Upcoming coding enhancements will impact the logic behind the clinical quality indicators applicable to your practice specialty. Please refer to this grid for a summary of the coding enhancements and some codes and tips to improve your practice s data, and ultimately, your practice s approach to quality patient care. (This grid is a companion piece to the Special Bulletin mailing dated March 24, 2008.) Persistence of Beta- Report, as appropriate, any of the Blocker Treatment following CPT Category II Codes and G Codes: After a Heart Attack Internal Medicine Those in the denominator who had a beta-blocker prescription filled on an ambulatory basis while hospitalized for AMI or within 7 days of discharge. Age 35 and older by the end of the Continuously enrolled for 7 days after discharge for AMI no breaks in enrollment. Member of the plan in the Identified as being hospitalized with AMI and discharged alive. The measurement period is the current AMI patients with evidence of at least 135 days of therapy for any beta-blocker drug. Beta-blocker supply dispensed is 135 days in the 180- day measurement period after discharge. To also account for members who are on beta blockers prior to admission, those prior scripts should be factored into drug compliance rates if the actual TX days fall within the 180 days post-discharge. (In the last 6 months of the year prior to the through the first 6 months of the Only include the first AMI discharge if more than one is found.) OR 2 encounters with G Code or CPT Category II Code notation that patient is on beta-blocker therapy. The above codes must be present in 135 days in the 180-day measurement period after discharge. Members 18 years of age or older who were hospitalized and discharged alive with a diagnosis of AMI (Patient should be 18 at the time of admission) AND continuous enrollment = 90 days prior to admission and 6 months from discharge (with one 20-day gap allowed) AND pharmacy benefit Exclusions: Heart block/sinus bradycardia or hypotension OR patients transferred to non-acute care facility (SNF, Rehab or LTC facility) within 6 months after discharge OR diagnosis of COPD, asthma OR documented prior MI and patient not eligible candidate for beta-blocker therapy (CPT Category II/G Code) Exclusion codes for denominator: G8035 4006F 1P modifier G8033 4006F REV 6/27/08 1
Cholesterol Patients who have had 1 total lipid Patients age 18-75 (patient should be at Report, as appropriate, any of the Management in profile or LDL-C test least 18 years old at time of admission but following CPT Category II Codes who received an LDL-C test not older than 75 years) who were and G Codes: Patients with in the OR 1 designated G/CPT Category II hospitalized in an acute care setting and Cardiovascular Code for lipoprotein discharged alive for AMI or CABG Conditions Internal Medicine The denominator consists of the population that met the enrollment and the diagnostic requirements. Age 18-75 by the end of the Continuously enrolled during the measurement year and the preceding year with no more than 1 break in enrollment of up to 45 days per year. Identified as hospitalized and discharged alive after CV event in the year prior to the or with ischemic vascular disease in both the measurement year and the prior year. and the preceding year. AND during the OR discharged alive with a diagnosis of PTCA in any setting AND during the (12 months) prior to the OR had 1 face-to-face encounter in an outpatient or inpatient setting with the diagnosis of IVD anytime during both the and the year prior to the AND continuous enrollment = 24 months in the and prior year (with 1 gap up to 20 days allowed per year) Exclusions: CPT Category II Codes with exclusion modifiers and G Codes that identify medical reason for no LDL screening, Discharged Dead Codes Exclusion codes for denominator: 3011F 1P modifier 3048F 1P modifier 3049F 1P modifier 3050F 1P modifier G8021 G8041 G8019 G8020 G8039 G8040 3011F 3048F 3049F 3050F REV 6/27/08 2
CHF Annual Care Internal Medicine who received advanced standard annual care for CHF: Continuously enrolled in the and enrolled the preceding year with no more than 1 break of up to 45 days in Patients who had 1 lab test for BUN and potassium and creatinine or 1 lab panel that includes the preceding tests Patients 18 years and older with diagnosis of CHF Report, as appropriate, any of the following CPT Category II Codes and G Codes: enrollment 2 evaluation/management visits 1 BUN (blood urea nitrogen) test 1 Potassium test 1 Creatinine test 1 or more defined prescriptions Member of the plan in the Identified with CHF in the year preceding the and the preceding year AND patients receiving 1 Rx for ACEI or ARB or BBH or 1 CPTII/ G Code to identify that ACEI or ARB or BBH were prescribed AND 2 outpatient visits for CHF with PCP or specialist AND within the (12 months) AND 1 face-to-face encounter with a PCP or specialist office in any setting during the year (12 months) prior to the measurement year AND continuous enrollment = 12 months in the (with 1 gap up to 20 days allowed) AND pharmacy benefit during the (12 months) Exclusions: Diagnoses of heart block, sinus bradycardia or hypotension, CPT Category II or G Code documentation that heart failure patient was not an eligible candidate for ACEI/ARB therapy or beta-blocker therapy, Discharged Dead Codes Exclusion codes for denominator: G8029 G8032 4006F 1P modifier 4009F 1P modifier G8027 G8030 4006F 4009F REV 6/27/08 3
Comprehensive Diabetes Care: Internal Medicine Retinopathy Those in the denominator Age 18-75 by the end of the Patients with a retinal exam in the Patients age 18-75 identified as having Report, as appropriate, any of the Evaluation who had a retinal eye or year prior to the diabetes and continuously enrolled for 24 following CPT Category II Codes: examination by an eye care Continuously enrolled months with up to 1 gap of 20 days allowed professional within the through the measurement per year. AND member of plan at the end of Exclusion codes for denominator: or the year no more than one Indicated by 1 optometry visit OR the measurement. AND has a drug benefit. 2022F 1P modifier year prior. break of up to 45 days in ophthalmology visit with retinopathy AND diabetes diagnosis. enrollment. screening Member of the plan at the Diabetes diagnosis identified by any of the 2022F end of the measurement OR 1 designated CPT Category II following: 2 office visits for diabetes 2024F year. Code to indicate that a dilated retinal diagnosis on different dates of service 2026F Identified as diabetic in the exam was performed by an eye care (outpatient or nonacute setting) in 3072F measurement period. provider or year prior Time frame to identify The numerator has been expanded exclusions for steroidinduced OR 1 ER visit or hospital stay with to include additional codes for or gestational diabetes diagnosis in or procedures such as certain I.V. diabetes is the measurement year prior photodynamic therapies and year and the vitreous strands procedures. preceding year. OR 1 Rx for diabetes (insulin OR oral hypoglycemic OR antihyperglycemic) in or year prior and the preceding year. AND 24-month continuous enrollment (1 gap up to 20 days allowed) (Continued on Pg. 5) REV 6/27/08 4
[24-month measurement period] Exclusions: Polycystic ovaries, gestational diabetes, steroid-induced diabetes, SNF patients HbA1c Testing Those in the denominator who received 1 HbA1c (glycosylated hemoglobin) in the Age 18-75 by the end of the Continuously enrolled through the measurement year no more than 1 break of up to 45 days in enrollment. Member of the plan at the end of the measurement year. Identified as diabetic in the measurement period. Time frame to identify exclusions for steroidinduced or gestational diabetes is the measurement year and the preceding year. and the preceding year. Patients with evidence of 1 HbA1c test or 1 designated G/CPT Category II Code during the Patients 18-75 years identified as having diabetes and continuously enrolled for 24 months with up to 1 gap of 20 days allowed per year. AND member of plan at the end of the measurement. AND has a drug benefit. AND diabetes diagnosis. Diabetes diagnosis identified by any of the following: 2 office visits for diabetes diagnosis on different dates of service (outpatient or non-acute setting) in or year prior OR 1 ER visit or hospital stay with diabetes diagnosis in or year prior OR 1 Rx for diabetes (insulin OR oral hypoglycemic OR antihyperglycemic) in or year prior AND 24-month continuous enrollment (1 gap up to 20 days allowed) (Continued on Pg. 6) Report, as appropriate, any of the following CPT Category II Codes and G Codes: G8015 G8016 3046F 3047F 3045F 3044F REV 6/27/08 5
24-month measurement period] Exclusions: Polycystic ovaries, gestational diabetes, steroid-induced diabetes, SNF patients LDL-C Screening Those in the denominator who received one LDL-C (low-density lipoprotein cholesterol) test within the Age 18-75 by the end of the Continuously enrolled through the measurement year no more than 1 break of up to 45 days in enrollment. Member of the plan at the end of the measurement year. Identified as diabetic in the measurement period. Time frame to identify exclusions for steroidinduced or gestational diabetes is the measurement year and the preceding year. and the preceding year. Patients screened with 1 LDL-C OR 1 lipid profile during the measurement year OR documented evidence of CPT Category II or G Codes during the Patients 18-75 years identified as having diabetes and continuously enrolled for 24 months with up to 1 gap of 20 days allowed per year. AND member of plan at the end of the measurement. AND has a drug benefit. AND diabetes diagnosis. Diabetes diagnosis identified by any of the following: 2 office visits for diabetes diagnosis on different dates of service (outpatient or non-acute setting) in or year prior OR 1 ER visit or hospital stay with diabetes diagnosis in or year prior OR 1 Rx for diabetes (insulin OR oral hypoglycemic OR antihyperglycemic)in or year prior AND 24-month continuous enrollment (1 gap up to 20 days allowed) (Continued on Pg. 7) Report, as appropriate, any of the following CPT Category II Codes and G Codes: Exclusion codes for denominator: 3011F-1P modifier 3048F-1P modifier 3049F-1P modifier 3050F-1P modifier G8021 G8041 3011F 3048F 3049F 3050F G8039 G8040 G8019 G8020 REV 6/27/08 6
[24-month measurement period] Exclusions: Polycystic ovaries, gestational diabetes, steroid-induced diabetes, SNF patients Nephropathy Screening Those in the denominator who had evidence of nephropathy, or who were screened for it within the If a claim is identified for a member having an ACE- ARB Rx dispensed on an ambulatory basis in the, the practice meets the quality guidelines for nephropathy screening. Age 18-75 by the end of the Continuously enrolled through the measurement year no more than 1 break of up to 45 days in enrollment. Member of the plan at the end of the measurement year. Identified as diabetic in the measurement period. Time frame to identify exclusions for steroidinduced or gestational diabetes is the measurement year and the preceding year. and the preceding year. Patients with nephropathy screening OR evidence of nephropathy (visit to nephrologist) OR nephropathy diagnosis OR screening for micro/macro albumin OR Rx for ACEI, OR ARB, OR evidence of CPT Category II or G Code indicating ACE or ARB during Patients 18-75 years identified as having diabetes and continuously enrolled for 24 months with up to 1 gap of 20 days allowed per year. AND member of plan at the end of the measurement. AND has a drug benefit. AND diabetes diagnosis. Diabetes diagnosis identified by any of the following: 2 office visits for diabetes diagnosis on different dates of service (outpatient or non-acute setting) in or year prior OR 1 ER visit or hospital stay with diabetes diagnosis in or year prior OR 1 Rx for diabetes (insulin OR oral hypoglycemic OR antihyperglycemic) in or year prior Report, as appropriate, any of the following CPT Category II Codes and G Codes: Exclusion codes for denominator: 4009F 1P modifier AND 24-month continuous enrollment (1 gap up to 20 days allowed) (Continued on Pg. 8) REV 6/27/08 7 4009F 3060F 3061F 3062F 3066F G8027 G8028 G0392 G0393 G0257 G0314 G0315 G0316 G0317 G0318 G0319 G0322 G0323 G0326 G0327 83518
[24-month measurement period] Acute Pharyngitis Testing Family Practice, Internal Medicine and Pediatrics Patients in the denominator who have had throat culture or antigen agglutination test for streptococcus (rapid screening test) on the date of diagnosis or the period 3 days before or 3 days after. Must be identified with a sole diagnosis of acute pharyngitis in the and have an antibiotic dispensed within 7 days of the diagnosis. Must be continuously enrolled 30 days preceding and 7 days following each time the diagnosis is documented during the Note: A member is counted in the denominator each time the requirements are met in the measurement year. current Patients who have a throat culture OR an antigen agglutination test for Group A streptococcus (rapid screening test) and administered in the 7-day period, beginning 3 days prior through 3 days after the first episode date. Exclusions: Polycystic ovaries, gestational diabetes, steroid-induced diabetes, SNF patients Patients with a sole diagnosis of pharyngitis with an outpatient service in the first 362 days of the (ER visits are no longer included in the denominator. Eliminated scarlet fever diagnosis. Added acute tonsillitis diagnosis. Added updated antibiotic NDC Codes to enhance denominator capture.) AND Pharmacy benefit AND who have an antibiotic prescription filled on or within 3 days after the episode date AND continuously enrolled for 90 days preceding and 3 days following the date of the diagnosis. (Only one episode per patient will be captured.) AND select only the first date in the first 362 days of the which meets all criteria. (Continued on Pg. 9) Ensure accurate coding of sick visits. Include other diagnoses as appropriate (e.g., otitis media, asthma, diabetes). REV 6/27/08 8
Exclusions: claims for encounters with more than one diagnosis or patients with filled prescription for antibiotic within 30 days prior to denominator visit Appropriate Asthma Medications Family Practice, Internal Medicine and Pediatrics who were dispensed one or more prescriptions for appropriate asthma medications in the Age 5-56 by the end of the Continuously enrolled in the and the preceding year; no more than 1 break of up to 45 days in enrollment each year. Member of the plan at the end of the measurement year. Identified with persistent asthma in BOTH the year preceding the and the and the preceding year. Members dispensed 1 script in the for either of the following: Inhaled corticosteroids OR Nedocromil OR Cromolyn sodium OR Leukotriene modifiers OR Methylxanthines. Patients age 5-56 years by the end of the AND pharmacy benefit in the measurement year and the year prior AND continuously enrolled in both the and the year prior with no more than 1 gap of up to 20 days during each year AND meet 1 of the 4 persistence criteria in each year (in both the and the preceding year. Criteria need not be the same across both years): 1. at least one emergency visit w/asthma as the principal diagnosis 2. one acute inpatient discharge with asthma as the principal diagnosis 3. four or more outpatient visits w/ asthma as one of the listed 4. diagnoses and at least two asthma medication dispensing events (Continued on Pg. 10) REV 6/27/08 9
5. four or more asthma medication dispensing events and at least one diagnosis of asthma in any setting AND member of the plan at the end of the Note: A dispensing event is 1 script of any amount lasting 30 days. If > 30- day supply, divide the days supply by 30 and round days to convert. Two different scripts dispensed on same day are counted as 2 events. Inhalers count as 1 event; multiple inhalers of the same medication filled on same date of services should be counted as 1 event. Cervical Cancer Screening Family Practice and Internal Medicine who received a Pap test within the measurement period. Female patients age 24-64 in the continuously enrolled in the measurement period with no more than 1 break of up to 45 days in enrollment each year. Must be a member of the plan at the end of the (Continued on Pg. 11) Patients having at least 1 Pap test OR an HPV test (CPT Procedure Codes 87620, 87621, 87622) during the or the 2 years prior. Exclusions: Emphysema & COPD Female patients age 24-64 (on last day of the ) AND who were continuously enrolled during the, and the 2 years prior to the (with up to one 20- day gap allowed during each year) Exclusions: 58548 (laparoscopic radical hysterectomy) Exclusion codes have been expanded to include additional hysterectomy and acquired absence of genital organs (e.g., ICD-9 Diagnosis Code V45.77) Report, as appropriate, any of the following G Codes to support your numerator: (Continued on Pg. 11) REV 6/27/08 10
and the 2 preceding years. G0101 G0123 G0124 G0141 G0143 G0144 G0145 G0147-G0148 screening Pap tests code range Please remember to report the Pap smear collection (Q0091) when billing for an annual gynecological exam using codes S0610, S0612, 99201 through 99215, or 99381 through 99397. Breast Cancer Screening Internal Medicine who had 1 or more mammograms within the measurement period. Female patients age 42-69 by the end of the Continuously enrolled in the measurement period no more than one break of up to 45 days in enrollment each year. Must be a member of the plan at the (Continued on Pg. 12) Females with at least 1 mammogram or documented G or CPT Category II Code anytime in the or the year prior. (Note: Certain diagnostic mammograms are acceptable for numerator compliance.) Women age 42-69 with at least 2 years continuous enrollment during measurement year and the preceding year with up to one 20-day gap in coverage allowed during each year Exclusions: bilateral mastectomies or 2 unilateral mastectomies, or G and CPT Category II Codes to document ineligibility for mammogram Report, as appropriate, any of the following CPT Category II and G Codes: Exclusion codes for denominator: G8113 3014F 1P modifier (Continued on Pg. 12) REV 6/27/08 11
end of the measurement year. and the preceding year. G8111 3014F G0202 G0204 MMR Vaccination Pediatrics who have had a mumps, measles or rubella vaccination or any combination of the three. Turned 7 years of age during the measurement year. Continuous enrollment through the measurement year and the 3 preceding years with no more than 1 break of up to 45 days in enrollment each year. Member of the plan at the end of the measurement year. and the 3 preceding years. Children who received a measles or rubella or mumps vaccination (or any combination) from age 4-7 during the measurement period OR have documented history of measles or rubella or mumps (will look back as far as claims allow) Children who turn 7 years of age during the AND who are continuously enrolled through the measurement period (current year plus 3 preceding years with one 20-day gap allowed in each year) AND a member of the plan at the end of the measurement period = 7 years old in the Exclusions: immunodeficiency or HIV or cancer of lymphoreticular or histiocytic tissue or multiple myeloma or leukemia (will look back as far as claims allow ) G0206 Submit $0.00 charge claim, as appropriate. See Special Bulletin/Physicians Guide, Pg. 2, for details. REV 6/27/08 12
Varicella Vaccination Pediatrics Clinical Quality Measures Number of children in the Children who have received a varicella Submit $0.00 charge claim, as denominator who had a vaccination during 12-18 months of age appropriate. See Special varicella vaccination from Bulletin/Physicians Guide, Pg. 2, for 12-18 months of age. details. Age 18 months during the Continuously enrolled through the measurement year plus the preceding six months with no more than one break of up to 45 days in enrollment. Member of the plan at the end of the and the preceding 6 months. OR who have documented evidence of varicella (will look back as far as claims allow) Children who turned 18 months of age during the AND were continuously enrolled from age 31 days to 18 months AND a member of the plan when reaching 18 months of age during Exclude immunodeficiency or HIV or cancer of lymphoreticular or histiocytic tissue or multiple myeloma or leukemia (will look back as far as claims allow) Well-Child Care: First 15 Months Pediatrics who had 5 well-child PCP visits in the first 15 months of life. Member reaches 15 months of age by the end of the Continuous enrollment in the plan from 31 days to 15 months old with no more than 1 break of up to 45 days in enrollment. Member of the plan at reaching 15 months. Measurement period is the current and the preceding 15 months. Children who had 5 or more well-child PCP visits in the first 15 months of life Must have 5 well-child visits to PCP in first 15 months of life Children who turned 15 months of age during the AND continuously enrolled in the plan from 31 days to 15 months of age (with no more than 1 gap of up to 20 days allowed) Exclude members if their initial hospitalization discharge is 60 days from member s date of birth Submit $0.00 charge claim, as appropriate. See Special Bulletin/Physicians Guide, Pg. 2, for details. ICD-9 CM (V) Code for preventive service can be reported when preventive service is provided during visit with illness/cpt Code. V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 REV 6/27/08 13
Well Child Care: 3, 4, 5, 6 Years Old Children who had 1 or more well- child PCP visits in the Pediatrics Adolescent Well Care Pediatrics who received one or more well-child visits in the who have had 1or more adolescent well-care visits in the Member reaches age 3, 4, 5, 6 by the end of the Continuously enrolled in the plan through the measurement year with no more than 1 break of up to 45 days in enrollment. Member of the plan at the end of the current Member reaches 12-21 by the end of the measurement year. Continuously enrolled through the measurement year with no more than 1 break of up to 45 days in enrollment. Member of the plan at the end of the current Must have 1 or more well-child PCP visits in the Percentage of adolescents 12-18 years of age who had 1 comprehensive wellcare visit within the OR Percentage of 19 to 21-year-olds who had 1 comprehensive well-care visit within the or the year prior Children who turned 3, 4, 5 or 6 years of age by the end of the AND continuously enrolled during the with no more than 1 gap of up to 20 days allowed, and a member of the plan at the end of Patients age 12-18 years of age at the end of the measurement AND continuous enrollment = 12 months in the with 1 gap up to 20 days allowed AND be a member of the plan at the end of the (12-month period) Submit $0.00 charge claim, as appropriate. See Special Bulletin/Physicians Guide, Pg. 2, for details. ICD-9 CM (V) Code for preventive service can be reported when preventive service is provided during visit with illness/cpt Code. V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Submit $0.00 charge claim, as appropriate. See Special Bulletin/Physicians Guide, Pg. 2, for details. REV 6/27/08 14 OR Patients 19-21 years of age at the end of the (Continued on Pg. 15) ICD-9 CM (V) Code for preventive service can be reported when preventive service is provided during visit with illness/cpt Code. V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
AND continuous enrollment = 24 months in the and year prior with 1 gap of up to 20 days per year allowed AND must be a member of the plan at the end of the and the year prior (24-month period) Highmark is a registered mark of Highmark Inc. Blue Shield and the Shield symbol are registered service marks, and QualityBLUE is a service mark of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. REV 6/27/08 15