Performance Measures Reference Guide

Performance Measures Reference Guide Move your HEDIS through coordination of care, grouping multiple member services in to one visit, and avoiding missed opportunities to provide services. Our combined goal is to provide the best care possible to our shared membership, helping them to reach their best health. 1

Cenpatico Integrated Care (Cenpatico-IC) strives to provide quality healthcare to our membership. To assist your practice with your medical record abstraction we have created this Quick Reference Guide. The Quick Reference Guide describes key medical records requirements, commonly used billing codes, and helpful hints to h elp meet the measures. Table of Contents What is HEDIS?... 3 Why is HEDIS important?... 3 What is your role in HEDIS?... 3 Medical Records Request... 3 Health Insurance Portability and Accountability Act (HIPAA)... 3 HEDIS Dates to Remember... 3 HEDIS Measures (in alphabetical order by measure)... 4-30 Meet The Cenpatico Integrated Care HEDIS Team... 31 Cenpatico Integrated Care Directory... 31 Definitions and Resources... 31 2

What is HEDIS? Healthcare Effectiveness Data and Information Set (HEDIS) is the gold standard, and one of the most widely used data sets, in healthcare performance measurement in the United States. The National Committee for Quality Assurance (NCQA) has the responsibility of creating, testing, validating, and publishing the HEDIS Technical Specifications which is updated annually and usually released around 10/01 of the measurement year. HEDIS consists of 81 measures evaluating care and services that affect mortality and morbidity. Health Plans use HEDIS measure scores to assess and improve member health and provider healthcare performance and quality. Why is HEDIS Important? HEDIS is used by health plans to measure and compare provider performance on important dimensions of care and services provided to members. HEDIS is a methodical way to keep track of how well we re doing keeping our members healthy. AHCCCS requires Cenpatico-IC, as well as all health plans, to complete selected HEDIS and CMS Core measurement monitoring throughout the contract year. Improve Patient Outcomes Provide timely care and necessary services. Submit claims timely and code accurately. Develop internal processes to monitor members in need of annual preventative screenings, and management of chronic conditions. Identify the potential for missed opportunities by offering multiple preventative services at each office visit. HEDIS Medical Records Requests: Your Office Plays a Key Role! Please respond timely to all requests for medical records. A timely response to medical records requests is defined as within 10 days of receipt of the request. The AHCCCS AMPM Chapter 630-4, 5, indicates that providers have ten business days from receipt of a request to respond and provide the medical records requested. There are several ways for the data collection to occur such as fax, secure email, electronic medical record access, and on site visits. Send the minimum necessary medical records to satisfy the request for documentation. Health Information Portability and Accountability Act (HIPAA) Data disclosure and collection for HEDIS is permitted under HIPAA rule and does not require member permission or a release of information from the member for the period the individual is or was enrolled in the health plan. The HEDIS data collection and disclosure of information is part of quality healthcare operations of assessment and improvement activities. Dates to Remember: Cenpatico-IC HEDIS medical records request timeline for Measurement Year 2018 will occur in February/March 2018 and again in August/September 2018. Arizona Health Care Cost Containment System (AHCCCS) measurement year is 10/01/2017 through 09/30/2018. 3

Performance Measure Overview For Measurement Year 2018 Measure Information, Medical Record Documentation and Commonly Used CPT Codes (CPT Codes are examples only and not coding recommendations) 4

Adults Access to Preventative/Ambulatory Health Services (AAP) The percent of member s age 20 years and older who had one or more ambulatory visits or preventative care visits during the measurement year. Minimum performance standard (MPS) 75%. Evidence of the ambulatory or preventative care visit/encounter must be in the medical record. 99201-99205, 99211-99215, 99241-99245, 99347-99350, 99385-99387, 99395-99397, 99401, 99404, 99411, 99412, 99240, 99429 Consider combining services into one appointment. If member comes in for acute service, add a preventive service onto the appointment. Distributing information on the importance of preventative care for personal health maintenance may increase efficacy. 5

Ambulatory Care-ED Utilization (AMB) This measure summarizes utilization of ambulatory care in the following categories: Outpatient Visits ED Visits Ensure proper documentation in medical record. Use correct diagnosis and procedure codes. Use correct exclusion codes where necessary. 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 Consider combining services into one appointment. If member comes in for acute service, add a preventive service onto the appointment. Distributing information on the importance of preventative care for personal health maintenance may increase efficacy 6

Annual Monitoring for Patients on Persistent Medications (MPM) The percent of members age 18 and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent (one or more of the following: ACE, ARB, Digoxin or Diuretics) and at least one therapeutic monitoring event (laboratory test) for the therapeutic agent. MPS 75%. The dated result of the therapeutic monitoring event for the therapeutic agent in the medical record. ACE/ARBS-Diuretics: 80051, 84131, 82565, 82575, 80047, 80048, 80050, 80053, 80069 Members on Angiotensin Converting Enzyme (ACE) inhibitors, Angiotensin Receptor Blocker (ARB) or diuretics need at least one serum potassium and one serum creatinine monitoring test in the same measurement year (the tests do not need to have occurred on the same day). 7

Asthma in Younger Adults Admission Rate Number of inpatient hospital admission for asthma per 100,000 enrollee months for ages 18 to 39 years The dated result of the therapeutic monitoring event for the therapeutic agent in the medical record. J45, J45.2, J45.20, J45.21, J45.21, J45.22, J45.3, J45.30, J45.31, J45.32, J45.4, J45.40, J45.41, J45.42, J45.5, J45.50, J45.51, J45.52, J45.9, J45.90, J45.901, J45.902 J45.909, J45.99, J45.990, J45.991, J45.991, J45.998 Develop individualized care plans for members with asthma. Ongoing monitoring for changes in health status. 8

Breast Cancer Screening (BCS) The percent of women age 50 74 years old who had a mammogram or digital breast tomosynthesis between October 1 two years prior to the measurement year and December 31 of the measurement year. MPS 50%. The medical record must include the date of the mammogram during the measurement year. Mammogram 77055-77057, 77067, digital tomosynthesis 77061, 77062 Consider that there are various cultural views on medical care and testing. Provide culturally competent education to members on breast cancer and preventative screenings to increase awareness. 9

Cervical Cancer Screening (CCS): Age 21-64 with Cervical Cytology or PAP/HPV Co-Test The percent of women age 21-64 years old who were screened for cervical cancer with a PAP (Papanicolaou) test or PAP and HPV (Human Papillomavirus) Co-Test on the same day of service. A PAP test is valid for three years, PAP & HPV Co-Test are valid for five years. MPS 64%. A note indicating the date when the Pap test was performed and the result / finding of the cervical cancer screening test (Pap test) must be in the medical record. The medical record must include the dated results of the cervical cancer screening Pap test and HPV Co -test. If the member had a hysterectomy, the medical record needs to indicate the absence or presence of the cervix. Cervical Cytology: 88141-88143, 88147-88148, 88150, 88152-88154, 88164-88167, 88174-88175 HPV Test: 87620-87622 Common challenges related to this measure include lack of documentation regarding the cervical cancer screening results and the incomplete hysterectomy documentation regarding presence or absence of the cervix. Consider that there are various cultural views on medical care and testing. 10

Chlamydia Screening (CHL) The percent of women age 21-24 years old who have had a Chlamydia screening in the measurement year. The medical record must include the date and result of Chlamydia test during the measurement year. MPS 63%. 87110, 87270, 87320, 87490-87492, 87810 Sexually active women age 21-24 years old should be tested for Chlamydia yearly. Common challenges related to this measure may include member maturity/comfort level discussing sexual activity, cultural barriers, fear of judgments or stigma related to STDs, and lack of knowledge about safe sexual practices to prevent STDs. 11

Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate Number of inpatient hospital admissions for chronic obstructive pulmonary disease (COPD) or asthma per 100,000 enrollee months for 40 years and older. Qualifying Events: Verify the two age groups, ages 40-64 and age 65 and older. Verify measured as a rate per 100,000 enrollee months. Use of at least on billing code. Encounter indicating a definite COPD diagnosis. J410, J418, J42, J430, J431, J432, J438, J439, J440, J441, J449, J470, J471, J479 Emphysema and chronic bronchitis are the most common conditions that make up COPD. 12

Colorectal Cancer Screening The percent of members age 50-75 years old who had an appropriate screening for colorectal cancer. MPS 65%. The medical record must include either a dated screening result, or list the service performed with a date of service and the results in the office history and physical (example: Colonoscopy, normal, 10/12/2016). Common Used CPT Codes: FOBT: 82270, 82274 Flexible Sigmoidoscopy: 45330-45335, 45337-45342, 45345 Colonoscopy: 44388-44394, 44397, 44355, 45378-45387, 45391, 45392 CT Colonography (CTC): 74251-74263 Fecal Immunochemical Test (FIT-DNA, FOBT, Cologuard Testing): 81528 Common challenges associated with this measure can be cultural barriers, members embarrassed to discuss the topic, unaware of other screening options, and may think screenings are intended for those with symptoms. 13

Comprehensive Diabetes Care: Eye Exam The percent of members who received an eye screening for Diabetic Retinal Disease. This would include a retinal, dilated eye exam or bilateral eye enucleation performed by an eye care professional (ophthalmologist or optometrist) during the measurement year. MPS 49%. The medical record must include the date and the results of the dilated eye exam performed by an ophthalmologist or optometrist. Documentation of a negative retinal or dilated eye exam performed by an ophthalmologist or optometrist within the last two years, where results indicate retinopathy not present meets the measure requirements. 67227, 67228, 92002, 92004, 92012, 92014, 92134, 92225-92228, 92230, 92235, 92240, 92250, 2260, 203-99205, 99213, 99214, 99215, 99242-99245 Common challenges with this measure include medical record deficiencies such as incomplete or missing medical record information regarding the date and result of the retinal or dilated eye exam, and/or the identification of eye care professional and/or practice where service was provided. 14

Comprehensive Diabetes Care: Diabetic HbA1c Testing The percent of members age 18-75 years old with diabetes who had HbcA1c testing during the measurement year. MPS 77%. The medical record must include the date of the most recent HbA1c and the test result. 83036, 83037 Common challenges with this measure are the lack of HbA1c Screening done in the measurement year, the result and date not in the medical record. Distributing information on the importance of diabetic preventative care may increase efficacy. 15

Comprehensive Diabetes Care: Diabetes Poor Control HbA1c >9 The percent of members age 18-75 years old with diabetes who had HbA1c in poor control (HbA1c result >9) in the measurement year. MPS 43%. The dated result of the HbA1c during the measurement year in the medical record. 3044F, 3045F, 3046F Members with poor glucose control should be prioritized as high risk due to the possibility of severe health complications associated with poor control. 16

Diabetes Admissions, Short-Term Complications Number of inpatient hospital admissions for diabetes short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 enrollee months for Medicaid beneficiaries age 18 and older. Qualifying Events: Calculate and report this measure for two age groups (as applicable): ages 18 to 64 and age 65 and older. Report this measure as a rate per 100,000 enrollee months. E1010, E1011, E10641, E1065, E1100, E1101, E11641, E1165 Short term hospitalizations may be avoided if clinicians effectively diagnose, treat and educate members. Good outpatient care can prevent hospitalizations. 17

Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) The percent of members age 18-64 years old with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year. MPS 80%. Administrative Measure: Members must have been diagnosed with schizophrenia or bipolar disorder and have been both: o Dispensed antipsychotic medications and o Received a diabetes screening test with HbA1c or a finger stick glucose level at provider office. 80047, 80048, 80050, 80053, 80069, 82947.82950,82951, 83036, 83037, 3044F, 3045F, 3046F HbA1c screening, fasting serum glucose or finger stick glucose level are all acceptable. Screen all the members who take medications for schizophrenia or bipolar disorder for diabetes. 18

Early Periodic Screening Diagnostic Treatment (EPSDT) EPSDT provides comprehensive and preventive health care services for members age 18 20 years old for Cenpatico-IC during the measurement year (from 18th birthday to the 21st birthday). MPS 68%. The medical record must include a copy of the AHCCCS EPSDT form or an internal EHR form that includes the elements of the EPSDT form. 99383-99385, 99393-99395 Focused outreach efforts may be necessary to engage this population in conversation regarding the importance of presenting for preventative care/services (EPSDT and Dental benefits and services). Providers (PCP or OB/GYN providers) need to submit AHCCCS EPSDT forms for all members age 18 to 21 to Cenpatico-IC. Fax completed EPSDT forms or EHR internal forms to Cenpatico Integrated Care Attn: EPSDT/ MCH Coordinator at 1-866-601-0111. 19

Flu Shots for Adults, Age 18 and Older (FVA) The percent of member s age 18 years or older who received an influenza/flu vaccination in the measurement year. MPS 50%. The medical record must include the immunization record. 90630, 90654, 90655, 90656, 90658, 90672, 90673, 90686, 90688, 90661, 90662 Enter influenza/flu vaccination information into Arizona State Immunization Information System (ASIIS) for all age groups. Contact ASIIS to inquire if your EHR is compatible for an electronic data feed directly to the ASIIS system. 20

Follow-Up After Emergency Department Visit for Mental Illness or Alcohol and Other Drug Dependence (FUA-AD) The percentage of emergency department (ED) visits for which members 18 and older with a principal diagnosis of mental illness, alcohol or other drug dependence who had a follow-up visit for mental illness. Percentage of ED visits for which the member had a follow up visit for mental health within 7 days. Percentage of ED visits for which the member had a follow up visit for mental health within 30 days. Medical Record Documentation Guidelines: The medical record should document the DOS for follow-up visit and all aspects of the visit. Clarify in the event/diagnosis that the member was 13 years or older on date of visit. 98960,98961, 98962, 99078, 99201, 99202, 99203,T 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99241, 99242, 99243, 99244, 99245, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99384, 99385, 99386, 99387, 99394, 99395, 99396, 99397, 99401, 99402 99403, 99404, 99408, 99409, 99411, 99412, 99510, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853 90875, 90876 Encourage members to participate in behavioral health case management. Encourage members to utilize urgent care clinics Provide members with education regarding substance abuse and medication management 21

Follow-Up After Hospitalization for Mental Illness, 7 and 30 days (FUH) The percentage of discharges for members 6 years and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up with a mental health practitioner. Clarify the event/diagnosis that the member must be 6 years of older on the date of visit. F20.0-F20.3; F20.5; F20.81; F20.89; F20.9; F21-F24; F25.0-F25.1; F25.8- F25.9; F28; F29; F30.10-F30.13; F30.2- F30.4; F30.8-F30.9; F31.0; F31.10-F31.13; F31.2; F31.30-F31.32; F31.4- F31.5; F31.60-F31.64; F31.70- F31.78; F31.81; F31.89; F31.9; F32.0- F32.5; F32.8-F32.81; F32.9; F33.0- F33.3; F33.40-F33.42; F33.8-F33.9; F34.0- F34.1; F34.8-F34.81; F34.89; F34.9; F39; F42; F42.2-F42.4; F42.8- F42.9; F43.0; F43.10- F43.12; F43.20- F43.25; F43.29; F43.8-F43.9; F44.89; F53; F60.0-F60.7; F60.81; F60.89; F60.9; F63.1-F63.3; F63.81; F63.89; F63.9; F68.10-F68.13; F68.8; F84.0; F84.2-F84.3; F84.5; F84.8-F84.9; F90.0- F90.2; F90.8-F90.9; F91.0-F91.3; F91.8- F91.9; F93.0; F93.8- F93.9; F94.0-F94.2 The measure no longer includes visits that occur on the date of d ischarge. Telehealth modifiers were added to the numerator. Encourage members to participate in behavioral health case management. Educate members and their spouses or guardians about the importance of compliance. 22

Heart Failure Admission Rate Number of inpatient hospital admissions for heart failure per 100,000 enrollee months for age 18 and older. Verify member ages 18 to 64 and age 65 and older. Verify the event was reported as a rate per 100,000 enrollee months. I0981,I110, I130, I132,I501, I5020,I201, I5022, I5023, I5030, I5031, I5033, I5040, I5041, I5042, I5043, I509 Lower risk-standardized acute admission rate scores are better. The goal is to evaluate and improve the quality of care for members with diabetes. 23

Hospital Readmission within 30 Days of Discharge Age 18 and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days. Data are reported in the following three categories: Count of Index Hospital Stays (IHS) Count of 30-Day Readmissions Readmission Rate Calculate and report this measure for two age groups (as applicable): ages 18 to 64 and age 65 and older. Measurement comes from HEDIS calculation methodology. Increase coordination of care between member and providers To reduce admissions, increase member education and improve discharge planning. 24

Inpatient Utilization (IPU) The measure summarizes utilization of acute inpatient care and services in the following categories: Total inpatient. Maternity. Surgery. Medicine. Calculate the rates for discharges/1,000 member months. Calculate and report this measure for two age groups (as applicable): ages 40 to 64 and age 65 and older. 99281-99285, 10021-699990 Focus on improving coordination with providers, especially in relation to discharge planning. Ensure members are involved in a disease management program. 25

Mental Health Utilization (MPT) The number and percentage of members receiving the following mental health services during the measurement year. Any service. Inpatient. Intensive outpatient or partial hospitalization. Count only the first visit in the measurement year. F10., F11., F12, F13, F14, F15, F16, F17, F18, F19 Establish coordination of care between mental health provider and PCP. 26

Timeliness of Prenatal Care (PPC) The percent of live births where the member received a prenatal care visit in the first trimester of the pregnancy or within 42 days of enrollment with Cenpatico-IC. MPS 80%. The medical record must include the following: Date and notation of prenatal visit in first trimester by OB/GYN, prenatal care practitioner or PCP (For prenatal visit with PCP a diagnosis of pregnancy must be present). Date of prenatal visit, and evidence of one of the following: a basic physical obstetrical examine that includes auscultation of fetal heart tone, or pelvic exam with obstetric observations, or fundal height. Evidence a prenatal care procedure was performed such as: screening test in form of OB panel (including hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO blood typing, or TORCH Antibody panel alone, or a rubella antibody test/ titer with an RH incompatibility (ABO/Rh) blood ty ping, or Echography of pregnant uterus. Documentation of LMP or EDD in conjunction with either of the following: prenatal risk assessment and counselling/education; or a complete obstetrical history. The American Congress of Obstetricians and Gynecologists (ACOG) Prenatal Flow Sheet (or an internally developed EHR adaptation of the flow sheet that includes the same elements as the ACOG). 59400, 59424, 59426, 59510, 59610, 59618, 99201-99205, 99211-99215, 99241-99245, 99500 The first prenatal visit should include a comprehensive history, laboratory work, height and weight (for BMI calculation), and education about pregnancy health. Fax in the Notice of Pregnancy (NOP) to Cenpatico-IC Maternal/Child Health Coordinator: Fax Number 877-505-9571. Common challenges with this measure are the ACOG or EHR Prenatal Flow Sheet are either missing from the medical record or lack the complete documentation of the visits as listed above. 27

Postpartum Care (PPC) The percentage of members that had a postpartum visit on or between 21-56 days after delivery. MPS 64%. Medical Record must include the date and notation that the postpartum visit occurred and at least one of the following: o Pelvic exam; o Evaluation of weight, BP, breasts and abdomen (notation of breastfeeding works for breast evaluation). o Notation of postpartum care including but not limited to (PP care, PP check, 6-week check, a preprinted postpartum care form, in-which the information was documented during the visit. 57170, 58300, 59430, 59400, 59410, 59510, 59515, 59610, 59614, 59618, 59622, 99501 Common challenges with this measure are that the post-partum visit is not documented as a post-partum visit in the medical record or the visit occurs outside of the time parameter of 21-56 days after delivery. 28

Use of Opioids at High Dosage in Persons Without Cancer (OHD) Rate per 1,000 Medicaid beneficiaries included in the denominator age 18 and older without cancer who received prescriptions for opioids with a daily dosage greater than 120 morphine milligram equivalents (MME) for 90 consecutive days or longer. Patients in hospice are also excluded. Verify age groups 18-64 and age 65 and older. Age groups should be based on age as of January 1 of measurement year. Any member with two or more prescription claims for opioids. A lower rate indicates better performance. Providers must check the AZ Prescription Monitoring Program prior to prescribing a controlled substance. 29

Use of Opioids from Multiple Providers (UOP) For members 18 years and older, the rate per 1,000 receiving prescription opioids for 15 days during the measurement year who received opioids from multiple providers. Three rates are reported. 1. Multiple Prescribers: The rate per 1,000 of members receiving prescriptions for opioids from four or more different prescribers during the measurement year. 2. Multiple Pharmacies: The rate per 1,000 of members receiving prescriptions for opioids from four or more different pharmacies during the measurement year. 3. Multiple Prescribers and Multiple Pharmacies: The rate per 1,000 of members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year. Prescriptions from four or more providers. Prescriptions from four or more pharmacies.. A lower rate for all three indicators indicates better performance 30

Do you have questions for the Cenpatico-IC HEDIS Team? M e e t t h e C e n p a t i c o - I C H E D I S T e a m M e m b e r s : Jennifer Tonges, Manager of Quality Improvement jtonges@cenpatico.com Tony DeQuinzio, Quality Improvement Analyst tdequinzio@cepatico.com Vanessa Zuniga, LPN, HEDIS Specialist vzuniga@cenpatico.com Leeann Taylor, Process Improvement Specialist leeann.taylor@cenpatico.com Cenpatico-IC HEDIS Medical Records Fax Number: 844-870-6493 Cenpatico-IC Notice of Pregnancy (NOP) Fax Number: 877-505-9571 Cenpatico-IC EPSDT Tracking Forms Fax Number: 866-601-0111 Cenpatico Integrated Care (Cenpatico-IC) Directory Cenpatico-IC Website: www.cenpaticointegratedcareaz.com Cenpatico-IC Contact Number: 866-495-6738 Cenpatico-IC Claims Concerns: CAZClaims@cenpatico.com Cenpatico-IC Membership: CAZMEMBERSHIP@cenpatico.com Cenpatico-IC Provider Portal Concerns: CAZSystemsOps@cenpatico.com HEDIS Resources: Cenpatico Integrated Care: Provider Manual https://www.cenpaticointegratedcareaz.com/providers/providerresources/provider-manual.html CMS Adult Core Specifications https://www.medicaid.gov/medicaid/quality-ofcare/downloads/medicaid-adult-core-set-manual.pdf Harry s HEDIS Hints www.cenpaticointegratedcareaz.com National Committee for Quality Assurance (NCQA) www.ncqa.org 31