during the treatment period within the past year. Two Rates: Medication Compliance 50% - Members who were covered by one asthma control medication at least 50% of the treatment period Medication Compliance 75% - Members who were covered by one asthma control medication at least 75% of the treatment period Appropriate Medications Antiasthmatic combinations, Antibody inhibitor, Inhaled steroid combinations, Inhaled corticosteroids, Leukotriene modifiers, Mast cell stabilizers, Methylxanthines Use of Appropriate Medications for People with Asthma Measure evaluates the percentage of members age 5-64 who were identified as having persistent asthma and who were appropriately prescribed medication. Medications considered appropriate for the measure include: Appropriate Medications Antiasthmatic combinations, Antibody inhibitor, Inhaled steroid combinations, Inhaled corticosteroids, Leukotriene modifiers, Mast cell stabilizers, Methylxanthines CONTINUED ON BACK
HEDIS Quick Reference Guide PEDIATRICS continued Childhood and Adolescent Immunizations Immunization Details HCPCS ICD-9 CM Diagnosis Childhood Immunizations percentage of 2 year olds that have all of the required immunizations listed below by age 2. DTaP At least 4 doses < age 2 90698, 90700, 90721, 90723 IPV At least 3 doses < age 2 90698, 90713, 90723 MMR At least 1 dose < age 2 90707, 90710 wmeasles/rubella-90708 Measles-90705, Rubella-90706 Measles-055, Rubella-056 Hib At least 3 doses < age 2 90645-90648, 90698, 90721, 90748 Hepatitis B At least 3 doses < age 2 90723, 90740, 90744, 90747, 90748 G0010 070.2, 070.3, V02.61 VZV At least 1 doses < age 2 90710, 90716 052, 053 Pneumococcal At least 4 doses < age 2 90669, 90670 G0009 Hepatitis A At least 1 doses < age 2 90633 070.0, 070.1 Rotavirus 1 Before age 2: 2 doses of 2-dose vaccine; 1 dose of the 2 dose vaccine and 2 doses of the 3 dose vaccine or 3 doses of the 3 dose vaccine 2 dose schedule-90681 3 dose schedule-90680 Influenza At least 2 doses < age 2 90655, 90657, 90661, 90662, 90673, 90685 G0008 Adolescent Immunizations percentage of adolescents turning 13 who had all the required immunizations listed below. Meningococcal 1 on or between 11th 13th birthdays 90733, 90734 Tdap/Td 1 on or between 10th 13th birthdays Tdap-90715 Td-90714 or 90718 Tetanus-90703 Diphtheria-90719 Human Papillomavirus (HPV) Three doses by 13th birthday 90649, 90650 1 Record must document if Rotavirus is 2 or 3 dose vaccine. Parent refusal for any reason is not a reason for exclusion. Follow Up Care For Children Prescribed ADHD Medication Measure demonstrates the percent of members ages 6 to 12 newly prescribed an ADHD medication that had at least three follow-up care visits within a 10 month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates: Initiation Phase one face-to-face outpatient follow-up visit with a practitioner with prescribing authority within 30 days after the date the ADHD medication was newly prescribed. HCPCS 99349, 99350, 99383, 99384, 99393, 99394, 99401, 99402, 99403, 99404, 99411, 99412, 99510 G0155, G0176, G0177, G0409, G0410, G0411, G0463, H0002, H0004, H0031, H0034, H0035, H0036, H0037, H0039, H0040, H2000, H2001, H2010, H2011, H2012, H2013, H2014, H2015, H2016, H2017, H2018, H2019, H2020, M0064, S0201, S9480, S9484, S9485 90791, 90792, 90801, 90802, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, WITH 3, 5, 7, 9, 11, 12, 13, 14, 15, 20, 22, 33, 49, 50, 52, 53, 71, 72 90826, 90827, 90828, 90829, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90857, 90862, 90875, 90876 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251, 99252, 99253, 99254, 99255 WITH 52, 53 Continuation and Maintenance Phase Two more follow-up visits from 31 to 300 days after the first ADHD medication was newly prescribed. One of the two visits may be a telephone visit with a practitioner. Codes to identify visits POS codes to identify telephone visits Any code noted above in the initiation phase. 98966, 98967, 98968, 99441, 99442, 99443 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Measure demonstrates the percentage of members ages 3 to 17 who had an outpatient visit with a PCP or OB/GYN and who had evidence of the following completed at least annually: 1) BMI percentile documentation 1 2) counseling for nutrition 3) counseling for physical activity Description ICD-9-CM Procedure HCPCS BMI Percentile V85.0-V85.5 Counseling for Nutrition 97802-97804 V65.3 G0270, G0271, G0447, S9449, S9452, S9470 Counseling for Physical Activity V65.41 G0447, S9451 1 Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value. The percentile ranking is based on the Centers for Disease Control and Prevention s (CDC) BMI-for-age growth charts. Pregnant members excluded. Well Child Visits Components of a comprehensive well visit include: 1) a health history; 2) a physical developmental history; 3) a mental developmental history; 4) a physical exam; and 5) health education/anticipatory guidance. Visits must be with a primary care practitioner (pediatrician, family practice, OB/GYN), even though the PCP does not have to be the practitioner assigned to the child. Well Child Visits in the First 15 Months of Life Measure evaluates the percentage of infants who had 6 well child (EPSDT) visits within the first 15 months of life. Well Child Visits, Ages 3 to 6 Years Old Measure evaluates the percentage of children ages 3, 4, 5 or 6 years old who had at least one comprehensive well care visit (EPSDT) per year. Adolescent Well Care Visits Measure evaluates the percentage of adolescents age 12 to 21 years old who had at least one comprehensive well care visit (EPSDT) per year. ICD-9 HCPCS 99381-99385, 99391-99395, 99461 V20.2, V20.31, V20.32, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 G0438, G0439 Use age-appropriate codes when submitting well child visits.
WRNMMC HEDIS ROLLING 12 REPORT 75TH 90TH AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL Jan-Jul MEASURE BENCHMARK BENCHMARK ASTHMA MEDS MGMT 05 TO 11 98.32% 100.00% 96.25% 94.52% 94.74% 94.67% 93.94% 93.51% 93.42% 91.14% 93.83% 94.20% 95.31% 95.38% 1.87% ASTHMA MEDS MGMT 12 TO 18 95.51% 97.53% 97.87% 96.08% 94.87% 90.24% 93.02% 93.33% 91.49% 93.48% 93.33% 96.23% 95.92% 96.30% 2.97% ASTHMA MEDS MGMT 19 TO 50 90.98% 93.75% 94.29% 96.00% 96.04% 94.23% 96.19% 96.15% 96.08% 98.06% 97.96% 98.96% 99.01% 98.11% 1.96% ASTHMA MEDS MGMT 51 TO 64 94.68% 96.35% 97.75% 97.80% 96.67% 97.70% 97.62% 97.50% 95.06% 95.00% 93.75% 96.34% 97.53% 98.82% 1.32% ASTHMA MEDS MGMT TOTAL 93.38% 94.52% 96.26% 96.19% 94.95% 94.79% 95.64% 95.42% 94.44% 94.81% 95.07% 96.67% 97.29% 97.42% 2.00% BREAST CANCER SCREENING TOTAL 78.85% 82.00% 81.62% 81.32% 81.24% 81.26% 81.17% 80.46% 80.23% 80.54% 81.08% 81.40% 81.40% 81.45% 0.99% CERVICAL CANCER SCREENING * * 79.50% 79.30% 79.48% 79.18% 79.87% 78.47% 77.66% 77.50% 78.06% 78.60% 79.29% 79.69% 1.22% COLORECTAL CANCER SCREENING 69.65% 74.39% 61.15% 61.01% 61.35% 61.19% 61.08% 60.96% 60.91% 60.75% 60.66% 60.66% 60.52% 60.38% -0.58% CHLAMYDIA SCREENING 16 TO 20 47.35% 57.78% 39.74% 40.14% 39.63% 39.12% 39.92% 40.70% 42.18% 42.30% 42.97% 44.31% 45.40% 43.00% 2.30% CHLAMYDIA SCREENING 21 TO 24 57.02% 65.71% 61.68% 64.25% 64.35% 64.16% 64.59% 64.56% 64.74% 63.47% 62.34% 64.45% 66.56% 68.80% 4.24% CHLAMYDIA SCREENING TOTAL 52.35% 61.99% 51.65% 52.90% 52.93% 52.88% 53.53% 53.70% 54.50% 53.85% 53.68% 55.33% 57.03% 57.49% 3.79% A1C CONTROL <=9 76.61% 81.02% 75.90% 75.73% 77.19% 78.00% 77.89% 76.58% 76.74% 78.29% 78.11% 77.00% 76.04% 75.81% -0.77% A1C SCREENING 92.70% 94.69% 91.46% 91.35% 92.08% 91.60% 92.38% 91.87% 91.99% 92.51% 91.51% 90.43% 90.53% 90.20% -1.67% LOW BACK PAIN IMAGING 79.78% 83.06% 77.34% 78.89% 77.42% 75.67% 76.20% 75.95% 76.03% 76.19% 76.21% 76.69% 76.34% 76.55% 0.60% AMM ACUTE PHASE TRTMNT 69.05% 73.84% 65.78% 65.29% 64.22% 64.01% 64.29% 65.68% 65.18% 64.24% 65.40% 66.04% 68.37% 69.96% 4.28% AMM CONTINUOUS TRTMNT 53.28% 57.59% 44.40% 45.06% 43.35% 44.19% 44.47% 45.23% 44.20% 41.11% 43.46% 46.67% 47.98% 48.71% 3.48% MENTAL HEALTH FOLLOW-UP 30-DAYS 80.56% 84.84% 83.73% 82.35% 83.23% 84.31% 83.56% 85.21% 86.40% 84.06% 82.73% 81.48% 82.39% 85.51% 0.30% MENTAL HEALTH FOLLOW-UP 7-DAYS 63.75% 71.54% 66.87% 65.88% 66.47% 69.28% 69.86% 70.42% 70.40% 70.29% 69.78% 70.37% 71.13% 71.74% 1.32% CHILDREN WITH PHARYNGITIS 88.32% 92.67% 83.51% 85.58% 88.24% 88.44% 89.36% 90.75% 89.69% 88.11% 87.12% 87.08% 85.19% 83.67% -7.08% CHILDREN WITH UPPER RESPIRATORY INFECTION 90.92% 94.97% 94.08% 94.48% 94.74% 94.68% 94.46% 94.86% 94.84% 95.09% 95.57% 95.15% 95.37% 95.91% 1.05% WELL CHILD 6 VISITS 86.73% 89.83% 84.48% 84.94% 83.33% 83.68% 83.17% 82.93% 83.04% 83.79% 81.95% 81.31% 79.45% 78.95% -3.98% This is a rolling 12 month report. Please note the benchmarks are current as of January 2015. Data prior to January 2015 is scored using 2014 benchmarks and may not reflect the current benchmark color * No 2015 Cervical Cancer Screening Benchmark