HEDIS MEASURES (CY ) MEDICARE QUICK REFERENCE GUIDE FOR BILLING DEPARTMENT Care for Older Adults Colorectal Cancer Screening Annual Monitoring for Patients on Persistent Medications COA COL MPM Age Description CPT HCPCS Codes Revenue Codes ICD-9 Codes & Procedure 66 and older 51-75 as of, 18 s and older as of, Advance care planning Medication review/list S0257 1160F & 1159F Functional evaluation 1170F 93.01 Pain Screening One of the following: 0521F, 1125F, 1126F Fecal Occult Blood Test (in 2011) 82270, 82274 G0328 Flexible sigmoidoscopy (during measurement or the four s prior) Colonoscopy (during measurement or the nine s prior) Received at least 180 treatment days of ARB and needs at least ONE therapeutic monitoring event. 45330-45335, 45337-45342, 45345 G0104 45.24 44388-44394, 44397, 45355, 45378-45387, 45391, 45392 Therapeutic monitoring event: Lab panel, Serum potassium (K+), Serum creatinine (SCr) or Blood G0105, G0121 45.22, 45.23, 45.25, 45.42, 45.43 Received at least 180 treatment days of ACE inhibitors and needs at least ONE therapeutic monitoring event. Received at least 180 treatment days of digoxin and needs at least ONE therapeutic monitoring event. Therapeutic monitoring event: Lab panel, Serum potassium (K+), Serum creatinine (SCr) or Blood Therapeutic monitoring event: Lab panel, Serum potassium (K+), Serum creatinine (SCr) or Blood Received at least 180 treatment days of anticonvulsants and needs at least ONE therapeutic monitoring event. Therapeutic monitoring event: Lab panel, Serum potassium (K+), Serum creatinine (SCr) or Blood Medication reconciliation post discharge MRP 66 s and older as of, Reconcile members medications on or within 30 days of discharge. Inpatient discharge occurring on or between January 1 and December 1,. 1111F Controlling high blood pressure; chart review CBP 18-85 s as of, Document blood pressure on members who have a diagnosis of hypertension. 401 Osteoporosis management in women who had a fracture OMW Women 67 s and older as of, Ensure a Bone Mineral Density (BMD) test is performed on date of fracture or 180 days after or during the inpatient stay or dispensed prescription to treat osteoporosis on or in the 180 day period after the fracture. 76070, 76071, 76075-76078, 76977, 77078-77083, 78350, 78351 G0130 88.98
HEDIS MEASURES (CY ) MEDICARE QUICK REFERENCE GUIDE FOR BILLING DEPARTMENT Use of spirometry testing in the assessment and diagnosis of COPD SPR Age Description CPT HCPCS Codes Revenue Codes ICD-9 Codes & Procedure 42 s or older as of, Determine how many members with a new diagnosis or newly active COPD who received appropriate spirometry testing to confirm diagnosis. 94010, 94014-94016, 94060, 94070, 94375, 94620 491, 492,493.2 496 Glaucoma screening in older adults. Must be performed by an ophthalmologist or optometrist GSO 67 s and older as of, To ensure members receive glaucoma eye exam by an eye care professional for early identification of glaucomatous conditions. 92002, 92004, 9, 92014, 92081-92083, G0117, G0118, S0620, 92100, 92120, 92130, 92140, 99202-99205, 99213- S0621 99215, 99242-99245 95.02, 95.03, 95.26 Potentially harmful drug-disease interactions in the elderly DDE 67 s and older as of, Medicare members who have evidence of an underlying disease, condition or health concern and who were dispensed an ambulatory prescription for contraindicated medication, concurrent with or after the diagnosis. A history of falls and a prescription for tricyclic antidepressants, antipsychotics or sleep agents Dementia and a prescription for tricyclic antidepressants or anticholinergic agents CRF and prescription for nonaspirin NSAIDs or Cox-2 Selective NSAIDs Use of high-risk medication in the elderly. DAE 66 s and older as of, Medicare members who received at least one high risk medication or two different high risk medications Adult BMI ABA 18 s as of January 1,2010 to 74 s as of, Medicare members who had an outpatient visit and who had their body mass index (BMI) documented during the measurement or the prior the G0402 V85.0-V85.5
HEDIS MEASURES (CY ) MEDICARE QUICK REFERENCE GUIDE FOR BILLING DEPARTMENT Adults' Access to preventive/ambulatory health services AAP Age Description CPT HCPCS Codes Revenue Codes ICD-9 Codes & Procedure 20-65 s and older as of of the Percentage of members who had an ambulatory or preventative care visit. Office:99201-99205, 99211-99215. Home services: 99241-99245, 99341-99345, 99347-99350. Nursing facility care: 99304-99310, 99315, 99316, 99318. Domiciliary, rest home or custodial care services: 99324-99328, 99334-99337. Preventive medicine: 99385-99387, 99395-99397, 99401-99404, 99411, 99412, 99420, 99429. Ophthalmology and optometry: 92002, 92004, 9, 92014, S0620, S0621 G0344, G0404 V70.0, V70.3, V70.5, V70.6, Breast cancer screening BCS Women between 42- One mammogram to screen for breast cancer. 77055-77057 G0202, G0204, G0206 87.36, 87.37 69 Cholesterol management for patients with CVD CMC 18-75 s as of of the Medicare members who were discharged alive for AMI, 80061, 83700, 83701, 83704, 83721 CABG, PCI from January 1- November 1 of the prior to the measurement, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement and the prior to the measurement, who had EACH of the following during the measurement : LDL-C screening and LDL-C control (<100mg/dL) Disease modifying antirheumatic drug therapy in rheumatoid arthritis ART 18 s and older as of, Members who were diagnosed with rheumatoid arthritis and who were dispensed at lease one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD). J1600, J9250, J9260, J0129, J0135, J1438, J1745, J9310, J7502, J7515, J7516 Follow-up after hospitalization for mental illness FUH 6 s and older as of the date of discharge. Members who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practioner. Initiation of engagement of alcohol and other drug dependence treatment IET 13 s and older as of of the measurement. Members with a new episode of alcohol or other drug (AOD) dependence who received the following: Initiation of AOD treatment within 14 days of diagnosis and Engagement of AOD treatment within 30 days of the initiation visit. H0008-H0014 116, 126, 136, 146, 156 94.62, 94.65, 94.68, 94.61, 94.63, 94.64, 94.66, 94.67, 94.69
HEDIS MEASURES (CY ) MEDICARE QUICK REFERENCE GUIDE FOR BILLING DEPARTMENT Persistence of Beta-Blocker treatment after a heart attack PBH Age Description CPT HCPCS Codes Revenue Codes ICD-9 Codes & Procedure 18 s and older as of of the measurement Members who were hospitalized and discharged alive from July 1 of the prior to the measurement to June 30 of the measurement with a diagnosis of AMI and who RECEIVED persistent beta-blocker treatment for six months after discharge. Pharmacotherapy Management of COPD exacerbation PCE 40 s or older as of January 1 of the Members who had an acute inpatient discharge or ED encounter between January 1-November 30 of the measurement and who were DISPENSED appropriate medications (systemic corticosteroid within 14 days of the event or bronchodilator within 30 days of the event) Antidepressant Medication Management AMM 18 Years and older as of April 30 of the measurement Members who were diagnoses with a new episode of major depression and treated with antidepressant medication, and who remained on an antidepressant medication treatment for 84 days or at least 180 days 296.20-296.25, 296.30-296.35, 298.0, 300.4, 309.1, 311 Test HEDIS 18-75 s as of HbA1c Tests 83036, 83037 poor control <9.0% HEDIS 18-75 s as of HbA1c Tests- Poor Control 83036, 83037 Control <8.0% HEDIS 18-75 s as of HbA1c Tests- Control <8% 83036, 83037 CDC- LDC screen CDC- LDL control <100 mg/dl CDC- Nephropathy test 18-75 s as of 18-75 s as of 18-75 s as of LDL-C Screening- Screening 80061, 83700, 83701, 83704, 83721 LDL-C (Control) 80061, 83700, 83701, 83704, 83721 Nephropathy screening test 82042, 82043, 82044, 84156
HEDIS MEASURES (CY ) MEDICARE QUICK REFERENCE GUIDE FOR BILLING DEPARTMENT CDC-Evidence of tx of nephropathy Age Description CPT HCPCS Codes Revenue Codes ICD-9 Codes & Procedure 18-75 s as of Evidence of treatment for nephropathy 36800, 36810, 36815, 36818, 36819-36821, 36831-36833, 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90920, 90921, 90924, 90925, 90935, 90937, 90939, 90940, 90945, 90947, 90989, 90993, 90997, 90999, 99512 G0257, G0314-G0319, G0322, G0323, G0326, G0327, S9339 250.4, 403, 404, 405.01, 405.11, 405.91, 580-588, 753.0, 753.1, 791.0, V42.0, V45.1, V56. 38.95, 39.27, 39.42, 39.43, 39.53, 39.93-39.95, 54.98, 55.4-55.6. 250, 357.2, 362.0, 366.41, 648.0 CDC-B/P CDC-B/P 18-75 s as of 18-75 s as of Document chart blood pressure. Numerator compliant (BP <130/80 mm Hg) Document chart blood pressure. Numerator compliant (BP <140/90 mm Hg)
Adolescent Well-Care Visits. Provider Incentive: $20 per eligible claim. Member incentive: $20.00 gift card to AMC or Regal Children and Adolescent Access to Primary Care Practitioners AWC CAP Children and Adolescent s Access to Primary Care Practitioners CAP COMMUNITY HEALTH GROUP HEDIS MEASURES (CY ) HEALTHY FAMILIES QUICK REFERENCE GUIDE FOR BILLING DEPARTMENT Age 12-21 s as of, 12-24 months as of, 25 months- 6 s as of, Description CPT ICD-9 Codes & Procedure At least one comprehensive well-care visit during the Members who had a visit with a PCP. 99204-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99385, 99391-99395, 99401-99404, 99411-99412, 99420, 99429 Members who had a visit with a PCP. 99204-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99385, 99391-99395, 99401-99404, 99411-99412, 99420, 99429 99383-99385, 99393-99395 V70.6, V70.6, V70.6, Children and Adolescent s Access to Primary Care Practitioners CAP 7-11 s as of December 31, Members who had a visit with a PCP. 99204-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99385, 99391-99395, 99401-99404, 99411-99412, 99420, 99429 V70.6, Children and Adolescent s Access to Primary Care Practitioners CAP 12-19 s as of, Members who had a visit with a PCP. 99204-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99385, 99391-99395, 99401-99404, 99411-99412, 99420, 99429 V70.6, Chlamydia Screening for sexually active women. Member incentive: $20.00 gift card CHL Women between 16-24 s Women who were identified as sexually active and who had at least one test for Chlamydia during the measurement. 87110, 87270, 87320, 87490, 87491, 87492, 87810 Childhood Immunization CIS 2 yrs of age during DtaP- Qty 4 90698, 90700, 90701, 90720, 90721, measurement 90723 Childhood Immunization CIS IPV- Qty 3 90698, 90713, 90723 045, 99.41 Childhood Immunization CIS MMR - Qty 1 90707, 90710 99.48 Childhood Immunization CIS HiB- Qty 3 90645, 90646, 90647, 90648, 90698, 90720, 90721, 90748 Childhood Immunization CIS Hepatitis B- Qty 3 90723, 90740, 90744, 90747, 90748 070.2, 070.3 Childhood Immunization CIS VZV- Qty 1 90710, 90716 052, 053 Childhood Immunization CIS Pneumococcal conjugate (PCV)- Qty 4 90669 Childhood Immunization CIS- 10 Hepatitis A- Qty 1 90633 Childhood Immunization CIS- 10 Rotavirus 90680 & 90681 Childhood Immunization CIS- 10 Influenza- Qty 2 90655, 90657, 90661, 90662 Immunizations for adolescents IMA Members who turn 13 s of age during the Adolescents 13 s of age who had one dose of meningococcal vaccine and Tdap or Td by their 13th birthday. 90733, 90734, 90715, 90714, 90718, 90703, 90719 99.39 041.5, 038.41, 320.0, 482.2 Appropriate testing for children with pharyngitis. CWP 2 s as of July 1, 2010 to 18 s as of June 30, Children with a diagnosis of pharyngitis are dispensed an antibiotic and receive a group A strep test for the episode. 87070, 87071, 87081, 87430, 87650-87650, 87880 462, 463, 034.0 (Dx for pharyngitis)
Appropriate treatment for children with upper respiratory infection. COMMUNITY HEALTH GROUP HEDIS MEASURES (CY ) HEALTHY FAMILIES QUICK REFERENCE GUIDE FOR BILLING DEPARTMENT Age URI 2 months as of July 2, 2010 to 18 s as of June 30, Description CPT ICD-9 Codes & Procedure Children with a diagnosis of upper respiratory infection are not dispensed an antibiotic prescription on or after three days after the diagnosis. 460, 465 Well-Child visit in the first 15 months of life. Member incentive: $100.00 gift card when six well visits are completed. Well-Child visit in the Third, Fourth, Fifth and Sixth Years of Life. Member incentive: $20.00 gift card W15 W34 15 months old during the measurement () 3-6 s as of December 31 Appropriate meds for asthma ASM 5-64 s by of the Six or more well-child visits with a PCP before the child turns 15 months. One or more well-child visits with a PCP during the Members during the measurement who were identified as having persistent asthma and who were appropriately prescribed medication during the 99381, 99382, 99391, 99392, 99461, G0438, G0439 V70.6, 99382, 99383, 99392, 99393 V70.6, 493.0, 493.1, 493.8, 493.9, 493.2 Lead Screening in Children LSC 2 s old during the Children who had one or more capillary or venous lead blood test for lead poisoning by their second birthday. 83655
HEDIS MEASURES (CY) MEDI-CAL QUICK REFERENCE GUIDE FOR BILLING DEPARTMENT Age Description CPT HCPCS Codes CHDP Code Adolescent Well-Care Visits. Member Incentive: $20 gift card to AMC or Regal Theaters. AWC 12-21 s as of, At least one comprehensive well-care visit during the 99383-99385, 99393-99395 01-A, C OR D ICD-9 Codes & Procedures V70.6, Annual Monitoring for Patients on Persistent Medications MPM 18 s and older as of, Received at least 180 treatment days of ARB and needs at least ONE therapeutic monitoring event. Therapeutic monitoring event: Lab panel, Serum potassium (K+), Serum creatinine (SCr) or Blood Received at least 180 treatment days of ACE inhibitors and needs at least ONE therapeutic monitoring event. Received at least 180 treatment days of digoxin and needs at least ONE therapeutic monitoring event. Therapeutic monitoring event: Lab panel, Serum potassium (K+), Serum creatinine (SCr) or Blood Therapeutic monitoring event: Lab panel, Serum potassium (K+), Serum creatinine (SCr) or Blood Avoidance of antibiotic treatment in adults with Acute Bronchitis. AAB Adults 18 as of January 1, 2009 to 64 s as of, Adults with a diagnosis of acute bronchitis are not dispensed an antibiotic prescription. 466 Cervical Cancer Screening. Member Incentive: $25 gift card. CCS Women between 24-64 s One or more Pap tests to screen for cervical cancer. 88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175 G0123, G0124, G0141, G0143- G0145, G0147, G0148, P3000, P3001, Q0091 91.46 Children and Adolescent Access to Primary Care Practitioners Children and Adolescent s Access to Primary Care Practitioners CAP CAP 12-24 months as of December 31, 25 months- 6 s as of, Members who had a visit with a PCP. 99204-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99385, 99391-99395, 99401-99404, 99411-99412, 99420, 99429 Members who had a visit with a PCP. 99204-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99385, 99391-99395, 99401-99404, 99411-99412, 99420, 99429 V70.6, V70.6, Children and Adolescent s Access to Primary Care Practitioners CAP 7-11 s as of, Members who had a visit with a PCP. 99204-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99385, 99391-99395, 99401-99404, 99411-99412, 99420, 99429 V70.6,
HEDIS MEASURES (CY) MEDI-CAL QUICK REFERENCE GUIDE FOR BILLING DEPARTMENT Age Description CPT HCPCS Codes CHDP Code Children and Adolescent s Access to Primary Care Practitioners CAP 12-19 s as of, Members who had a visit with a PCP. 99204-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99385, 99391-99395, 99401-99404, 99411-99412, 99420, 99429 ICD-9 Codes & Procedures V70.6, Childhood immunization CIS 2 yrs of age during measurement DtaP- Qty 4 90698, 90700, 90701, 90720, 90721, 90723 45 99.39 IPV- Qty 3 90698, 90713, 90723 39, 64 045, 99.41 MMR - Qty 1 90707, 90710 33, 48 99.48 HiB- Qty 3 90645, 90646, 90647, 90648, 90698, 90720, 90721, 90748 Hepatitis B- Qty 3 90723, 90740, 90744, 90747, 90748 Postpartum Visits after a live birth. Provider PPC None specified Visit or pelvic exam must be in on or between 21 incentive: $100 per eligible claim. Member incentive: and 56 days after delivery $20 gift card to Sears Photo Center and baby t-shirt. 38 041.5, 038.41, 320.0, 482.2 40, 42, 51 070.2, 070.3 VZV- Qty 1 90710, 90716 46, 52 052, 053 Pneumococcal conjugate (PCV)- Qty 4 90669 55 n/a Z1038 or 59430 n/a 91.46, 89.26 V codes: V24.1, V24.2, V25.1, V72.3, V76.2 Prenatal Care for a live birth. Provider incentive: $100 per eligible claim. Member incentive: $25 gift card PPC None specified Visit must be in the first trimester or within 42 days of enrollment n/a Z1032 with modifier ZL. Box 14 MUST contain the LMP or E&M code w/diagnosis V22-V23 n/a Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents WCC 3-17 as of of the BMI Percentile Enter % V85.5 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents WCC 3-17 as of of the Counseling for nutrition 97802-97804 S9470, S9452, S9449, G0270- G0271 03 V65.3
HEDIS MEASURES (CY) MEDI-CAL QUICK REFERENCE GUIDE FOR BILLING DEPARTMENT Age Description CPT HCPCS Codes CHDP Code Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents WCC 3-17 as of of the Counseling for physical activity S9451 Document in comments ICD-9 Codes & Procedures V65.41 Test poor control 18-75 s as of HbA1c Tests 83036, 83037 250, 357.2, 362.0, 366.41, 648.0 18-75 s as of HbA1c Tests- Poor Control 83036, 83037 250, 357.2, 362.0, 366.41, 648.0 Control 18-75 s as of HbA1c Tests- Control <8% 83036, 83037 250, 357.2, 362.0, 366.41, 648.0 CDC- LDC screen CDC- LDL control CDC- Nephropathy test 18-75 s as of LDL-C Screening- Screening 80061, 83700, 83701, 83704, 83721 18-75 s as of LDL-C (Control) <100mg/dL 80061, 83700, 83701, 83704, 83721 18-75 s as of Nephropathy screening test 82042, 82043, 82044, 84156 CDC- Evidence of tx of nephropathy 18-75 s as of Evidence of treatment for nephropathy 36800, 36810, 36815, 36818, 36819-36821, 36831-36833, 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90920, 90921, 90924, 90925, 90935, 90937, 90939, 90940, 90945, 90947, 90989, 90993, 90997, 90999, 99512 G0257, G0314- G0319, G0322, G0323, G0326, G0327, S9339 250.4, 403, 404, 405.01, 405.11, 405.91, 580-588, 753.0, 753.1, 791.0, V42.0, V45.1, V56. 38.95, 39.27, 39.42, 39.43, 39.53, 39.93-39.95, 54.98, 55.4-55.6. 250, 357.2, 362.0, 366.41, 648.0 CDC-B/P 18-75 s as of Document chart blood pressure. Numerator compliant (BP <140/90 mm Hg) 250, 357.2, 362.0, 366.41, 648.0
HEDIS MEASURES (CY) MEDI-CAL QUICK REFERENCE GUIDE FOR BILLING DEPARTMENT Age Description CPT HCPCS Codes CHDP Code (DX: 250, 357.2, 362.0, 366.41, 648.0). Member incentive: $25 Wal- Mart gift card and an additional $25 Wal-Mart gift card with proof of purchase of new prescription eyeglasses. CDC-EYE 18-75 s as of. Eye exam. Retinal or dilated eye exam by an eye 67028,67030, 67031, 67036, care professional (optometrist or ophthalmologist) 67038-67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 9, 92014, 92018, 92019, 92225, 92226, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245 S0620, S0621, S0625, S3000 ICD-9 Codes & Procedures Well-Child visit in the Third, Fourth, Fifth and Sixth Years of Life. Member incentive: $20.00 gift card W34 3-6 s as of One or more well-child visits with a PCP during the 99382, 99383, 99392, 99393 01-A, C OR D V70.6, Use of imaging studies for low back pain LBP 18 s as of January 1 to 50 s as of Percentage of members with a primary diagnosis of low back pain who did not have an imaging (plain x-ray, MRI, CT scan) within 28 days of the diagnosis 72010, 72020, 72052, 72100, 72110, 72114, 72120, 72131-72133, 72141, 72142, 72146-72149, 72156, 72158, 72200, 72202, 72220 721.3, 722.10, 722.32, 722.52, 722.93, 724.02, 724.2, 724.3, 724.5, 724.6, 824.7, 738.5, 793.3, 739.4, 846, 847.2 Use of Spirometry Testing in the Assessment & Diagnosis of COPD SPR 42 s or older as of December 31 Immunizations for adolescents IMA Members who turn 13 s of age during the measurement. Determine how many members with a new diagnosis or newly active COPD who received appropriate spirometry testing to confirm diagnosis. Adolescents 13 s of age who had one dose of meningococcal vaccine and Tdap or Td by their 13th birthday. 94010, 94014-94016, 94060, 94070, 94375, 94620 491, 492, 496 90733, 90734, 90715, 90714, 90718, 90703, 90719