HEDIS/Quality Assurance Reporting Requirements coding review

HEDIS/Quality Assurance Reporting Requirements coding review

Agenda What is HEDIS /Quality Assurance Reporting Review (QARR)? Why is coding important for HEDIS/QARR? Coding focus topics: o Adolescent well visits Adult body mass index (BMI) o Antidepressant medication management o Breast cancer screening o Cervical cancer screening o Childhood and adolescent immunizations: 0 to 2 years of age o Childhood and adolescent immunizations: 9 to 13 years of age o Chlamydia screening o Colorectal screening o Comprehensive diabetes care: HbA1c testing o Comprehensive diabetes care: retinal eye exam o Comprehensive diabetes care: nephropathy screening and urine microalbumin test o Comprehensive diabetes care: evidence of treatment for nephropathy

Agenda (cont.) Coding focus topics (cont.): o Controlling high blood pressure o Diabetes screening for people with schizophrenia or bipolar disorder o Follow-up after hospitalization for mental illness o Follow-up care for children prescribed ADHD medication o Initiation and engagement of alcohol and other drug dependence treatment o Medication management for people with asthma o Prenatal care o Postpartum care o Spirometry testing for members with chronic obstructive pulmonary disease (COPD) o Viral load suppression o Weight assessment, counseling for nutrition and counseling for physical activity o Well-child visits: 0-15 months o Well-child visits: 3 to 6 years

What is HEDIS? Healthcare Effectiveness Data and Information Set: HEDIS is a National Committee on Quality Assurance (NCQA)-developed tool used to measure performance on important dimensions of care and service. More than 90% of America s health plans use HEDIS. HEDIS makes it possible to compare the performance of health plans on an apples-to-apples basis. Measures address a range of health issues and outcomes. To ensure the validity of HEDIS results, all of the data is audited by certified auditors. NCQA has a process for evolving the measurement set each year.

What is QARR? Quality Assurance Reporting Requirements: The New York State Department of Health (NYSDOH) version of HEDIS Set of performance measures that health plans must report on an annual basis to NYSDOH under Medicaid Managed Care and Child Health Plus Includes performance measures related to many preventive health services, such as well-care visits, age-appropriate immunizations, screenings for cancer and comprehensive diabetes care Has many measures in common with HEDIS

Why is coding important for HEDIS and QARR? When documented, each measure includes a set of codes that meet the requirements for the measure. Codes may be ICD-10, CPT or HCPCS codes. Some measures are considered administrative only. This means the data for compliance comes strictly from claim and encounter submission. No medical record review is performed. If services are being performed but the codes are not being submitted on claims or encounters, you will not receive credit. In addition, if only some of the services are coded but others are not, you will not have met all the required components of the measure.

Coding focus: Adolescent well visits Measure description Diagnosis coding Procedure coding Members ages 12 to 21 years who have had at least one annual comprehensive well-care visit with a PCP or OB/GYN during the year 12 to 21 years of age, must be enrolled during the Z00.00, Z00.01, Z00.121, Z00.129 99384, 99385, 99394, 99395, G0438, G0439 Make sure your medical records reflect all of the following: a health and developmental history (both physical and mental), a physical exam, health education and anticipatory guidance. Do not include services rendered during an inpatient or emergency department visit, or that are specific to the assessment or treatment of an acute or chronic condition. Sick visits may be missed opportunities for your patient to get health checks; complete an annual exam during the sick visit.

Coding focus: Adult body mass index (BMI) Measure description Diagnosis coding The percentage of members 18 to 74 years of age who had an outpatient visit and whose BMI was documented during the or the year prior to the Members younger than 21 must have a height, weight and BMI percentile documented and/or plotted on a BMI chart The measurement year and the year prior to the ; anchor date December 31 of For members 21 and older: Z68.1 (BMI of 19 or less) Z68.2 (BMI of 20-29) Z68.20 (20.0 20.9) Z68.21 (21.0 21.9) Z68.22 (22.0 22.9) Z68.23 (23.0-23.9) Z68.24 (24.0-24.9) Z68.25 (25.0-25.9) Z68.26 (26.0-26.9) Z68.27 (27.0-27.9) Z68.28 (28.0-28.9) Z68.29 (29.0-29.9) Z68.3 (BMI of 30-39) Z68.30 (30.0-30.9) Z68.31 (31.0-31.9) Z68.32 (32.0-32.9) Z68.33 (33.0-33.9) Z68.34 (34.0-34.9) Z68.35 (35.0-35.9) Z68.36 (36.0-36.9) Z68.37 (37.0-37.9) Z68.38 (38.0-38.9) Z68.39 (39.0-39.9) Z68.4 (BMI of 40 or greater) Z68.41 (40.0-44.9) Z68.42 (45.0-49.9) Z68.43 (50.0-59.9) Z68.44 (60.0-69.9) Z68.45 (BMI of 70 or greater) For 19- and 20-year-old members (in percentiles): Z68.51 (less than 5th) Z68.52 (5th to less than 85th) Z68.53 (85th to less than 95th) Z68.54 (greater than or equal to 95th) Document all discussions about BMI in the medical record, including documentation of any patient nutritional counseling sessions.

Coding focus: Antidepressant medication management Measure description Diagnosis coding Procedure coding Members ages 18 years or older with a diagnosis of major depression who were newly treated with an antidepressant medication and remained on antidepressant medication treatment The and the year prior to the ; anchor date December 31 of F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9 Not applicable Two timelines are required for this measure: o Effective acute phase treatment patients newly diagnosed and treated who remained on an antidepressant medication for at least 84 days (12 weeks) o Effective continuation phase treatment members newly diagnosed and treated who remained on an antidepressant medication for at least 180 days (six months) Educate your patients and their caregivers about the importance of complying with long-term medications, not abruptly stopping medications, contacting you immediately if they experience any unwanted/adverse reactions.

Coding focus: Breast cancer screening Measure description The percentage of women 50 to 74 years of age who had a mammogram to screen for breast cancer October 1 two years prior to the through December 31 of the Diagnosis coding Procedure coding Not applicable 77065, 77066, 77067, 87.36, 87.37, G0202, G0204, G0206 The procedure codes for mammography are most often billed by a radiology center or outpatient hospital location. MRIs do not count as primary breast cancer screening. Be sure to follow-up with patients after giving a referral for a mammogram to ensure they follow through with your plan of care. Tell your patients to make sure the radiology center or outpatient hospital location sends a copy of the screening to your office for your records.

Coding focus: Cervical cancer screening Measure description Ages 21 to 64 years: At least one cervical cytology (Pap) test every three years Ages 30 to 64: Pap test/human papillomavirus (HPV) cotesting every five years Ages 21 to 64 years and enrolled during measurement year Diagnosis Procedure coding coding Z12.4 Pap codes: 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175, G0123, G0124, G0141, G0143-G0145, G0147, G0148 HPV codes: 87623-87625, G0476 Remember to document any history of hysterectomy in your patient s chart; include details (complete, total, radical abdominal or vaginal hysterectomy). Also document history of cervical agenesis or acquired absence of cervix. Be sure to keep a copy of the lab results on file.

Coding focus: Childhood and adolescent immunizations: 0 to 2 years of age Description Members ages 2 years and younger who received these specific vaccinations by their 2nd birthday Ages 2 years and younger and enrolled on the date of their 2nd birthday Immunization Doses Procedure coding CVX Diphtheria, tetanus and acellular pertussis (Dtap) 4 90698, 90700, 90723 20, 50, 106, 110, 120 Polio (IPV) 3 90698, 90713, 90723 10, 110, 112 Measles, mumps and rubella (MMR) Haemophilus influenza type B (Hib) Hepatitis B (Hep B) 3 1 90707, 90710 03, 94 3 90647, 90648, 90698, 90748 90723, 90740, 90744, 90747, 90748 46-51, 120, 148 Varicella Zoster (VZV) 1 90710, 90716 21, 94 Pneumococcal Conjugate (PCV) 08, 44, 51, 110 4 90670 100, 133 Hepatitis A (Hep A) 1 90633 83 Rotavirus 3 Influenza 2 Two dose = 90681 Three dose = 90680 90655, 90657, 90661, 90662, 90673, 90685, 90687 119, 116 135, 140, 141, 153, 155, 161, 166 Document any parental refusal, history of anaphylactic reaction or seropositive test result.

Coding focus: Childhood and adolescent immunizations: 9 to 13 years of age Description Members ages 9 to 13 who received these specific immunizations by their 13th birthday Ages 9 to 13, males and females Immunization Doses Specific age Procedure coding CVX Meningococcal 1 11 to 13 90644, 90734 136, 138 Tdap 1 10 to 13 90715 115 HPV 3 9 to 13 90649,90650, 90651 62, 118, 165 Be sure to document: o A note indicating the name of the specific antigen and the date of the immunization. o The certificate of immunization prepared by an authorized health care provider or agency. o Any parental refusal, history of anaphylactic reaction or seropositive test result. o The date of the first hepatitis B vaccine given at the hospital and name of the hospital if available.

Coding focus: Chlamydia screening Measure description Members who as of December 31, 2017, are 16 to 24 years of age, identified as sexually active and who had at least one test for chlamydia in 2015 Must be eligible during the Diagnosis coding Procedure coding Not applicable 87110, 87270, 87320, 87490, 87491, 87492, 87810 Remember to document any history of hysterectomy in your patient s chart; include details (complete, total, radical abdominal or vaginal hysterectomy). Also document history of cervical agenesis or acquired absence of cervix. Be sure to keep a copy of the lab results on file.

Coding focus: Colorectal screening Measure description Diagnosis coding Procedure coding The percentage of members 51 to 75 years of age who had one of the appropriate screenings for colorectal cancer: Fecal occult blood test (FOBT) during the Flexible sigmoidoscopy during the or during the prior four years Colonoscopy during the measurement year or during the prior nine years 51 to 75 years of age by December 31, 2017, and enrolled in the Not applicable Colonoscopy: 44388-44392, 44401-44408, 45378-45393, 45398, 45399, G0105, G0121 Flex sigmoidoscopy: 45330-45347,45349, 45350, G0104 FOBT: 82270, 82274, G0328 Be sure to follow up with patients after giving a referral for colonoscopy to ensure they follow through with your plan of care. Tell your patients to make sure the service location sends a copy of the screening to your office for your records. Exclusions for this measure include: Evidence of a diagnosis of colorectal cancer on or before December 31, 2017, or documentation of a total colectomy on or before December 31, 2017.

Coding focus: Comprehensive diabetes care: HbA1c testing Measure description Members ages 18 to 75 years with type 1 or type 2 diabetes with a HbA1c test once per year Must be eligible during the Diagnosis coding Procedure coding Not applicable 83036, 83037, 3044F, 3045F, 3046F For the recommended frequency of testing and screening, refer to the Clinical Practice Guidelines for diabetes mellitus. Educate your patients about the multiple tests needed to properly manage their diabetes. Be sure to keep a copy of the lab results on file. Try scheduling your patients to come in for all diabetes care services on the same day.

Coding focus: Comprehensive diabetes care: retinal eye exam Measure description Members ages 18 to 75 years with type 1 or type 2 diabetes with a dilated eye exam in current year or negative exam in previous year Must be eligible during the Procedure coding 67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108, 67110, 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, 92213-99215, 99242-99245 Tell your patients to make sure the service location sends a copy of the screening to your office for your records.

Coding focus: Comprehensive diabetes care: nephropathy screening and urine microalbumin test Measure description Members ages 18 to 75 years with type 1 or type 2 diabetes with a nephropathy screening at least once per year Must be eligible during the Diagnosis Procedure coding coding Not applicable 82042, 82043, 82044, 84156 Urine microalbumin codes: 81000-81003, 81005, 3060F-3062F Be sure to follow up with patients after giving referral for a nephrologist visit to ensure they follow through with your plan of care. Tell your patient to ask the nephrologist to send a visit summary to your office and be sure to keep a copy on file.

Coding focus: Comprehensive diabetes care: evidence of treatment for nephropathy Measure description Members ages 18 to 75 years with type 1 or type 2 diabetes with evidence of treatment for nephropathy Must be eligible during the Procedure coding 36800, 36810, 36815, 36818-36821, 36831-36833, 36901-36906, 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947,90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512 Be sure to follow up with patients after giving referral for a nephrologist visit to ensure they follow through with your plan of care. Tell your patient to ask the nephrologist to send a visit summary to your office and be sure to keep a copy on file.

Coding focus: Controlling high blood pressure Measure description Members ages 18 to 75 years who have had a diagnosis of hypertension and whose blood pressure (BP) is regularly monitored and controlled 18 to 85 years and eligible during the Diagnosis coding Procedure coding I10 3074F: systolic BP <130 3075F: systolic BP 130-139 3077F: systolic BP > 140 3078F: diastolic BP <80 3079F: diastolic BP 80-89 3080F: > 90 Members whose BP is adequately controlled include: Member age range Blood pressure 18 to 59 years <140/90 mm Hg 60 to 85 years with diabetes <140/90 mm Hg 60 to 85 years without diabetes <150/90 mm Hg Both systolic and diastolic must be below stated value to be considered controlled. Most recent BP measurement during the year counts towards compliance. Retake BPs over 140/90 during the same visit and document the second reading.

Coding focus: Diabetes screening for people with schizophrenia or bipolar disorder Measure description The percentage of members 18 to 64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the Must be eligible during the Diagnosis coding Procedure coding Not applicable 80047, 80048, 80050 80053, 80069, 82947 82950, 82951, 83036 83037 3044F, 3045F, 3046F Be sure to follow up with patients after giving referral for a psychologist visit to ensure they follow through with your plan of care. Tell your patient to ask the psychiatrist to send a visit summary to your office and be sure to keep a copy on file.

Coding focus: Follow-up after hospitalization for mental illness Measure description Members ages 6 years and older who were hospitalized for treatment of select mental health disorders and who had an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner 6 years and older and enrolled for the Diagnosis coding F03.90, F03.91, F20.0 F99 Procedure coding Not applicable Two timelines are required: o An outpatient visit, intensive outpatient encounter or partial hospitalization within seven days of discharge o An outpatient visit, intensive outpatient encounter or partial hospitalization within 30 days of discharge The date of service on the claim is the date of the face-to-face visit

Coding focus: Initiation and engagement of alcohol and other drug dependence treatment Measure description CPT and HCPCS coding Members ages 13 years and older for two indicators related to alcohol and other drug dependence treatment 13 years and older and enrolled in the measurement year IET visits group 1: 90791, 90792, 90832-90840, 90845, 90847, 90849, 90853, 90875, 90876 IET stand-alone outpatient visits: 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99344-99350, 99384-99837, 99394-99397, 99401-99404, 99408, 99409, 99411, 99412, 99510 IET visits group 2: 99221-99223, 99231-99233, 99238, 99239, 99251-99255, G0155, G0176, G0177, G0396, G0397, G0409, G0443, G0463 H0001, H0002, H0004, H0005, H0007, H0016, H0020, H0022, H0031, H0034, H0037, H0039, H0040, H2000, H2010, H2020, H2035, H2036, S9475, T1006, T1012, T1015 Initiation of treatment refers to the percentage of members diagnosed with alcohol or other drug dependence and who have initiated treatment within 14 days of being diagnosed. Engagement of treatment refers to the percentage of members who had two additional alcohol or other drug dependence treatment sessions within 30 days after initiating treatment.

Coding focus: Medication management for people with asthma Measure description Members ages 5 to 64 years old who were identified as having persistent asthma, were dispensed appropriate medications and remained on asthma controller medication during the treatment period 5 to 64 years and enrolled during the measurement year Asthma controller medications Anti-asthmatic combinations Antibody inhibitors Inhaled steroid combinations Inhaled corticosteroids Leukotriene modifiers Mast cell stabilizers Methylxanthines Dyphylline-guaifenesin Omalizumab Budesonide-formoterol Fluticasone-formoterol Mometasone-formterol Beclomethasone Budesonide Ciclesonide Flunisolide Fluticasone CFC-free Mometasone Triamcinolone Montelukast Zafirlukast Zileuton Cromolyn Aminophylline Dyphylline Theophylline

Coding focus: Medication management for people with asthma (cont.) Measure description Asthma reliever Medications Members ages 5 to 64 years old who were identified as having persistent asthma, were dispensed appropriate medications and remained on asthma controller medication during the treatment period 5 to 64 years and enrolled during the Short-acting inhaled beta-2 agonists Albuterol, Levalbuterol, Pirbuterol, Notes and Tips: For patients with asthma, you should: Prescribe controller medication. Educate patients in identifying asthma triggers and proper use of controller medications. Create an asthma action plan. Be aware of what medications are on formulary as well as require prior authorization and/or step therapy prior to prescribing. Advise your patients to use mail order whenever possible; this will assist with compliance. Remind your patients to get their controller medications filled regularly and to continue taking them even if they are feeling better and are symptom-free.

Coding focus: Prenatal care Measure description Diagnosis coding Procedure coding The percentage of pregnant members who received at least one prenatal care visit on the enrollment start date or within 42 days of enrollment or within the first trimester of pregnancy Enrolled during the measurement year O00-O08 pregnancy with abortive outcome O09 supervision of a high-risk pregnancy O10-O16 edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium O20-O29 other maternal disorders O30-O48 maternal care related to the fetus O94-O9A other obstetric conditions Prenatal visits: 59400, 59425, 59426, 59510, 59610, 59618, 99201-99205, 99211-99215 or 99241-99245 with one of the following CPT II codes: 0500F, 0501F, 0502F, G0463, H1002-H1004, H1005, T1015 Prenatal ultrasound: 76801, 76805, 76811, 76813, 76815-76821, 76825-76828 The patient must have at least 14 visits for a 40-week pregnancy. Make sure your records accurately reflect all prenatal visit dates When seeing a PCP for monitoring of a pregnancy, the diagnosis of pregnancy must be present and a basic physical obstetrical examination or a standard prenatal care visit must be documented.

Coding focus: Postpartum care Measure description Enrolled during the Diagnosis coding Procedure coding The percentage of members who had a postpartum visit on or between 21 and 56 days after delivery Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2 57170, 58300, 59400, 59410, 59430, 59510, 59515, 59610, 59614, 59618, 59622 99201 with CPT II code 0503F G0101 Be sure to document the exact date of the postpartum visit. A visit for post cesarean staple removal or incision check does not satisfy the postpartum requirement. At the time of the visit, remind your patient to return for a postpartum visit within 21-56 days post delivery; if possible, schedule the appointment before the patient leaves your office. If you use a global billing code, make sure the postpartum visit date is on the claim.

Coding focus: Spirometry testing for members with COPD Measure description Enrolled during the Diagnosis coding Procedure coding Members ages 40 years and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry testing to confirm the diagnosis Chronic bronchitis: J41.0, J41.1, J41.8, J42 Emphysema: J43.0, J43.1, J43.2, J43.8, J43.9 COPD: J44.0, J44.1, J44.9 94010, 94014-94016, 94070, 94375, 94620 Perform a spirometry test for patients who present with dyspnea, chronic cough, increased sputum production or wheezing. To support a COPD diagnosis, perform and document a spirometry test prior to initiating pharmacotherapy treatment. Educate patients about the use of and compliance with both long-term and quick-relief medications, the proper use of metered inhalers and avoiding elements that trigger attacks.

Coding focus: Viral load suppression This measure is unique in that health plans do not report the data; instead the AIDS Institute and the Office of Quality and Patient Safety will calculate the performance in this measure using the laboratory testing data captured in the NYSDOH HIV Surveillance System. It is important to make sure patients with HIV keep their follow-up appointments and complete a viral load screening at least every six months or twice in one calendar year. Regular testing helps identify any needs for changes in a patient s medication regimen or helps determine if he or she is complying with treatment plans. Reaching viral load suppression can help your patients to live healthier, longer lives and reduce the risk of transmitting the virus to others. For more information on viral load suppression and HIV treatment guidelines, please visit the NYSDOH AIDS Institute website at https://www.hivtrainingny.org Preschedule the next follow-up appointment while the patient is still in your office and make a reminder call prior to the appointment. Be sure to keep a copy of the lab results on file.

Coding focus: Weight assessment, counseling for nutrition and counseling for physical activity Measure description Nutrition The percentage of members 3 to 17 years of age who had an outpatient visit with a PCP or OB/GYN and who had counseling for nutrition during the BMI The percentage of members 3 to 17 years of age who had an outpatient visit with a PCP or OB/GYN and who had a BMI percentile documented during the Physical activity The percentage of members 3 to 17 years of age who had an outpatient visit with a PCP or OB/GYN and who had counseling for physical activity during the Must be eligible during the measurement year Must be eligible during the measurement year Must be eligible during the measurement year Diagnosis coding Procedure coding Z71.3 97802, 97803, 97804 Z68.51, Z68.52, Z68.53, Z68.54 Z71.9 This is a miscellaneous code; therefore, you must document counseling specific to physical activity. Do not document solely for sports activity Not applicable Not applicable Remember a nutritional evaluation and anticipatory guidance are required as part of the routine health check visit. Document any advice you give the patient and/or their caregivers.

Coding focus: Well-child visits: 0 to 15 months Measure description Children turning 15 months old in 2017 who have five visits with one of the listed CPT codes or one of the listed ICD-10 codes during their first 15 months of life with a PCP 31 days to 15 months of age; enrolled at 15 months Diagnosis coding Z00.110, Z00.111, Z00.121, Z00.129 Procedure coding 99381, 99382, 99391, 99392, 99461 G0438, G0439 The PCP of record will be the PCP as of the date the child turns 15 months old. If the dates of service are less than 14 days apart, only one will count for this measure. Confirm that your medical record reflects all of the following: five or more visits with a PCP completed at least two weeks apart, a medical history, physical and mental developmental histories, a physical exam, health education, and anticipatory guidance. Sick visits may be missed opportunities for your patient to get health checks; complete an annual exam during the sick visit and code with appropriate ICD-10 codes.

Coding focus: Well-child visits 3 to 6 years Measure description 3 to 6 years of age, enrolled during the Diagnosis coding Procedure coding Members ages 3 to 6 years who had one or more comprehensive well-child visits with a PCP during the year Z00.121, Z00.129, Z00.8, Z02.0 99382, 99383, 99384, 99392, 99393, 99394, G0438, G0439 Make sure your medical records reflect all of the following: a note indicating a visit to a PCP, the date the well-child visit occurred, physical and mental developmental histories, a physical exam, health education, and anticipatory guidance. Sick visits may be missed opportunities for your patient to get health checks; complete an annual exam during the sick visit.

Legal notice The codes and measure tips listed are informational only, not clinical guidelines or standards of medical care, and do not guarantee reimbursement. All member care and related decisions of treatment are the sole responsibility of the provider. This information does not dictate or control your clinical decisions regarding the appropriate care of members. Your state/provider contract(s), Medicaid, member benefits and several other guidelines determine reimbursement for the applicable codes. Proper coding and providing appropriate care decrease the need for high volume of medical record review requests and provider audits. It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members. Please note: The information provided is based on HEDIS 2017 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA), the Centers for Medicare & Medicaid Services (CMS) and state recommendations. Please refer to the appropriate agency for additional guidance.

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