Introduction to HEDIS 2016 Presented by the Quality Improvement Department at Gold Coast Health Plan Ventura County s Medi-Cal Managed Care Plan Serving Ventura County since July 1, 2011 1
Contents I. What is HEDIS? II. HEDIS Measures GCHP Reports III. HEDIS Measure Definitions III. Reasons for Low HEDIS Rates IV. How to Improve your HEDIS Rates 2
What is HEDIS? 3
What is HEDIS? HEDIS is a standardized set of performance measures called Healthcare Effectiveness Data Information Set which are developed and maintained by the National Committee for Quality Assurance (NCQA). 4
Who participates in HEDIS? Over 90% of America s health plans (Medicare, Medicaid, and commercial) participate in HEDIS quality reviews. California s Medi-Cal Managed Care Plans are mandated by the Department of Health Care Services (DHCS) to report HEDIS measures annually. 5
Purpose of HEDIS Health Plans use HEDIS reviews to: Evaluate quality of care and services provided to health plan members Evaluate accessibility of care Develop performance improvement initiatives Perform outreach to providers and members Compare performance with other health plans 6
Reporting HEDIS Rates HEDIS measures evaluate the previous year s clinical data. For example, most HEDIS rates reported in 2016 are based on clinical services performed in 2015. Some measures, such as Cervical Cancer Screening, look for services performed up to 5 years prior to the reporting year. Results of HEDIS reviews are reported to DHCS and NCQA in June each year. GCHP distributes HEDIS Provider Report Cards in June & July. 7
HEDIS Timeline Month HEDIS Meetings HEDIS Training Data Integration Runs HEDIS Audit Activity Medical Record Retrieval Medical Record Review HEDIS Submissions Measure Improvement Projects September X X X October X X Q3 Run X X November X X X X December X X X X January X X Q4 Run X Roadmap X February X X X X X X March X X X X Convenience Samples April X Q1 Run X X X Preliminary Rates May X X X X Medical Record Review Validations June X X Final Rates X X X X July X Q2 Run Audit Results X August X X 8
What does HEDIS measure? HEDIS consists of 88 measures across the following 7 domains of care: 1. Effectiveness of Care 2. Access/Availability of Care 3. Experience of Care 4. Utilization and Risk Adjusted Utilization NCQA combined Utilization with Risk Adjusted Utilization in 2015. 5. Relative Resource Use NCQA removed the Utilization measures from this domain in 2015. Previously this domain was titled Utilization and Relative Resource Use. 6. Health Plan Descriptive Information 7. Measures Collected Using Electronic Clinical Data Systems New domain added by NCQA in 2015. 9
Clinical Data Reviewed for HEDIS Reporting Claims data Encounter data Pharmacy data Medical records Member data Provider data Supplemental clinic data such as: Lab Vision Immunization Electronic medical records 10
Two Types of Measures Hybrid measures Population size reviewed: Sample size of up to 411 eligible members randomly selected Requires reviewing claims, encounter, and supplemental data (e.g. labs, Rx, Vision, CAIR, etc.). Requires reviewing medical record documentation to validate if members received the service or care being measured. Admin measures Population size reviewed: Entire eligible population Requires reviewing only claims, encounter and supplemental data (e.g. labs, Rx, Vision, CAIR, etc.). No medical record reviews required. 11
HEDIS Measures GCHP Reports 12
HEDIS Measure Type of Measure Domain Sub-Domain 1 Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents Hybrid Effectiveness of Care Prevention & Screening 2 Childhood Immunization Status Hybrid Effectiveness of Care Prevention & Screening 3 Immunizations for Adolescents Hybrid Effectiveness of Care Prevention & Screening 4 Cervical Cancer Screening Hybrid Effectiveness of Care Prevention & Screening 5 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Admin Effectiveness of Care Overuse/Appropriateness 6 Use of Imaging Studies for Low Back Pain Admin Effectiveness of Care Overuse/Appropriateness 7 Medication Management for People with Asthma Admin Effectiveness of Care Respiratory Conditions 8 Controlling High Blood Pressure Hybrid Effectiveness of Care Cardiovascular 9 Comprehensive Diabetes Care Hybrid Effectiveness of Care Diabetes 10 Annual Monitoring for Patients on Persistent Medications Admin Effectiveness of Care Medication Management 11 Children & Adolescent Access to PCPs Admin Access & Availability of Care Access & Availability of Care 12 Prenatal & Postpartum Care Hybrid Access & Availability of Care Access & Availability of Care 13 Well-Child Visits in the 3 rd, 4 th, 5 th, and 6 th Years of Life Hybrid Utilization & Risk Adjusted Utilization 14 Ambulatory Care Admin Utilization & Risk Adjusted Utilization Utilization Utilization 13
HEDIS Measure Definitions 14
Domain: Effectiveness of Care Sub-Domain: Prevention & Screening 15
Weight Assessment & Counseling for Nutrition & Physical Activity in Children & Adolescents (WCC) The percentage of 3 to 17 year old children and adolescents who had an outpatient visit with a PCP or OB/GYN and who received ALL of the following three services during the 2015 measurement year: BMI percentile assessment Counseling for nutrition Counseling for physical activity Three separate rates are reported for each service Data reviewed to identify compliance with measure: Claims and encounter data Medical records Hybrid Measure NCQA s Changes to the WCC Measure in 2015 Documentation of BMI value for adolescents aged 16-17 is no longer accepted BMI percentile must be documented Documentation of anticipatory guidance related to safety (e.g. wears helmet or water safety) without specific mention to physical activity recommendations no longer meets criteria for counseling for physical activity. 16
Codes to Identify WCC Description ICD-9-CM Diagnosis BMI Percentile, Pediatric <5% V85.51 Z68.51 ICD-10-CM Diagnosis CPT HCPCS UB Revenue BMI Percentile, Pediatric 5% to <85% BMI Percentile, Pediatric 85% to <95% V85.52 Z68.52 V85.53 Z68.53 BMI Percentile, Pediatric 95% V85.54 Z68.54 Counseling for Nutrition V65.3 Z71.3 97802-97804 G0270-G0271, G0447, S9449, S9452, S9470, S9449 Counseling for Physical Activity V65.41 G0447, S9451 Outpatient Visits 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, 99455-99456 G0402, G4038, G4039, G0463, T1015 0510-0523, 0526-0529, 0982-0983 17
Childhood Immunization Status (CIS) The percentage of 2-year old children who had the following childhood immunizations between 42 days after birth and on or before their 2 nd birthday: 4 DTaP (diphtheria, tetanus, and acellular pertussis) 3 IPV (polio) 1 MMR (measles, mumps, rubella) 3 HiB (H influenza type B) 3 Hep B (Hepatitis B) newborn Hep B vaccine administered during 8-day period after birth is acceptable 1 VZV (chicken pox) 4 PCV (pneumococcal conjugate) Eight rates reported: One rate for each of the seven immunizations One combo rate reported showing the percentage of children who had all seven immunizations Data reviewed to identify compliance with measure: Claims and encounter data Medical records CAIR Immunization Registry Hybrid Measure 18
Codes to Identify CIS Immunization CPT ICD-9-CM Diagnosis ICD-10-CM Diagnosis DTaP 90698, 90700, 90721, 90723 IPV 90698, 90713, 90723 MMR 90707, 90710 Measles and rubella 90708 Measles 90705 055.0, 055.1, 055.2, 055.71, 055.79, 055.8, 055.9 B05.0 B05.4, B05.81, B05.89, B05.9 Mumps 90704 072.0 072.3, 072.71, 072.72, 072.79, 072.8, 072.9 B26.0 B26.3, B26.81 B26.85, B26.89, B26.9 Rubella 90706 056.00, 056.01, 056.09, 056.71, 056.79, 056.8, 056.9 B06.00-B06.02, B06.09, B06.81-B06.82, B06.89, B06.9 19
Codes to Identify CIS Immunization CPT HCPCS ICD-9-CM Diagnosis ICD-10-CM Diagnosis ICD-9-PCS ICD-10-PCS HiB 90645-90648, 90698, 90721, 90748 Hepatitis B 90723, 90740, 90744, 90747, 90748 G0010 070.20-070.23, 070.30-070.33, V02.61 B16.0-B16.2, B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, Z22.51 99.55 3E0234Z VZV 90710,90716 052.0-052.2, 052.7-052.9, 053.0, 053.10-053.14, 053.19-053.22, 053.29, 053.71, 053.79, 053.8, 053.9 B01.0, B01.11, B01.12, B01.2, B01.81, B01.89, B01.9, B02.0, B02.1, B02.21- B02.24, B02.29-B02.34, B02.39, B02.7 B02.9 Pneumococcal Conjugate 90669, 90670 G0009 20
Immunization for Adolescents (IMA) The percentage of 13-year old adolescents who had the following immunizations: 1 Meningococcal between the member s 11 th and 13 th birthday 1 Tdap/Td between the member s 10 th and 13 th birthday Three rates are reported: One rate for each immunization One combo rate reported showing the percentage of adolescents who had both immunizations Data reviewed to identify compliance with measure: Claims and encounter data Medical records CAIR Immunization Registry Hybrid Measure 21
Codes to Identify IMA Description CPT Tetanus vaccine 90703 Td vaccine 90714, 90718 Tdap vaccine 90715 Diphtheria vaccine 90719 Meningococcal vaccine 90733, 90734 22
Cervical Cancer Screening (CCS) Measures the percentage of women, between the ages of 21 to 64, who had one of the following cervical cancer screenings: 1. Women, aged 21-64, who had a cervical cytology screening within the last 3 years 2. Women, aged 30-64, who had a cervical cytology/hpv co-screening within the last 5 years One rate reported Data reviewed to identify compliance with measure: Claims and encounter data Medical records Labs Hybrid Measure 23
Codes to Identify CCS Description CPT HCPCS LOINC UB Revenue Cervical Cancer Screening 88141-88143, 88147-88150, 88152-88154, 88164-88167, 88174-88175 G0123-G0124, G0141- 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 0923 HPV Screening 87620, 87621, 87622 21440-3, 30167-1, 38372-9, 49896-4, 59420-0, 75406-9, 75694-0 24
Domain: Effectiveness of Care Sub-Domain: Respiratory Conditions 25
Medication Management for People with Asthma (MMA) The percentage of members, 5 to 64 years of age, 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 Data reviewed to identify compliance with measure: Claims and encounter data Pharmacy data Administrative measure 26
Codes to Identify MMA Description ICD-9-CM ICD-10-CM CPT HCPCS UB Revenue Asthma 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.81, 493.82, 493.90, 493.91, 493.92 J45.20-J45.22, J45.30-J45.32, J45.40-J45.42, J45.50-J45.52, J45.901-J45.902, J45.909, J45.990, J45.991, J45.998 Outpatient 99201-99205, 99211-99215, 99217-22220, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, 99455-99456 G0402, G0438, G0439, G0463, T1015 0510-0517, 0519-0523, 0526-0529, 0982-0983 ED 99281-99285 0450-0452, 0456, 0459, 0981 Acute Inpatient 99221-99223, 99231-99233, 99238-99239, 99251-99255, 99291 0100-0101, 0110-0114, 0119-0124, 0129-0134, 0139-0144, 0149-0154, 0159-0160, 0164, 0167, 0169, 0200-0204, 0206-0214, 0219, 0720-0724, 0729, 0987 27
Domain: Effectiveness of Care Sub-Domain: Cardiovascular 28
Controlling High Blood Pressure (CBP) The percentage of 18 to 85 year old adults who had a diagnosis of hypertension and whose blood pressure was adequately controlled in 2015 based in the following criteria: Members 18 to 59 years of age whose BP was < 140/90 Members 60 to 85 years of age with diabetes whose BP was <140/90 Members 60 to 85 year of age without diabetes whose BP was <150/90 One rate reported for all three groups Data reviewed to identify compliance with measure: Medical records Hybrid Measure 29
Codes to Identify CBP Description Essential Hypertension ICD-9-CM Diagnosis ICD-10-CM Diagnosis I10 CPT HCPCS Malignant Hypertension 401.0 Benign Hypertension 401.1 Hypertension, NOS 401.9 Outpatient Visits 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, 99455-99456 G0402, G0438, G0439, G0463 30
Domain: Effectiveness of Care Sub-Domain: Diabetes 31
Comprehensive Diabetes Care (CDC) The percentage of 18 to 75 year old adults with diabetes (Type 1 & 2) who had the following six screenings: Six rates reported: Hemoglobin A1c (HbA1c) testing HbA1c poor control (>9.0%) HbA1c control (<8.0%) Diabetic retinal eye exam Medical attention for nephropathy that includes a nephropathy screening, monitoring test or evidence of nephropathy. Blood Pressure control (<140-90 mm Hg) Data reviewed to identify compliance with measure: Claims and encounter data Vision claims Medical records Labs Hybrid Measure 32
Codes to Identify Members with Diabetes Description ICD-9-CM ICD-10-CM Diabetes 250.00. 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 366.41, 648.00, 648.01, 648.02, 648.03, 648.04 E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, E13.36, E13.39, E13.40, E13.41, E13.42, E413.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, 024.012, 024.013. 024.019, 024.02, 024.03, 024.111, 024.112, 024.113, 024.119, 024.12, 024.13, 024.311, 024.312, 024.313, 024.319, 024.32, 024.33, 024.811, 024.812, 024.813, 024.819, 024.82, 024.83 33
Codes to Place of Diabetic Services Description CPT CPT Category II LOINC Outpatient 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, 99455-99456 G0402, G0438, G0439, G0463, T1015 0510-0517, 0519-0523, 0526-0529, 0982-0983 Observation 99217-99220 ED 99281, 99282, 99823, 99284, 99285 Nonacute Inpatient 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337 Inpatient 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251, 99252, 99253, 99254, 99255, 99291 0450, 0451, 0452, 0456, 0459, 0981 0118, 0128, 0138, 0148, 0158, 0190-0194, 0199, 0524, 0525, 0550-0552, 0559-0663, 0669 0100, 0101, 0110-0114, 0116-0124, 0126-0134, 0136-0144, 0146-0154, 0156-0160, 0164, 0167, 0169-0174, 0179, 0190-0194, 0199-0204, 0206-0214, 0219, 0720-0724, 0729, 0987, 1000-1002 34
Codes to Identify HbA1c Screening for Diabetic Members Description CPT CPT Category II LOINC HbA1c Tests 83036, 83037 3044F, 3045F, 3046F 17856-6, 4548-4, 4549-2 HbA1c Levels < 7.0 % HbA1c Levels 7.0 9.0 % 3044F 3045F HbA1c Levels > 9.0 % 3046F 35
Codes to Identify Retinal Eye Exams for Diabetic Members Description CPT CPT Category II HCPCS Diabetic Retinal Screening 67028, 67030, 67031, 67036, 67039, 67040, 67041, 67042, 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, 92226, 92227, 92228, 92230, 92235, 92240, 92250, 92260, 99203, 99204, 99205, 99213, 99214, 99215, 99242, 99243, 99244, 99245 2022F, 2024F, 2026F, S0620, S0621, S0625, S3000 Negative Diabetic Retinal Screening 3072F 36
Codes to Identify Screening/Monitoring for Nephropathy Description ICD-9-CM ICD-10-CM CPT Category II Evidence of Nephropathy Treatment 250.40-250.43, 403.00, 403.01, 403.10, 403.11, 403.90, 403.91, 404.00-404.03, 404.10-404.13, 404.90-404.93, 405.01, 405.11, 405.91, 580.0, 580.4, 580.81, 580.89, 580.9, 581.0-581.3, 581.81, 581.89, 581.9, 582.0, 582.1, 582.2, 582.4, 582.81, 582.89, 582.9, 583.0-583.2, 583.4, 583.6, 583.7, 583.81, 583.89, 583.9, 584.5-584.9, 586, 587, 588.0, 588.1, 588.81, 588.89, 588.9, 753.0, 753.10-753.17, 753.19, 791.0 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-N00.9, N01.0-N01.9, N02.0-N02.9, N03.0-N03.9, N04.0-N04.9, N05.0-N05.9, N06.0-N06.9, N07.0-N07.9, N08, N14.0-N14.4, N17.0, N17.1, N17.2, N17.8, N17.9, N18.1-N18.6, N18.9, N19, N25.0, N25.1, N25.81, N25.89, N25.9, N26.1, N26.2, N26.9, Q60.0- Q60.6, Q61.00-Q61.02, Q61.11, Q61.19, Q61.2-Q61.5, Q61.8, Q61.9, R80.0-R80.3, R80.8, R80.9 3066F, 4010F Description CPT CPT Category II LOINC Nephropathy 3060F, 3061F, Screening Test 3062F 81000, 81001, 81002, 81003, 81005, 82042, 82043, 82044, 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, 9318-7 37
Codes to Identify Evidence of Nephropathy Description ICD-9-CM ICD-9-PCS ICD-10-CM ICD-10-PCS CPT HCPCS Revenue Codes CKD Stage 4 585.4 N18.4 ESRD 585.5, 585.6, V45.11, V45.12 38.95, 39.27, 39.42, 39.43, 39.53, 39.93, 39.94, 39.95, 54.98 N18.5, N18.6, Z91.15, Z99.2 3E1M39Z, 5A1D00Z, 5A1D60Z 36147, 36800, 36810, 36815, 36818-36821, 36831-36833, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512 G0257, S9339 0800-0804, 0809, 0820-0825, 0829-0835, 0839-0845, 0849-0855, 0859, 0880-0882, 0889 Kidney Transplant V42.0 55.61, 55.69 Z94.0 0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY1072 50300, 50320, 50340, 50360, 50365, 50370, 50380 S2065 0367 38
Domain: Effectiveness of Care Sub-Domain: Medication Management 39
Annual Monitoring for Patients on Persistent Medications (MPM) The percentage of adults, 18 years of age and older, who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and had at least one therapeutic monitoring event for the therapeutic agent during the measurement year. Four rates are reported for the following therapeutic agents: Angiotensin Converting Enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) Digoxin Diuretics Total rate Data reviewed to identify compliance with measure: Claims and encounter data Pharmacy Data Labs Administrative measure 40
Codes to Identify MPM Description CPT LOINC Lab Panel 80047, 80048, 80050, 88053, 80069 Digoxin Level 80162 3563-4, 10535-3 Serum Potassium (K+) 80051, 84132 12812-4, 12813-2, 22760-3, 2823-3, 2824-1, 29349-8, 32713-0, 39789-3, 39790-1, 41656-0, 51618-7, 6298-4 Serum Creatinine (SCr) 82565, 82575 11041-1, 11042-9, 12195-4, 13441-1, 13442-9, 13443-7, 13446-0, 13447-8, 13449-4, 13450-2, 14682-9, 16188-5, 16189-3, 21232-4, 2160-0, 2163-4, 2164-2, 26752-6, 31045-8, 33558-8, 35203-9, 35591-7, 35592-5, 35593-3, 35594-1, 38483-4, 39955-0, 39956-8, 39957-6, 39958-4, 39959-2, 39960-0, 39961-8, 39962-6, 39963-4, 39964-2, 39965-9, 39966-7, 39967-5, 39968-3, 39969-1, 39970-9, 39971-7, 39972-5, 39973-3, 39974-1, 39975-8, 39976-6, 40112-5, 40113-3, 40114-1, 40115-8, 40116-6, 40117-4, 40118-2, 40119-0, 40120-8, 40121-6, 40122-4, 40123-2, 40124-0, 40125-7, 40126-5, 40127-3, 40128-1, 40248-7, 40249-5, 40250-3, 40251-1, 40252-9, 40253-7, 40254-5, 40255-2, 40256-0, 40257-8, 40258-6, 40264-4, 40265-1, 40266-9, 40267-7, 40268-5, 40269-3, 40270-1, 40271-9, 40272-7, 40273-5, 44784-7, 50380-5, 50381-3, 51619-5, 51620-3, 59826-8, 59834-2, 62425-4 41
Domain: Effectiveness of Care Sub-Domain: Overuse/Appropriateness NCQA Added New Sub-Domain in 2015 42
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) The percentage of 18 to 64 year old adults with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. One rate reported Data reviewed to identify compliance with measure: Claims and encounter data Rx data Administrative measure NCQA s Changes to the AAB Measure in 2015 AAB measure moved from Respiratory Conditions sub-domain to Overuse/Appropriateness sub-domain 43
Codes to Identify AAB Description Acute Bronchitis Outpatient Visits ICD-9-CM Diagnosis* ICD-10-CM Diagnosis 466.0 J20.3-J20.9 CPT HCPCS UB Revenue 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, 99455-99456 G0402 G0438 G0439 G0463 T1015 0510-0517, 0519-0523, 0526-0529, 0982-0983 Emergency Department Visits 99281-99285 0450-0452, 0456, 0459, 0981 44
Use of Imaging Studies for Low Back Pain (LBP) The percentage of members (any age) with a primary diagnosis of low back pain who did not have an imaging study within 28 days of the diagnosis. One rate reported Data reviewed to identify compliance with measure: Claims and encounter data Administrative measure NCQA s Changes to the LBP Measure in 2015 LBP measure moved from Musculoskeletal Conditions sub-domain to Overuse/Appropriateness sub-domain 45
Codes to Identify LBP Description ICD-9-CM Diagnosis ICD-10-CM Diagnosis Low Back Pain 721.3, 722.10, 722.32, 722.52, 722.93, 724.02, 724.03, 724.2, 724.3, 724.5, 724.6, 724.70, 724.71, 724.79, 738.5, 739.3, 739.4, 846.0, 846.1, 846.2, 846.3, 846.8, 846.9, 847.2 M46.46-M46.48, M47.26-M47.28, M47.816-M47.818, M47.896-M47.898, M48.06-M48.08, M51.16, M51.17, M51.26, M51.27, M51.36, M51.37, M51.46, M51.47, M51.86, M51.87, M53.2X6 - M53.2X8. M53.3, M53.86 - M53.88, M54.30 - M54.32, M54.40- M54.42, M54.5, M54.89, M54.9, M99.83, M99.84, S33.100A, S33.100D, S33.100S, S33.110A, S33.110D, S33.110S, S33.120A, S33.120D, S33.120S, S33..130A, S33.130D, S33.130S, S33.140A, S33.140D, S33.140S, S33.5XXA, S33.6XXA, S33.8XXA, S33.9XXA, S39.002A, S39.002D, S39.002S, S39.0012A, S39.012D, S39.012S, S39.029A, S39.029D, S39.029S, S39.82XA, S39.82XD, S39.82XS, S39.92XA, S39.92XD, S39.92XS 46
Codes to Identify LBP Description CPT HCPCS UB Revenue Osteopathic Manipulative Study 98925-98929, 98940-98942 Imaging Study 72010, 72020, 72052, 72100, 72110, 72114, 72120, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72158, 72200, 72202, 72220 0320, 0329, 0350, 0352, 0359, 0610, 0612, 0614, 0619, 0972 Outpatient Visits/Observation 99201-99205, 99211-99215, 99217-9220, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, 99455-99456 G0402, G0438, G0439. G0463, T1015 0510-0517, 0519-0523, 0526-0529, 0982-0983 Emergency Department Visits 99281-99285 0450, 0451, 0452, 0456, 0459, 0981 47
Domain: Access and Availability of Care 48
Children & Adolescents Access to PCPs (CAP) The percentage of members: 12 months to 6 years old who had a visit with a PCP during the measurement year (2015) 7 to 19 years old who had a visit with a PCP during the measurement year (2015) or the year prior to the measurement year (2014) Four rates are reported for the following age groups: 12 to 24 months 25 months to 6 years 7 to 11 years 12 to 19 years Data reviewed to identify compliance with measure: Claims and encounter data Administrative measure 49
Codes to Identify CAP Description Wellness Exams V20.2 V70.0 V70.3 V70.5 V70.6 V70.8 V70.9 ICD-9-CM Diagnosis ICD-10-CM Diagnosis Z00.00 Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.81- Z02.83, Z02.89, Z02.9 CPT HCPCS UB REV Ambulatory Visit 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429 Wellness Visits G0402, G4038, G4039, G0463, T1015 0510-0517, 0519-0523, 0526-0529, 0982-0983 50
Prenatal & Postpartum Care (PPC) The percentage of women with live birth deliveries, between November 6, 2014 and November 5, 2015, who had prenatal and postpartum care visits. Two rates are reported: Prenatal Care: The percentage of women who had a prenatal care visit during the first trimester or within 42 days of enrollment with their health plan Postpartum Care: The percentage of women who had a postpartum care visit between 21 and 56 days after delivery Data reviewed to identify compliance with measure: Claims and encounter data Medical records Hybrid measure 51
Codes to Identify Members for the Prenatal and Postpartum Care Measure Description ICD-9-CM ICD-10 CM Pregnancy Diagnosis 640.x3, 641.x3, 642.x3, 643.x3, 644.x3, 645.x3, 646.x3, 647.x3, 648.x3, 649.x3, 651.x3, 652.x3, 653.x3, 654.x3, 655.x3, 656.x3, 657.x3, 658.x3, 659.x3, 678.x3, 679.x3, V22.0- V22.2, V23.0- V23.3, V23.41, V23.42, V23.49, V23.5, V23.7, V23.81-V23.87, V23.89, V23.9, V28.0-V28.6, V28.81, V28.82, V28.89, V28.9 O09.0x, O09.1x, O09.21x, O09.29x, O09.3x, O09.4x, O09.51x, O09.52x, O09.61x, O09.62x, O09.7x, O09.81x, O09.82x, O09.89x, O09.9x, O10.1x, O10.21x, O10.31x, O10.41x, O10.91x, O11.x, O12.0x, O12.1x, O12.2x, O13.x, O14.0x, O14.1x, O14.2x, O14.9x, O15.0x, O15.1, O15.9, O16.x, O20.x, O21.x, O22.0x, O22.1x, O22.2x, O22.3x, O22.4x, O22.5x, O22.8Xx, O22.9x, O23.0x, O23.1x, O23.2x, O23.3x, O23.4x, O23.51x, O23.52x, O23.59x, O23.9x, O24.01x, O24.11x, O24.31x, O24.41x, O24.81x, O24.91x, O25.1x, O26.0x, O26.1x, O26.2x, O26.3x, O26.4x, O26.5x, O26.61x, O26.71x, O26.81x, O26.82x, O26.83x, O26.84x, O26.85x, O26.86, O26.87x, O26.89x, O26.9x, O28.x, O29.01x, O29.02x, O29.09x, O29.11x, O29.12x, O29.19x, O29.21x, O29.29x, O29.3Xx, O29.4x, O29.5Xx, O29.6x, O29.8Xx, O29.9x, O30.00x, O30.01x, O30.02x, O30.03x, O30.04x, O30.09x, O30.10x, O30.11x, O30.12x, O30.19x, O30.20x, O30.21x, O30.22x, O30.29x, O30.80x, O30.81x, O30.82x, O30.89x, O30.9x, O31.00Xx, O31.01Xx, O31.02Xx, O31.03Xx, O31.10Xx, O31.11Xx, O31.12Xx, O31.13Xx, O31.20Xx, 031.21Xx, O31.22Xx, O31.23Xx, O31.30Xx, O31.31Xx, O31.32Xx, O31.33Xx, O31.8X1x, O31.8X2x, O31.8X3x, O31.8X9x, O32.0XXx, O32.1XXx, O32.2XXx, O32.3XXx, O32.4XXx, O32.6XXx, O32.8XXx, O32.9XXx, O33.0 - O33.2, O33.3XXx, O33.4XXx, O33.5XXx, O33.6XXx, O33.7-O33.9, O34.0x, O34.1x, O34.2x, O34.3x, O34.4x, O34.51x, O34.52x, O34.53x, O34.59x, O34.6x, O34.7x, O34.8x, O34.9x, O35.0XXx, O35.1XXx, O35.2XXx, O35.3XXx, O35.4XXx, O35.5XXx, O35.6XXx, O35.7XXx, O35.8XXx, O35.9XXx, O36.011x, O36. 012x, O36.013x, O36.019x, O36.091x, O36.092x, O36.093x, O36.099x, O36.111x, O36.112x, O36.113x, O36.119x, O36.191x, O36.192x, O36.193x, O36.20Xx, O36.21Xx, O36.22Xx, O36.23Xx, O36.4XXx, O36.511x, O36.512x, O36.513x, O36.519x, O36.591x, O36.592x, O36.593x, O36.599x, O36.60Xx, O36.61Xx, O36.62Xx, O36.63Xx, O36.70Xx, O36.71Xx, O36.72Xx, O36.73Xx, O36.80Xx, O36.812x, O36.813x, O36.819x, O36.821x, O36.822x, O36.823X, O36.829x, O36.891x, O36.892x, O36.893x, O36.899x, O36.90Xx, O36.91Xx, O36.92Xx, O36.93Xx, O40.1XXx, O40.2XXx, O40.3XXx, O40.9XXx, O41.00Xx, O41.01Xx, O41.02Xx, O41.03Xx, O41.101x, O41.102x, O41.103x, O41.109x, O41.121x, O41.122x, O41.123x, O41.129x, O41.141x, O41.142x, O41.143x, O41.149x, O41.8X1x, O41.8X2x, O41.8X3x, O41.8X9x, O41.90Xx, O41.91Xx, O41.92Xx, O41.93Xx, O42.00, O42.01x, O42.02, O42.10, O42.11x, O42.12, O42.90, O42.91x, O42.92, O43.01x, O43.02x, O43.10x, O43.11x, O43.12x, O43.19x, O43.21x, O43.22x, O43.23x, O43.81x, O43.89x, O43.9x, O44.0x, O44.1x, O45.00x, O45.01x, O45.02x, O45.09x, O45.8Xx, O45.9x, O46.00x, O46.01x, O46.02x, O46.09x, O46.8Xx, O46.9x, O47.0x, O47.1, O47.9, O48.x, O60.0x, O71.0x, O71.1-O71.7, O71.8x, O71.9, O88.01x, O88.11x, O88.21x, O88.31x, O88.81x, O91.01x, O91.03, O91.11x, O91.03, O91.21x, O91.23, O92.01x, O92.03, O92.11x, O92.13, O92.3-O92.6, O92.7x, O98.01x, O98.11x, O98.21x, O98.31x, O98.41x, O98.51x, O98.61x, O98.71x, O98.81x, O98.91x, O99.01x, O99.11x, O99.21- O99.213, O99.280-O99.283, O99.310-O99.313, O99.320-O99.323, O99.330-O99.333, O99.340-O99.343, O99.350-O99.353, O99.41x, O99.51x, O99.61x, O99.71x, O99.810, O99.820, O99.840-O99.843, O9A.11x, O9A.21x, O9A.31x, O9A.41x, O9A.51x, Z03.7x, 52 Z33.x, Z34.0x, Z34.8x, Z34.9x, Z36
Codes to Identify Members for the Prenatal and Postpartum Care Measure Description ICD-9-CM ICD-9-PCS ICD-10-PCS CPT Live Deliveries 640.x1, 641.x1, 642.x1, 642.x2, 643.x1, 644.21, 645.x1, 646.x1, 646.x2, 647.x1, 647.x2, 648.x1, 648.x2, 649.x1, 649.x2, 650, 651.x1, 652.x1, 653.x1, 654.x1, 654.x2, 655.x1, 656.01, 656.11, 656.21, 656.31, 656.51, 656.61, 656.71, 656.81, 656.91, 657.01, 658.x1, 659.x1, 660.x1, 661.x1, 662.x1, 663.x1, 664.x1, 665.x1, 665.x2, 666.x2, 667.x2, 668.x1, 668.x2, 669.x1, 669.x2, 670.02, 671.x1, 671.x2, 672.02, 673.x1, 673.x2, 674.x1, 674.x2, 675.x1, 675.x2, 676.x1, 676.x2, 678.x1, 679.x1, 679.x2, V27.0, V27.2, V27.3, V27.5, V27.6 72.0, 72.1, 72.21, 72.29, 72.31, 72.39, 72.4, 72.51-72.54, 72.6, 72.71, 72.79, 72.8, 72.9, 73.01, 73.09, 73.1, 73.21, 73.22, 73.3, 73.4, 73.51, 73.59, 73.6, 73.8, 73.91-73.94, 73.99, 74.0-74.2, 74.4, 74.99 10D00Z0, 10D00Z1, 10D00Z2, 10D07Z3, 10D07Z4, 10D07Z5, 10D07Z6, 10D07Z7, 10D07Z8, 10D17ZZ, 10D18ZZ, 10D27ZZ, 10D28ZZ, 10E0XZZ 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620, 59622 53
Codes to Identify Prenatal Office Visits Description CPT CPT Category II HCPCS UB Revenue Prenatal Bundles Visits Billed on date of delivery 59400, 59425, 59426, 59510, 59610, 59618 Prenatal Visits 80055, 99201-99205, 99211-99215, 99241-99245, 99500 H1005 0500F, 0501F, 0502F G0463, H1000, H1001, H1002, H1003, H1004, T1015 0514 54
Codes to Identify Prenatal Screenings Description ICD-9-PCS ICD-10-PCS CPT LOINC Prenatal Ultrasound 88.78 BY49ZZZ, BY4BZZZ, BY4CZZZ, BY4DZZZ, BY4FZZZ, BY4GZZZ 76801, 76805, 76811, 76813, 76815-76821, 76825-76828 Antibody Screenings: Taxoplasmy, Rubella, Herpes Simplex, or Cytomegalovirus 86644, 86694, 86695, 86696, 86762, 86777, 86778 ABO Screening 86900 883-9, 57743-7 Rh Screening 86901 10331-7, 1305-2, 34961-3, 972-0, 978-7 ABO and Rh Screening 10350-7, 11598-0, 12261-4, 12262-2, 13225-8, 13279-5, 13280-3, 13286-0, 13323-1, 13324-9, 13501-2, 13505-3, 13949-3, 14213-3, 15377-5, 16714-8, 16715-5, 16716-3, 16944-1, 16949-0, 16950-8, 16954-0, 16955-7, 16957-3, 16958-1, 17550-5, 17717-0, 17850-9, 17851-7, 19106-4, 21326-4, 21327-2, 21570-7, 22239-8, 22241-4, 22244-8, 22246-3, 22247-1, 22249-7, 22339-6, 22341-2, 22343-8, 22496-4, 22497-2, 22577-1, 22580-5, 22582-1, 22584-7, 23485-6, 23486-4, 23784-2, 24014-3, 24116-6, 24119-0, 24242-0, 25298-1, 25300-5, 25420-1, 25435-9, 25514-1, 25542-2, 25837-6, 25839-2, 26927-4, 27948-9, 30325-5, 30355-2, 31411-2, 31616-6, 32170-3, 32687-6, 32688-4, 32790-8, 32791-6, 32831-0, 32834-4, 32835-1, 32846-8, 33291-6, 33336-9, 34152-9, 34403-6, 34421-8, 34422-6, 34613-0, 35281-5, 35282-3, 36921-5, 40466-5, 40667-8, 40677-7, 40678-5, 40697-5, 40728-8, 40729-6, 40785-8, 40786-6, 41123-1, 41124-9, 41149-6, 41399-7, 41763-4, 42337-6, 42338-4, 42949-8, 43028-0, 43030-6, 43031-4, 43111-4, 43180-9, 43810-1, 44008-1, 44480-2, 44494-3, 44507-2, 45210-2, 45326-6, 47230-8, 47307-4, 47363-7, 47389-2, 47390-0, 47430-4, 48784-3, 49107-6, 49539-0, 49848-5, 50694-9, 50758-2, 5121-9, 5122-7, 5124-3, 5125-0, 5126-8, 5127-6, 51915-7, 51916-5, 51931-4, 5202-7, 5203-5, 5204-3, 5205-0, 5206-8, 5207-6, 5208-4, 5209-2, 5210-0, 52976-8, 52977-6, 52981-8, 52984-2, 52986-7, 5330-6, 5331-4, 5332-2, 5333-0, 5334-8, 5335-5, 53377-8, 53560-9, 5387-6, 5388-4, 5389-2, 5390-0, 5391-8, 56990-5, 56991-3, 57321-2, 59838-3, 63462-6, 7851-9, 7852-7, 7853-5, 7907-9, 7908-7, 7909-5, 7910-3, 7911-1, 7912-9, 7913-7, 8013-5, 8014-3, 8015-0, 8039-0, 8040-8, 9422-7, 9513-3 882-1, 884-7 55
Codes to Identify Postpartum Visits Description ICD-9-CM ICD-10-CM CPT CPT Category II HCPCS LOINC UB Revenue ICD-9-PCS Postpartum Visits Postpartum Bundled Visits V24.1, V24.2, V25.11, V25.12, V25.13, V72.31, V72.32, V76.2 Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2 57170, 58300, 59430, 99501 59400, 59410, 59510, 59515, 59610, 59614, 59618, 59622 0503F G0101 89.26 Cervical Cytology 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175 G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091 10524-7, 18500-9, 0923 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5 56
Domain: Utilization and Risk Adjusted Utilization NCQA revised domain in 2015 from Utilization and Relative Resource Use to Utilization and Risk Adjusted Utilization 57
Well-Child Visits in the 3 rd, 4 th, 5 th, and 6 th Years of Life (W34) The percentage of 3 to 6 year old children who had one or more well-child visit(s) with a PCP in 2015 and the provider of care assessed and documented ALL of the following: Health history Physical developmental history Mental developmental history Physical Exam Health education/anticipatory guidance One rate reported Data reviewed to identify compliance with measure: Claims and encounter data Medical records Hybrid measure 58
Codes to Identify W34 Description ICD-9-CM Diagnosis ICD-10-CM Diagnosis CPT HCPCS Well care exam V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02-6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9 Annual Wellness Visit G0438, G0439 Office Visit 99381-99385, 99391-99395, 99461 59
Ambulatory Care (AMB) This measures summarizes utilization of ambulatory care in 2015 in the outpatient and emergency department. Two rates reported: Outpatient utilization Emergency Department utilization Data audited to identify compliance with measure: Claims and encounter data Administrative measure 60
Codes to Identify AMB Description CPT HCPCS UB Revenue POS Ambulatory Outpatient Visits 92002, 92004, 92012, 92014, 99201-99205, 99211-99215, 99241-99245, 99304-99310, 99315-99316, 99318, 99324-99328, 99334-99337, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99420, 99429, 99461 G0463, T1015 0510-0517, 0519-0529, 0982-0983 Emergency Department 99281-99285 0450-0452, 0456, 0459, 0981 23 61
Codes to Identify AMB Description CPT UB Revenue POS Emergency Department Visit 99281-99285 0450-0452, 0456, 0459, 0981 ED Procedure Code 10030, 10040, 10060, 10061, 10080, 10081, 10120, 10121, 10140, 10160, 10180. 11000, 11001, 11004-11006, 11008, 11010-10012, 10042-10047, 10055-10057, 11100, 11101, 11200, 11201, 11300-11208, 11310-11313, 11400-11406, 11420-11424, 11426, 11440-11446, 11450, 11451, 23 23 62
Reasons for Low HEDIS Rates 63
Reason for Low HEDIS Rates Clinics did not submit claims or encounter data No data = No history of services performed Coding on claims and encounter data is incomplete or inaccurate Incomplete or inaccurate coding = No history of services performed Delayed claims & encounter submissions Medical record documentation is incomplete Patients did not receive annual screenings Patients with chronic conditions are not monitored Patients on persistent medications are not monitored Clinics are not familiar with HEDIS measure criteria 64
How to Improve your HEDIS Rates 65
How to Improve your HEDIS Rates Timely submission of all claims and encounter data Complete and accurate coding of all services performed Document all services and care provided in the medical record Include child and adolescent counseling for nutrition and physical activity Schedule patients for their annual screenings and check-ups Children are expected to have annual check-ups Continually monitor patients with chronic conditions Continually monitor patients on persistent medications Understand the HEDIS measure criteria and the standard practice guidelines 66
2016 Medical Codes for HEDIS Reporting To obtain a complete list of the medical codes used by NCQA to identify compliance with HEDIS measures click on the following link, NCQA s Quality Rating System HEDIS Value Set Directory or visit www.ncqa.org. 67
HEDIS Questions? Please email HEDIS questions to hedis@goldchp.org 68