Well Adult Well Visit 20 yrs > Yearly 99385-87, 99395-97, G0402, G0438, G0439, G0463 Total Health Quality Indicators For Providers 2018 Adult- Preventive Z00.00 Report ALL components of an annual visit using CPT and Dx code BMI Assessment BMI Recording 18-74 yrs Yearly G8417, G8418, G8420 3008F BMI%: for mbrs 18-20 yrs: BMI < 5% Z68.51 BMI 5% - < 85% Z68.52 BMI 85% - < 95% Z68.53 BMI >95% Z68.54 Report CPT II and Dx on the same line Patients <20 the BMI must be reported as a % or plotted on a age growth chart BMI codes for mbrs > 20 yrs: <or=19 Z68.1 32.0-32.9 Z68.32 20.0-20.9 Z68.20 33.0-33.9 Z68.33 21.0-21.9 Z68.21 34.0-34.9 Z68.34 22.0-22.9 Z68.22 35.0-35.9 Z68.35 23.0-23.9 Z68.23 36.0-36.9 Z68.36 24.0-24.9 Z68.24 37.0-37.9 Z68.37 25.0-259 Z68.25 38.0-38.9 Z68.38 26.0-26.9 Z68.26 39.0-39.9 Z68.39 27.0-27.9 Z68.27 40.0-44.9 Z68.41 28.0-28.9 Z68.28 45.0-49.9 Z68.42 29.0-29.9 Z68.29 50.0-59.9 Z68.43 30.0-30.9 Z68.30 60.0-69.9 Z68.44 31.0-31.9 Z68.31 70 and over Z68.45 Report CPT II and Dx on the same line Substance Abuse/Screening Tobacco Use Screening 13 yrs > Yearly *G9902, G9903, *G9906, *G9907-9909 - All New G9275 - G9276 1000F (tobacco use assessed) 1031F (Smoking status and exposure to secondhand smoke assessed in home) *1032F (current tobacco smoker or currently exposed to secondhand smoke) *1033F (current tobacco non smoker and not exposed to secondhand smoke) *1034F (current tobacco smoker), *1035F (smokeless tobacco user), 1036F (non tobacco user), *4004F (smoker/cessation intervention provided) F17.2XX, T65.211A, T65.212A, T65.213A, T65.214!, T65.221A, T65.222A, T65.223A, T65.224A, T65.291A, T65.292A, T65.293A, T65.294A Z87.891 Report E/M w/appropriate Z code and other Dx code(s) on the same line OR Report CPT II code w/dx code (s) on a separate line * tobacco use disorder, use this if they are tobacco users Alcohol Screening 13 yrs > Yearly G0396, G0397, G0442, G0443, 99408, 99409 3016F F10.10 F10.20 F10.21 Report E/M w/appropriate Dx or OR Report on a separate line, use CPT II with other appropriate Dx code(s) and CPT code(s) that reflect the office visit rendered Substance Abuse Screening 13 yrs > Yearly G0396, G0397, 99408, 99409 Multiple codes depending on the substance (refer to F section) Diagnosis codes listed reflect a positive drug dependence only report these if the screening is positive Tobacco Cessation Counseling ages 13 to 100 Tobacco 13 yrs > Yearly 99406, 99407, S9075, S9453, G0436, F0437 4000F (cessation-counseling), 4001F (cessation-pharm), 4004F (either one or both) F17.2XX, T65.211A, T65.212A, T65.213A, T65.214!, T65.221A, T65.222A, T65.223A, T65.224A, T65.291A, T65.292A, T65.293A, T65.294A Z87.891 appropriate CPT II and Dx on the same line revised 4.10.18 1
Colorectal Cancer Screening FIT DNA Cologuard, FOBT 50-75 yrs Yearly FOBT Cologuard - every 2 years 81528, 82270, 82274, G0464, G0328 3017F Z12.11 PCP - Order test (s) if not done. If already done, report CPT II and screening Dx if results discussed w/pt Blood Pressure (B/P) -No Previous dx of HTN Flexible Sigmoidoscopy 50-75 yrs Every 5 yrs 45330-45339, 45340-42, 45345, 45346-45350, G0104 Colonoscopy 50-75 yrs Every 10 yrs 44388-44394, 44397, 45355, 45378-45387, 45391, 45392, G0105, G0121, 44401-44408, 45388-45390, 45393, 45398 B/P Reading Documented 2 yrs and > B/P < 120/80 (screen q2 years), 140/90 (rescreen in one month), 139/80-90 (q 1 yr) G8476, G8477, G8752- G8755, G8783, G8950, G9273, G9274 3017F Z12.11, Z12.12 3017F Z12.11, Z12.12 2000F B/P Measured Z00.00 *report the CPT II BP reading on claim as noted (see under frequency) Glucose Screening Laboratory Test 19 yrs > Yearly 80047, 80048, 80050, 80053, 80069, 82947, 82948, 82950, 82951, 82952, 83036, 83037 LDL-C Screening Laboratory Test 19 yrs > Yearly 80061, 83700, 83701, 83704, 83721 3754F 3011F Lipid results documented/reviewed 3048F LDL C<100 mg/dl 3049F LDL C 100-129 mg/dl 3050F LDL C >130 mg/dl Influenza vaccine Immunization 18-64 yrs Yearly 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90664, 90672-90674, 90685, 90686, 90687, 90688, G0008, Q2034 - Q2039 4037F ; Make certain patient is aware as this is measure is captured through CAHPS survey based on member response. Depression Screen 12-75 yrs Yearly G0444, G8431, G8510 3725F Report the appropriate E/M code and report other appropriate CPT II and diagnosis code(s); administer PHQ2/PHQ9 as appropriate revised 4.10.18 2
Women Preventive Breast Cancer Screening Mammogram 50-74 yrs Yearly G0202, G0204, G0206, 77055-77057, 77063 3014F Z12.31 PCP - Order/schedule test for pt. If already done, report CPT II and screening Dx on claim Cervical Cancer Screening Pap Test or Pap Test and HPV Pap Test 21-64 yrs Pap and HPV 30-64 yrs 3 yrs 5 yrs Pap: 88141-43, 88147, 88148, 88150-55, 88164-67, 87623-25, 88174-75, G0123, G0124, G0141, G0143- G0145, G0147, G0148, P3000, 93001, Q0091 3015F Z00.00, Z01.419, Z01.411, Z12.4 Z85.41 Chlamydia Screening Laboratory Test 16-24 yrs, must be sexually active Pap plus HPV: above codes plus 87623, 87624, 87625 Yearly 87110, 87270, 87320, 87490, 87491,87492, 87810 3511F Z11.8 Z01.411 A74.9 ; urine screen will complete the measure Prenatal Prenatal Visits Prenatal visit in the first trimester or within 42 days of enrollment Per Occurrence 99201-99215 if 1-3 visits, 99241-99245 if 1-3 visits, 59425 for 4-6 visits, 59426-7 or > 0500F, 0501F, 0502F Z34.00-03, Z34.80-83, Z34.90-93 Do not bill globally Post Partum Post Partum Visit visit between 21 and 56 days after delivery Per Occurrence 59430, 57170, 58300 0503F Z39.2 Do not bill globally Adult with Illness Antibiotic Avoidance with Acute Bronchitis Absence of antibiotic Rx on day of dx or up to 3 days after the episode 18-64 yrs Per Occurrence Appropriate Office Visit Code 4124F J20.3 J20.9 Z91.12X Z91.13X Z91.14 Patients with a diagnosis of actue bronchitis should NOT be dispensed an antibiotic Beta-Blocker Treatment after Heart Attack (AMI) 18 ys old or older who were hospitalized/discharg ed with dx of AMI who remained on beta blocker treatment for 6 months 18 yrs > Per Occurence G8450 4008F I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4 Retinal Eye Exam 18-75 yrs Yearly Optometrist/ophthlmologist: 67015, 67028, 67030-31, 67036, 67039-67043, 37101, 67105, 67107-108, 67110, 67112-113, 67121, 67141, 67145, 67208, 67210, 67218, 67220-21, 67227-28, 92002, 92004, 92012, 92014, 92018-19, 92133, 92134, 92225-92228, 92230, 92235, 92240, 92250, 92260, 99203-205, 99213-215, 99242-245 2022F, 2024F, 2026F 3072F - no evidence of retinopathy E10.10-E10.9, E11.00-E11.9, E13-E13.9, O24.011-O24.33, O24.811-O24.83 Any provider type may report CPT II revised 4.10.18 3
HbA1c 18-75 yrs Yearly 83036, 83037 3044F (<7), 3046F (>9) E08.XX - E13.35XX, 024.319-024.93 For Diabetic Dx, please annually report HbA1c result as a CPT II codes ONLY if range is <7 or >9 Diabetes Care B/P Control < 140/90 18-75 yrs Yearly Sys BP < 130 3074F Sys BP 130-139 3075F Sys BP > 140 3077F Dia BP < 80 3078F Dia BP 80-89 3079F Dia BP > 90 3080F E10.10-E10.9, E11.00-E11.9, E13-E13.9, O24.011-O24.33, O24.811-O24.83 Diabetic Care Monitoring for Nephropathy Statin Therapy males 21-75 18-75 yrs Yearly 36147, 36800, 38810, 36815, 36818-36821, 36831-36833, 90935, 90937, 90940. 90945, 90947, 90957-90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512 Nephropathy Screening Test: 82042, 82043, 82044, 85156 females 40-75 Two rates are reported for this measures: 1. Recvd Statin therapy (dispensed at least one Rx for high or moderate statin) 2. Statin adherence 80% of the treatment period 3060F - positive microalbumin 3061F - negative microalbumin 3066F - treatment for nephropathy 4010F - ACE prescribed N000 - N08, N140 - N144, N170 - N172, N178 - N189; N19, N250, N251, N2581, N2589, N259, N261, N262, N269 Q600 - Q606, Q612 - Q615, Q618, Q619 R800 - R803, R808, R809 Z992, Z9115 Medical attention for nephropathy include: nephropathy test, evidence of nephropathy, uring macro albumin tests or at least one ACE inhibitor or ARB dispensing event This is a measure for diabetics without evidence or ASCVD to improve the use and adherence of statin therapy for primary prevention. COPD Exacerbation- Pharmacotherapy Management Dispensed systemic corticosteroid within 14 days of event* Dispensed a bronchodilator within 30 days of event* 40 yrs> Per Occurrence 4025F, 4135F *COPD: J44.0-J44.9 *Chronic Bronchitis: J41.--J42 *Emphysema: J43-J43.9 *any Acute inpatient or ED visits COPD- Spirometry Evaluation Spirometry testing Performed and Results Documented 40 yrs> Yearly 94010, 94014, 94015, 94016, 94060, 94070, 94375, 94620 3023F, 3025F *COPD: J44.0-J44.9 *Chronic Bronchitis: J41.--J42 *Emphysema: J43-J43.9 *at least one encounter/claim for spirometry during 2 yrs prior to the event/dx of COPD - 6 mo afterward Asthma - Medication management Use of appropriate medication 21 yrs to 64 yrs 4015F J45.20 - J45.998 Indicator is measured on prescription(s) written and dispensed based on the listed diagnoses after inpatient or observation, ER visit, or 2 dispensing events Measure Test/Procedure Parameters Frequency CPT/HCPCS CPT II ICD-10 Comments revised 4.10.18 4
HTN Control B/P Recording If no BP is recorded, patient is "not controlled" 18-85 yrs with dx of HTN, whose B/P is < 140/90 Yearly 99201-99205, 99211-99215 99241-245, 99341-350, 99381-387, 99391-397, 99401-404, 994711-412, 99420-429, 99455-456 G8752 (Systolic <140), G8753 (systolic > 140), G8754 (Diastoic <90), G8755 (Diastolic >90) Medication Reconcilliation Post- % of discharge from 18 yrs+ Every Discharge 99495, 99496 - Transition of Discharge January 1 to Dec 31 with documentation on the discharge date or within 30 days of discharge noting medication reconcillation Care Sys BP < 130 3074F Sys BP 130-139 3075F Sys BP > 140 3077F Dia BP < 80 3078F Dia BP 80-89 3079F Dia BP > 90 3080F 1111F - Medication reconcillation *I10 MUST Report the G code and CPT II code with other appropriate Dx code(s) and CPT code(s) that reflect the office visit rendered *members are identified by claims indicating at least 1 outpatient visit w/htn Dx during the first 6 mo of the year Notation of no medications were prescribed or ordered upon discharge satisfies the measure Medication Management Imaging Studies for Low Back Pain (LBP) Use of appropriate medication Imaging Studies 18-64 yrs Yearly 4015F J45.20 - J45.998 Indicator is measure on prescription(s) written and dispensed based on the listed diagnosis 18-50 yrs with dx of LBP who did not receive an imaging study within 28 days of diagnosis Per Occurrence 72010, 72020, 72052, 72100, 72110, 72114, 72120, 72131, 72132, 72133, 72141, 72142, 72146-72149, 72158, 72200, 72202, 72220 1134F M47.814, M48.04, M48.06, M51.26-27, M51.46-47, M51.36-37, M46.47, M51.86-87, M54.5, M54.30, M54.89, M54.9, M43.8X9, M53.9, M53.3, M53.2X8, M53.3, M99.83-84, M99.03, M99.04, S33.8XXA, S33.6XXA, S33.9XXA, S33.5XXA Avoid ordering diagnostic studies in the first 6 weeks of new-onset back pain unless certain "red flags" are present. Exclusions: -Previous diagnosis of low back pain within prior 6 months -History of cancer -Recent trauma within last 3 months -History of intravenous drug abuse within last 12 month -Severe or progressive neurologic impairment anytime in last 12 months -History of HIV -History of Spinal Infection -History of Kidney Transplant -Prolonged use of corticosteriods (90 days) in the past 12 months Major Depression- Antidepressant Medication Medication for at least 84 days 18 yrs and > Per Occurrence 4064F F32.0-F32.9, F33.0-F33.3, F33.8, F33.9, F34.1 Report the appropriate and CPT code(s) that reflect the office visit rendered Medication for at least 180 days 18 yrs and > Per Occurrence 4064F F32.0-F32.9, F33.0-F33.3, F33.8, F33.9, F34.1 Report the appropriate and CPT code(s) that reflect the office visit rendered revised 4.10.18 5