Prevention and Screening Adolescent Preventive Care Measures (APC) The percentage of adolescents 12-17 years of age who had at least one outpatient visit with a PCP or OB/ GYN practitioner during the measurement year and received the following four components of care during the measurement year: Assessment or counseling or education on risk behaviors and preventive actions associated with sexual activity Assessment or counseling or education for depression Assessment or counseling or education about the risks of tobacco usage and Assessment or counseling or education about the risks of substance use (including alcohol and excluding tobacco) It is recommended an adolescent receive the above preventive care measures at least once per year during the ages of 12-17 ***Measure Compliance will be determined using the Hybrid Data Collection method (Chart Review) *** Performance will be determined through a sample chart audit. Five points may be deducted if less than the 75 th percentile is achieved. Counseling related to Sexual Activity Z30.011-Z30.019, Z30.2, Z30.9, Z71.7, Z71.89 Depression screening Z13.89 Tobacco Cessation Counseling 99406, 99407 Alcohol and Substance Use Counseling Z13.89, Z71.41, Z71.42, Z71.51, Z71.52, Z71.6 ** Ensure all diagnosis codes are included in the medical record Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents (WCC) The percentage of members 3-17 years of age who had an outpatient visit with a PCP or OB/ GYN practitioner and who had evidence of the following during the measurement year: BMI percentile documentation Counseling for nutrition Counseling for physical activity It is recommended a child receive weight assessment and counseling for nutrition and physical activity at least once per year during each of their 3 rd 17 th years of life *** Performance will be determined through a sample chart audit. BMI percentile Z68.51, Z68.52, Z68.53, Z68.54 ** Ensure all diagnosis codes are included in the medical record QI Multi-Specialty (Rev 6/17) Page 1
Childhood Immunizations Status (vaccination combo 3) (CIS) The percentage of children 2 years of age who have had the following immunizations on or before their second birthday: 4 diphtheria, tetanus, and acellular pertussis (DTaP) 3 polio (IPV) 1 MMR (Measles, Mumps and Rubella) 3 H influenza type B (HiB) 3 hepatitis B (HepB) 1 chicken pox (VZV) 4 pneumococcal conjugate (PCV) The initial vaccination of the following immunizations should be administered no earlier than 42 days after birth: DTaP; IPV; HiB; PCV The claim for each vaccine administered must include the vaccination supply code in addition to the administration code Vaccine codes: Refer to NYS VFC Provider Manual Appendix D Immunizations for Adolescents (IMA) Adolescents 13 years of age who have had the following immunizations by their 13th birthday: 1 dose of meningococcal conjugate vaccine and 1 tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine At least one meningococcal conjugate vaccine between the 11 th and 13 th birthday At least one Tdap vaccine between the 10 th and 13 th birthday Exclusion: Anaphylactic reaction to the vaccine or its components any time on or before the member's 13 th birthday The claim for each vaccine administered must include the vaccination supply code in addition to the administration code Vaccine codes: Refer to NYS VFC Provider Manual Appendix D QI Multi-Specialty (Rev 6/17) Page 2
Human Papillomavirus Vaccine for Adolescents (HPV) The percentage of adolescents 13 years of age who had three doses of the human papillomavirus (HPV) vaccine by their 13 th birthday. At least three HPV vaccinations with different dates of service on or between the 9 th and 13 th birthday Exclusion: Anaphylactic reaction to the vaccine or its components any time on or before the member's 13 th birthday ***Please note that we are awaiting notification of a change in the HEDIS requirements for HPV which recognizes the option of a 2 dose series for children under 15 yrs. of age per ACIP The claim for each vaccine administered must include the vaccination supply code in addition to the administration code Vaccine codes: Refer to NYS VFC Provider Manual Appendix D Lead Screening in Children (LSC) The percentage of children 2 years of age who had one or more capillary or venous lead blood tests for lead poisoning on or before their second birthday The result or finding and the date the test was performed must be documented in the medical record 83655 Breast Cancer Screening (BCS) The percentage of women 50 74 years of age who had a mammogram to screen for breast cancer (one or more mammograms any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year) Documentation in the medical record must include the result or finding as well as when the mammogram test was performed 77055, 77056, 77057, G0202 QI Multi-Specialty (Rev 6/17) Page 3
Cervical Cancer Screening (CCS) The percentage of women 21 64 years of age who were screened for cervical cancer using either of the following criteria: Women age 21 64 who had cervical cytology performed every 3 years Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years Documentation in the medical record must include the result or finding as well as when the cervical cytology and/or the HPV test was performed 87620-87622, 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175 Colorectal Cancer Screening (COL) Double Weighted Measure The percentage of members 50 75 years of age who had appropriate screening for colorectal cancer Screening for colorectal cancer by one of the following: Fecal occult blood test (FOBT) during the measurement year OR Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year OR Colonoscopy during the measurement year or the nine years prior to the measurement year FOBT: G0328, 82270, 82274 Flexible Sigmoidoscopy: 45330-45350 Chlamydia Screening in Women (CHL) The percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year Urine chlamydia tests are non-invasive and widely acceptable for this screening Chlamydia is most prevalent among adolescent (15-19) and young adult (20-24) women 87110, 87270, 87320, 87490, 87491, 87492, 87810 Screening is essential because the majority of females who have the condition do not experience symptoms QI Multi-Specialty (Rev 6/17) Page 4
Cardiovascular Conditions Controlling High Blood Pressure (CBP) The percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria: Members 18-59 years of age whose BP was <140/90 mm Hg Members 60-85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg Members 60-85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg The most recent BP reading during the measurement year as long as it occurred after the diagnosis of hypertension. *** Performance will be determined through a sample chart audit. Respiratory Conditions Appropriate Testing for Children with Pharyngitis (CWP) The percentage of children 3 18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode Pediatric clinical practice guidelines recommend that only children diagnosed with group A streptococcus (strep) pharyngitis, based on appropriate lab tests, be treated with antibiotics Perform a strep test each time antibiotics are prescribed for the diagnosis of pharyngitis J02.0, J02.8, J02.9, J03.00, J0301, J03.80, J03.81, J03.90, J03.91 87070-87071, 87081, 87430, 87650-87652, 87880 ** An additional diagnosis code reported with the pharyngitis diagnosis code will exclude the encounter from the measure QI Multi-Specialty (Rev 6/17) Page 5
Appropriate Treatment for Children with Upper Respiratory Infection (URI) The percentage of children 3 months to 18 years who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription The common cold (or URI) is a frequent reason for pediatric office visits. Clinical guidelines DO NOT support the use of antibiotics for the common cold Pediatric clinical practice guidelines DO NOT recommend antibiotics for a majority of upper respiratory infections because of the viral etiology of these infections, including the common cold Include all diagnosis codes related to a visit for URI ** An additional diagnosis code reported with the URI diagnosis code will exclude the encounter from the measure Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) The percentage of adults 18 64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription Antibiotics are not indicated in clinical guidelines for treating adults with acute bronchitis who do not have a comorbidity or other infection for which antibiotics may be appropriate Provide education to patients regarding appropriate use and risks related to antibiotic treatment Ensure accurate diagnosis coding If ACUTE bronchitis is not the diagnosis documented in the medical record, then acute bronchitis should NOT be indicated as the diagnosis on the claim QI Multi-Specialty (Rev 6/17) Page 6
Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) The percentage of members 40 years and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry testing to confirm the diagnosis Spirometry testing is required to confirm a new or newly active diagnosis of COPD (includes the diagnosis of emphysema and chronic bronchitis) Report at least one spirometry test result for each new or newly active diagnosis of COPD Spirometry testing is indicated for patients who received a COPD diagnosis from an office visit; urgent care visit; ED visit; or inpatient stay to confirm the diagnosis of COPD Only document a diagnosis code of COPD when the diagnosis has been confirmed by spirometry testing Spirometry testing codes: 94010, 94014, 94015, 94016, 94060, 94070, 94375, 94620 Medication Management for People With Asthma (MMA) The percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period According to New York State quality guidelines, persistent asthma is defined as: At least one ED visit, with a principal diagnosis of asthma, OR At least one acute inpatient encounter, with a principal diagnosis of asthma, OR At least four outpatient visits or observation visits on different dates of service, with any diagnosis of asthma and at least two asthma medication dispensing events, OR At least four asthma medication dispensing events Individuals with emphysema, COPD, or other respiratory conditions should NOT get diagnosed or coded as having asthma QI Multi-Specialty (Rev 6/17) Page 7
Musculoskeletal Conditions Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) The percentage of members who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD) Includes members who had at least one ambulatory prescription dispensed for a DMARD during the measurement year M05.00-M05.079, M05.09-M05.279, M05.30-M05.379, M05.39-M05.479, M05.49-05.9, M06.00-M06.39, M06.80- M06.9 QI Multi-Specialty (Rev 6/17) Page 8
Diabetes Comprehensive Diabetes Care: (CDC) Double Weighted Measure Retinal Eye Exam The percentage of members 18 75 years of age with diabetes (type 1 and type 2) who had a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or had a negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year Documentation in the medical record must include the result or finding as well as when the retinal eye exam was performed S0620-S0621, 92002, 92004, 92012, 92014, 2022F, 2024F, 2026F, 3072F Include all diagnosis codes related to diabetic retinal screening exam Annual Hemoglobin A1c (HbA1c) Testing The percentage of members 18 75 years of age with diabetes (type 1 and type 2) who had an Hemoglobin A1c (HbA1c) test performed during the measurement year Documentation in the medical record must include the result or finding as well as when the Hemoglobin A1c (HbA1c) test was performed 83036, 83037, 3044F-3046F Medical Attention for Nephropathy The percentage of members 18 75 years of age with diabetes (type 1 and type 2) who had medical attention for nephropathy during the measurement year ONE of the following: A nephropathy screening test Evidence of treatment for nephropathy or ACE/ARB therapy Evidence of stage 4 chronic kidney disease Evidence of ESRD Evidence of kidney transplant A visit with a nephrologist At least one ACE inhibitor or ARB dispensing event 81000-81003, 81005, 82042-82044, 84156, 3060F, 3061F, 3062F, 3066F, 4010F For providers with dual specialties (that include Nephrology); Submit the appropriate taxonomy code to indicate the nephrology specialty on the claim QI Multi-Specialty (Rev 6/17) Page 9
Behavioral Health Antidepressant Medication Management (AMM) Effective Acute Phase Treatment - The percentage of members 18 years of age and older with a diagnosis of major depression, who were initiated on an antidepressant drug, and who received an adequate acute-phase trial of medications (three months) Effective Acute Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks) F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9 Have you coded your visit to the highest degree of specificity? Follow Up Care for Children Prescribed ADHD Medication (ADD) Initiation Phase - The percentage of children 6-12 years of age with newly prescribed attention deficit hyperactivity disorder (ADHD) medication who had one follow-up visit with a practitioner with prescribing authority during the 30-day Initiation Phase Facilitate scheduling of ADHD follow-up appointments to occur within 30 days of newly prescribed medication Educate parents/caregivers regarding the importance of follow-up care for children taking ADHD medications F90.0, F90.1, F90.2, F90.8, F90.9 *** Five points may be deducted if less than the 75 th percentile is achieved. QI Multi-Specialty (Rev 6/17) Page 10
Annual Monitoring for Patients on Persistent Medications (MPM) The percentage of members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year Note: Tests do not need to occur on the same service date, only within the measurement year Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): Recommendation: At least one (annual) serum potassium and a serum creatinine therapeutic monitoring test in the measurement year Annual monitoring for members on digoxin: Recommendation: At least one (annual) serum potassium, one serum creatinine, and one serum digoxin therapeutic monitoring test in the measurement year Annual monitoring for members on diuretics: Recommendation: At least one (annual) serum potassium and a serum creatinine therapeutic monitoring test in the measurement year 80047, 80048, 80050, 80051, 80053, 80069, 80162, 80163, 82565, 82575, 80051, 84132 QI Multi-Specialty (Rev 6/17) Page 11
Utilization Well Child Visits in the First 15 Months of Life (W15) The percentage of members who turned 15 months old during the measurement year and who had six or more well child visits with a PCP during the measurement year It is recommended a child receive, at minimum, 6 preventive visits within the first 15 months of life YourCare will reimburse for preventive visits appropriately performed, documented, and billed by a PCP type specialty Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.2, Z00.3, Z00.70, Z00.71, Z00.8 Z02.0, Z02.2-Z02.6, Z02.8-Z02.9, Z76.1, Z76.2 99381, 99382, 99391, 99392, 99461 Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) The percentage of children 3-6 years of age who had one or more well child visits with a PCP during the measurement year It is recommended a child receive, at minimum, one preventive visit during each of their 3 rd, 4 th, 5 th and 6 th years of life YourCare will reimburse for preventive visits appropriately performed, documented, and billed by a PCP type specialty Z00.110, Z00.111, Z00.121, Z00.129, Z00.2, Z00.3, Z00.70, Z00.71, Z00.8, Z00.00, Z00.01, Z02.0-Z02.6, Z02.8-Z02.9 99382, 99383, 99392, 99393 Adolescent Well-Care Visits (AWC) The percentage of adolescents 12-21 years of age who had at least one comprehensive well-care visit with a PCP or OB/ GYN practitioner during the measurement year It is recommended that an adolescent receive, at minimum, one preventive visit during each of their 12 th 21 st years of life YourCare will reimburse for preventive visits appropriately performed, documented, and billed by a PCP or OB/GYN type specialty Z00.00, Z00.01, Z02.0-Z02.6, Z02.8-Z02.9 99384, 99385, 99394, 99395 QI Multi-Specialty (Rev 6/17) Page 12