Performance Recognition Program Incentive Materials 2017 Blue Cross Complete of Michigan 2017 Performance Recognition Program
Dear Blue Cross Complete of Michigan-affiliated primary care physician or group administrator: Blue Cross Complete of Michigan is pleased to provide you with details of our 2017 individual physician incentive materials. Enclosed you will find information about the Performance Recognition Program, including Pay As You Go and Medical Care Group incentives for 2017. These are the highlights of our 2017 program: 2017 Pay As You Go highlights Patient-Centered Medical Home Comprehensive diabetes care HbA1c test HbA1c control <8% Monitoring for nephropathy Health promotion Breast cancer screening Cervical cancer screening Chlamydia screening in women 16 to 24 years Chlamydia screening in men 16 to 24 years Immunizations Childhood immunizations Combo 3 Pregnancy care Prenatal Care Postpartum Visit Well care visits First 15 months 3 to 6 years 12 to 21 years Child BMI Adult access to care Adult BMI Adult access to preventive and ambulatory health services 2017 Medical Care Group bonus highlights Lead screening Lead screening all Medical Care Group eligible for a payment Sincerely, Brenda Lever Director, Provider Network Management Page 2 of 21
TABLE OF CONTENTS 2017 Pay As You Go... Page 4 2017 Medical Care Group bonus... Page 5 Performance Recognition Program questions... Page 7 2017 Performance Recognition Program performance measures and scoring methodology... Page 8 2017 Blue Cross Complete of Michigan Performance Recognition Program payment schedule... Page 21 Page 3 of 21
Pay As You Go Incentives Blue Cross Complete of Michigan plans to offer several Pay as You Go initiatives during 2017. Technical specification documents, which detail timeframes, measures and payment schedule, are listed in the back of this booklet in Exhibit A. Please use this information to make internal assessments of your clinical performance for each initiative. Our medical directors and provider Account Executives are available to assist you in preparation for these initiatives. Pay As You Go Quality Measures Measures Age Range Provider Incentive Child Immunizations Childhood immunizations - Combo 3 0 to 2 years old $50 Well Care Visits First 15 months (6th visit) 0 to 15 months old $100 Children 3 to 6 years old $50 Adolescents 12 to 21 years old $50 Child BMI 3 to 17 years old $50 Health Promotion Breast cancer screening 50 to 74 years old $50 Cervical cancer screening 21 to 64 years old $30 Chlamydia screening in women 16 to 24 years old $30 Chlamydia screening in men 16 to 24 years old $30 Comprehensive Diabetes Care HbA1c test 18 to 75 years old $25 HbA1c control <8% 18 to 75 years old $100 Monitoring for nephropathy 18 to 75 years old $25 Lead Screening Blood lead screening 0 to 2 years old $100 OB/Pregnancy Care Prenatal care timeliness Pregnant women Postpartum visit Pregnant women $200 Adult Access to Care Adult BMI 19 to 74 years old $50 Adult access to preventive and ambulatory health services 20 to 44 and 45 to 64 years old $20 Patient-Centered Medical Home Designated PCMH $0.50 Page 4 of 21
Medical Care Group Bonus Blue Cross Complete is offering Medical Care Groups a population-based incentive opportunity for HEDIS performance. The populations have been divided into three different categories: 1. Adult access to care 2. Child access to care 3. Pregnancy care Medical Care Groups must have a minimum of 250 members in order to be eligible for the bonus opportunity. In order for Medical Care Groups to earn the bonus, each measure within the population must meet either the 75 th or 90 th percentiles. Special Quality Bonus Details: Goal Bonus Amount 75 th percentile $3 pmpm* per measure for measure denominator 90 th percentile $6 pmpm* per measure for measure denominator *per member per month Page 5 of 21
Medical Care Group Bonus Structure Population # 1 2 Population Quality Goal Target 75th Adult Access to Preventive and Ambulatory Health Services 75th % Reward Target 90th Age 20 to 44 83.42% $3 pmpm* 86.04% Age 45 to 64 89.79% For members in the 91.59% Adult BMI 89.35% denominator 92.54% Child Access to Care Well Child Visit 6 visits by 15 months 67.76% $3 pmpm* 73.88% Well Child Visit Age 3 years to 6 years 77.57% For members in the 82.97% Child BMI 77.78% denominator 86.37% Pregnancy Care Prenatal Care Timeliness 87.56% $3 pmpm* 3 For members in the 91.00% Postpartum Care 67.53% denominator 73.61% *per member per month 90th % Reward $6 pmpm* For members in the denominator $6 pmpm* For members in the denominator $6 pmpm* For members in the denominator Page 6 of 21
Performance Recognition Program Questions If you have questions or concerns regarding the Blue Cross Complete Performance Recognition Program, direct them to your Blue Cross Complete provider account executive or one of the Blue Cross Complete contacts listed below: Contacts Kelly Losen, Manager, Provider Network Management Klosen@mibluecrosscomplete.com Brenda R. Lever, Director, Provider Network Management Blever@mibluecrosscomplete.com Donald Beam, M.D., Medical Director Dbeam@mibluecrosscomplete.com Blue Cross Complete of Michigan 100 Galleria Officentre Suite 210 Southfield, MI 48034 Note: No specific payments shall be made directly, or indirectly, to a physician or physician group as an inducement to reduce or limit medically necessary services. Page 7 of 21
Diabetes HbA1C testing Blue Cross Complete of Michigan Performance Recognition Program Performance Measures and Scoring Methodology Comprehensive Diabetes Care Codes to identify members with diabetes ICD-10 DIAGS: E10-E10.3519, E10.359-E10.36, E10.39-E11.3519, E11.359-E11.36, E11.39-E13.3519, E13.359-E13.36, E13.39-E13.9, 024.011-O24.33, O24.811-O24.83 Age 18 through 75 years old as of December 31,2017 One (or more) HbA1C tests conducted during 2017 Codes* to identify HbA1c Tests CPT: 83036, 83037 CPT Category II: 3044F, 3045F, 3046F LOINC: 4548-4, 4549-2, 17856-6 Measured against HEDIS specification (continuously enrolled with Blue Cross Complete for 2017) Diabetes HbA1C <8% Codes to identify members with diabetes ICD-10 DIAGS: E10-E10.3519, E10.359-E10.36, E10.39-E11.3519, E11.359-E11.36, E11.39-E13.3519, E13.359-E13.36, E13.39-E13.9, 024.011-O24.33, O24.811-O24.83 Age 18 through 75 years old as of December 31, 2017 Last A1C test performed in 2017 shows a level < 8% Codes* to identify HbA1C <8% CPT: 83036, 83037 If the most recent HbA1c level performed in 2017 < 8.0% CPT Category II: 3044F, 3045F If the most recent HbA1c level performed in 2017 is < 8.0% Measured against HEDIS specification (continuously enrolled with Blue Cross Complete for 2017) Page 8 of 21
Diabetes Monitoring for nephropathy Blue Cross Complete of Michigan Codes to identify members with diabetes ICD-10 DIAGS: E10-E10.3519, E10.359-E10.36, E10.39-E11.3519, E11.359-E11.36, E11.39-E13.3519, E13.359-E13.36, E13.39-E13.9, 024.011-O24.33, O24.811-O24.83 Age 18 through 75 years old as of December 31, 2017 At least one nephropathy screening or monitoring test in 2017 OR Evidence of medical treatment for nephropathy in 2017 OR Evidence of ACE/ARB therapy in 2017 OR Evidence of stage 4 chronic kidney disease in 2017 OR Evidence of ESRD in 2017 OR Evidence of kidney transplant in 2017 OR Had a visit with a nephrologist in 2017 OR Had at least one ACE inhibitor or ARB dispensing event in 2017 Codes* to identify nephropathy screening tests CPT: 81000, 81001, 81002, 81003, 81005, 82042, 82043, 82044, 84156 CPT CATEGORY II: 3060F, 3061F, 3062F LOINC: 1753-3, 1754-1, 1755-8, 1757-4, 2887-8, 2888-6, 2889-4, 2890-2, 5804-0, 9318-7, 11218-5, 12842-1, 13705-9, 13801-6, 14585-4, 14956-7, 14957-5, 14958-3, 14959-1, 18373-1, 20454-5, 20621-9, 21059-1, 21482-5, 26801-1, 27298-9, 30000-4, 30001-2, 30003-8, 32209-9, 32294-1, 32551-4, 34366-5, 35663-4, 40486-3, 40662-9, 40663-7, 43605-5, 43606-3, 43607-1, 44292-1, 47558-2, 49023-5, 50561-0, 50949-7, 53121-0, 53525-2, 53530-2, 53531-0, 53532-8, 56553-1, 57369-1, 57735-3, 58448-2, 58992-9, 59159-4, 60678-0, 63474-1, 76401-9, 77158-4, 77253-3, 77254-1 Codes* to identify nephropathy treatment or ACE/ARB therapy CPT CATEGORY II: 3066F, 4010F ICD-10 DIAGS: E08.21- E08.29, E09.21- E09.29, E10.21- E10.29, E10.29- E11.29, E13.21- E13.29, I12.0- I12.9, I13.0- I13.2, I15.0, I15.1 N00.0- N08, N14.0- N14.4, N17.0- N19, N25.0- N26.9, Q60.0- Q61.9, R80.0- R80.9 Page 9 of 21
Diabetes Monitoring for nephropathy continued Codes* to identify Stage 4 chronic kidney disease ICD-10 DIAG: N18.4 Codes* to identify ESRD CPT: 36147, 36800, 36810, 36815, 36818-36821, 36831-36833, 90935, 90937, 90940, 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999. 99512 HCPCS: G0257, S9339 ICD-10 DIAGS: N18.5, N18.6, Z91.15, Z99.2 ICD-10 PCS: 3E1M39Z, 5A1D00Z, 5A1D60Z POS: 65 UB REVENUE CODES: 0800-0804, 0809, 0820-0825, 0829-0835, 0839-0845, 0849-0855, 0859, 0880-0889 Codes* to identify kidney transplant CPT: 50300, 50320, 50340, 50360, 50365, 50370, 50380 HCPCS: S2065 ICD-10 DIAG: Z94.0 ICD-10 PCS: 0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY10Z2 UB REVENUE CODE: 0367 Measured against HEDIS specification (continuously enrolled with Blue Cross Complete for 2017) Page 10 of 21
Health Promotion Breast cancer screening Codes* to identify breast cancer screening (mammograms): CPT: 77055-77057 HCPCS: G0202, G0204, G0206 UB2 REVENUE CODES: 0401, 0403 Women who are age 52 to 74 as of December 31, 2017 Received one or more mammograms from October 1, 2015 through December 31, 2017 Exclusion: Women who have had a bilateral mastectomy on or before December 31, 2017 Measured against HEDIS specification (continuously enrolled with Blue Cross Complete for 2017) Cervical cancer screening Codes* to identify cervical cancer sreening (Pap test) CPT: 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175 HCPCS: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 UB2 REVENUE CODES: 0923 LOINC: 10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5 Women who are age 24 to 64 as of December 31, 2017 Received one or more pap tests during 2015, 2016 or 2017 Exclusion: Women who have had a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix on or before December 31, 2017 Measured against HEDIS specification (continuously enrolled with Blue Cross Complete 2017) Page 11 of 21
Chlamydia screening in women and men Blue Cross Complete of Michigan Codes* to identify chlamydia screening CPT: 87110, 87270, 87320, 87490, 87491, 87492, 87810 LOINC: 557-9, 560-3, 4993-2, 6349-5, 6354-5, 6355-2, 6356-0, 6357-8, 14463-4, 14464-2, 14467-5, 14470-9, 14471-7, 14474-1, 14509-4, 14510-2, 14513-6, 16600-9, 16601-7, 21189-6, 21190-4, 21191-2, 21192-0, 21613-5, 23838-6, 31771-9, 31772-7, 31775-0, 31777-6, 36902-5, 36903-3, 42931-6, 43304-5, 43404-3, 43406-8, 44806-8, 44807-6, 45067-6, 45068-4, 45069-2, 45070-0, 45074-2, 45076-7, 45078-3, 45080-9, 45084-1, 45091-6, 45095-7, 45098-1, 45100-5, 47211-8, 47212-6, 49096-1, 50387-0, 53925-4, 53926-2, 80360-1, 80361-9, 80362-7, 80363-5, 80364-3, 80365-0, 80367-6 Women who are age 16 to 24 as of December 31, 2017 Men who are age 18 to 24 as of Dec. 31, 2017 Received one or more chlamydia tests during 2017 Exclusion: Women who received a pregnancy test in 2017, followed within seven days (inclusive) by either a prescription for isotretinoin (Accutane) or an x-ray; this exclusion does not apply to members who qualify for the denominator based on services other than the pregnancy test alone. Measured against HEDIS specification (continuously enrolled with Blue Cross Complete for 2017) Page 12 of 21
Immunization: Childhood combination 3 Codes* to identify Childhood combination 3 DTaP CPT: 90698, 90700, 90721, 90723 Polio (IPV) CPT: 90698, 90713, 90723 MMR CPT: 90707, 90710 Measles and Rubella CPT: 90708 Measles CPT: 90705 ICD-10 DIAGS: B05.0-B05.9 Mumps CPT: 90704 ICD-10 DIAGS: B26.0-B26.9 Rubella CPT: 90706 ICD-10 DIAGS: B06.00-B06.9 HiB CPT: 90644-90648, 90698, 90721, 90748 Hepatitis B Blue Cross Complete of Michigan Immunizations CPT: 90723, 90740, 90744, 90747, 90748 HCPCS: G0010 ICD-10 DIAGS: B16.0-B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, Z22.51 ICD-10 PCS: 3E0234Z Page 13 of 21
Immunization: Childhood combination 3 continued Blue Cross Complete of Michigan Chicken Pox (VZV) CPT: 90710, 90716 ICD-10 DIAGS: B01.0 to B02.9 Pneumoccocal Conjugate CPT: 90669, 90670 HCPCS: G0009 Hepatitis A CPT: 90633 ICD-10 DIAGS: B15.0, B15.9 Rotavirus (2 dose) CPT: 90681 Rotavirus (3 dose) CPT: 90680 Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90687 HCPCS: G0008 EXCLUSIONS: Anaphylactic reaction to any particular vaccine or its components. ICD-10 DIAG: T80.52XA, T80.52XD, T80.52XS Children who turn age 2 during 2017 Meeting the combination 3 criteria: (1) Hepatitis A, (2 or 3) Rotavirus (depends on dose schedule), (2) Influenza, (4) DTaP* vaccinations, (3) IPV* vaccinations, (1) MMR, (1) VZV, (3) HiB* vaccinations, (3) hepatitis B vaccinations, and (4) pneumococcal conjugate vaccinations* (PCV) on or before the second birthday. Measured against HEDIS specification (continuously enrolled with Blue Cross Complete for 12 months prior to second birthday) *Vaccinations administered prior to 42 days after birth should not be counted as a numerator hit. Page 14 of 21
Lead Screening Lead screening Codes* to identify lead screening: CPT: 83655 Lead, quantitative; blood LOINC: 5671-3, 5674-7, 10368-9, 10912-4, 14807-2, 17052-2, 25459-9, 27129-6, 32325-3, 77307-7 Children turning 2 years old during 2017 Received one or more capillary or venous lead blood tests for lead poisoning on or before their second birthday. Measured against HEDIS specification (continuously enrolled with Blue Cross Complete for 12 months prior to second birthday) Prenatal care timeliness Pregancy Care Codes* to identify prenatal care: CPT: 99500 CPT CATEGORY II: 0500F, 0501F, 0502F HCPCS: H1000-H1004 All ages All women with a live birth delivery between November 6, 2016, and November 5, 2017, and who had a prenatal care visit as a member of the health plan in the first trimester or on enrollment start date or within 42 days of enrollment in the health plan. Measured against HEDIS specification (continuous enrollment with Blue Cross Complete 43 days prior to delivery through 56 days after delivery) Page 15 of 21
Postpartum care Codes* to identify postpartum care: CPT: 57170, 58300, 59430, 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175, 99501 CPT CATEGORY II: 0503F HCPCS: G0101, G0123, G0124, G0141, G0143- G0145, G0147, G0148, P3000, P3001, Q0091 ICD-10 DIAGS: Z01.411-Z01.42, Z30.430, Z39.1, Z39.2 UB REVENUE CODE: 0923 LOINC: 10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5 All ages All women with a live birth delivery between November 6, 2016, and November 5, 2017, and who had a postpartum visit from the 21st through the 56th day after the delivery date. Measured against HEDIS specification (continuous enrollment with Blue Cross Complete 43 days prior to delivery through 56 days after delivery) Page 16 of 21
Well child visits First 15 months - 6+ visits Blue Cross Complete of Michigan Well Care Visits Codes* to identify well-care visits ICD-10 DIAGS: Z00.00-Z00.129, Z00.5, Z00.8, Z02.0-Z02.9 CPT: 99381-99385, 99391-99395, 99461 HCPCS: G0438, G0439 Children turning 15 months old during 2017 Received at least six well-child visits with a primary care physcian during first 15 months of life Measured against HEDIS specification (continuously enrolled with Blue Cross Complete 31 days through 15 months of age) Well child visits - 3 to 6 years Codes* to identify well-care visits ICD-10 DIAGS: Z00.00-Z00.129, Z00.5, Z00.8, Z02.0-Z02.9 CPT: 99381-99385, 99391-99395, 99461 HCPCS: G0438, G0439 Children who are 3 to 6 years old as of December 31, 2017 Received at least one well-child visit with a primary care physician in 2017 Measured against HEDIS specification (continuously enrolled with Blue Cross Complete for 2017) Page 17 of 21
Well child visits 12 to 21 years Codes* to identify well-care visits ICD-10 DIAGS: Z00.00-Z00.129, Z00.5, Z00.8, Z02.0-Z02.9 CPT: 99381-99385, 99391-99395, 99461 HCPCS: G0438, G0439 Members who are 12 to 21 years old as of December 31, 2017 Received at least one comprehensive well-care visit with a PCP or an OB/GYN in 2017 Measured against HEDIS specification (continuously enrolled with Blue Cross Complete for 2017) BMI 3 to 17 years Codes* to identify BMI percentile ICD-10 DIAGS: Z68.51 Less than 5th percentile for age; Z68.52 5th percentile to less than 85th percentile for age; Z68.53 85th percentile to less than 95th percentile for age; Z68.54 Greater than or equal to 95 percentile for age Members who are 3 to 17 years old as of December 31, 2017 Members who had an outpatient visit with a PCP or an OB/GYN in 2017 Members whose body mass index (BMI) percentile was documented during 2017 Measured against HEDIS specification (continuously enrolled with Blue Cross Complete for 2017) Page 18 of 21
Adult Access to Care Adult BMI 19 to 74 years Codes* to identify BMI ICD-10 DIAG: Z68.1-Z68.45 Codes* to identify BMI Percentile ICD-10 DIAG: Z68.51- Z68.54 Age 19 to 74 years old as of December 31, 2017 Members who had an outpatient visit during 2016 or 2017 Members whose body mass index (BMI) or BMI Percentile was documented during 2016 or 2017 For members 20 years of age or older on the date of service, use BMI. For members younger than 20 years of age on the date of service, use BMI Percentile. Measured against HEDIS specification (continuously enrolled with Blue Cross Complete for 2016 and 2017) Page 19 of 21
Adults Access to Preventive Care and Ambulatory Health Services 20 to 44 and 45 to 64 years Codes* to identify health maintenance exams Preventive and Ambulatory Office Visits: CPT: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429 HCPCS: G0402, G0438, G0439, G0463, T1015 UB REVENUE CODES: 0510-0517, 0519-0523, 0526-0529, 0982, 0983 ICD-10 DIAGS: Z00.00-Z00.01, Z00.121-Z00.129, Z00.5, Z00.8, Z02.0- Z02.9 Other Ambulatory Visits: CPT: 92002, 92004, 92012, 92014, 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337 HCPCS: S0621, S0621 UB REVENUE CODES: 0524, 0525 Age 20 to 64 years old as of December 31, 2017 Received at least one ambulatory or preventive care visit in 2017 Measured against HEDIS specification (continuously enrolled with Blue Cross Complete for 2017) Page 20 of 21
2017 Blue Cross Complete of Michigan Performance Recognition Program Payment Schedule Measure Measurement Period Payment Payment Made To 2017 Pay As You Go January through June 2017 October 2017 Individual PCP 2017 Pay As You Go July through December 2017 July 2018 Individual PCP 2017 Medical Care Group Bonus January through December 2017 July 2018 Medical Care Group HEDIS is a registered trademark of the National Committee for Quality Assurance. *CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved. Page 21 of 21